WHEN TREATMENT IS PROVIDED BY… | AN IN-NETWORK DENTIST | AN OUT-OF-NETWORK DENTIST |
WHO’S COVERED |
Primary enrollee and spouse as well as dependent children to age 26 |
Primary enrollee and spouse as well as eligible dependent children to age 26 |
DEDUCTIBLES AND BENEFIT MAXIMUMS |
$0 per person, $0 per family per calendar year. The maximum benefit paid per calendar year is $2,000 per person |
$50 per person, $150 per family per calendar year. The maximum benefit paid per calendar year is $500 per person |
DIAGNOSTIC AND PREVENTIVE BENEFITS* - oral examinations, cleanings, x-rays, biopsy/tissue examinations, fluoride treatment, space maintainers, specialist consultation |
100% of PPO approved fee (no deductible applies for these services) |
50% of Delta approved fee (no deductible applies for these services) |
BASIC BENEFITS* - oral surgery (extractions), fillings, root canals, periodontal (gum) treatment, sealants |
100% of PPO approved fee |
50% of Delta approved fee |
CROWNS, JACKETS AND CAST RESTORATIONS* |
100% of PPO approved fee |
50% of Delta approved fee |
PROSTHODONTIC BENEFITS* - Bridges, partial dentures, full dentures |
50% of Delta approved fee (subject to a maximum allowance) |
50% of Delta approved fee (subject to a maximum allowance) |
DENTAL ACCIDENT BENEFITS* |
100% of Delta Dentist’s fee (separate $1,000 maximum per person per calendar year) |
100% of Delta Dentist’s fee (separate $1,000 maximum per person per calendar year) |
- Please refer to your Evidence of Coverage for limitations on these benefits. Some examples of limitations on services are the number of cleanings and oral exams covered in a calendar year, and time limitations on filling and crown replacements.
- Delta endodontists, oral surgeons and periodontists are not PPO dentists, but you get in-network benefits when visiting one of these specialists.
Under the PPO program, you may visit any licensed dentist you wish. However, you receive the maximum benefits available under the program when you choose one of the more than 8,600 in-network dental offices throughout California. If you choose an out-of-network dentist, you will benefit by selecting a Delta Dentist.
IN-NETWORK
DPO DENTIST | OUT-OF-NETWORK
DPO DENTIST | OUT-OF-NETWORK
NON-DELTA DENTISTS |
Your out-of-pocket expense will probably be less because PPO dentists have agreed to charge PPO patients reduced fees |
You will be charged no more than the fees approved by Delta as customary and reasonable |
You will be responsible for the dentist’s fees, which may be higher than those approved by Delta |
Claim forms will be completed and submitted for you at no charge |
Claim forms will be completed and submitted for you at no charge |
You may have to complete and submit your own claim forms or pay a service fee |
You may be charged only the patient share* at the time of treatment, not Delta’s portion |
You may be charged only the patient share* at the time of treatment, not Delta’s portion |
You may have to pay the entire amount in advance and wait for reimbursement |
“Patient share” is the copayment, applicable deductible and any amount over the annual maximum. Some services may not be covered; please refer to your Evidence of Coverage. Some examples of services not covered are cosmetic dentistry, experimental procedures and services to correct congenital malformations.
Services that are not covered under the Delta Premier Plan and the PPO Plan
Although both programs cover many of the most commonly needed services, some services are not covered. If you are unsure whether a particular procedure is covered, or how much of it is paid for by your program, check with Delta before proceeding.
The following are not covered by the programs:
- Services for injuries or conditions covered under Workers’ Compensation or Employer’s Liability Laws.
- Cosmetic surgery or dentistry or services to correct congenital malformation
- Experimental procedures
- Therapeutic drugs, premedication or pain relievers
- Hospital costs or extra charges for hospital treatment
- Anesthesia (except for general anesthesia for oral surgery)
- Extra-oral grafts, implants, and implant removal
- Treatment related to the temporomandibular joint (TMJ)
- Orthodontic treatment
THE PRECEDING INFORMATION IS NOT INTENDED FOR USE AS A SUMMARY PLAN DESCRIPTION, NOR IS IT DESIGNED TO SERVE AS AN EVIDENCE OF COVERAGE FOR THE PROGRAMS. BOTH THE DELTA PREMIER PLAN AND THE PPO PLAN ARE EASY TO USE
To use your Delta Premier plan or your Delta PPO plan, just call the dental office of your choice and make an appointment. During your first appointment, give your dentist your group number and the primary enrollee’s social security number
Your benefits administrator has a complete list of Delta Premier and Delta PPO network dental offices and Delta dentists, or you may call (800) 4-AREA-DR (800-427-3237) to obtain a list of participating dentists in your area. You may also search our online directory via our web site at
www.deltadentalca.org
THE DELTA PREMIER PROGRAM AND THE DELTA PPO PROGRAM ARE ADMINISTERED BY DELTA DENTAL PLAN OF CALIFORNIA. IF YOU HAVE SPECIFIC QUESTIONS REGARDING BENEFIT STRUCTURE, LIMITATIONS OR EXCLUSIONS, CONSULT THE EVIDENCE OF COVERAGE OR CONTACT DELTA’S CUSTOMER AND MEMBER SERVICE DEPARTMENT
DELTA DENTAL PLAN OF CALIFORNIA
P.O. BOX 7736
SAN FRANCISCO, CA 94120
For claims, eligibility and benefit inquiries, call Delta’s Customer and Member Service Department toll free at (888) 335-8227
Clovis Unified Quick Comparison of Premier and PPO Differences as presented to the Employee Benefits Committee (EBC) on 04-27-2017: