DENTAL

Dental Benefits

The Clovis Unified School District offers two dental plans to it’s full time and part time employees through  Delta Dental of California. Employees may choose the dental plan that best suits their needs. Below is a brief description of the benefit provisions under each plan:

Delta Premier Plan #6516 Managed Fee-For-Service Program 

Under this program, Delta pays 70% of the approved fees for covered diagnostic, preventive, basic, cast and crown benefits during the first year you are eligible. This percentage will increase 10% each year (to a maximum of 100%) for each enrollee, provided that person visits the dentist at least once during the year. If an enrollee does not use the program during a calendar year, the percentage remains at the level reached the previous year. If an enrollee becomes ineligible for benefits and later regains eligibility, the percentage will drop back to 70%.

PRINCIPAL BENEFITS AND COVERED SERVICES*

WHO’S COVEREDPrimary enrollee and spouse as well as eligible dependent to age 26
DEDUCTIBLES AND BENEFIT MAXIMUM$25.00 per person, $75.00 per family, per calendar year (no deductible applies if a PPO dentist is used). The maximum benefit paid per calendar year is $1,500.00 per person
DIAGNOSTIC AND PREVENTIVE BENEFITS* - oral examinations, cleaning, x-rays, biopsy/tissue examinations, fluoride treatment, space maintainers, specialist consultation70% - 100% of Delta dentist’s fee (no deductible applies for these services)
BASIC BENEFITS* - oral surgery (extractions), fillings, root canals, periodontal (gum) treatment, sealants70% - 100% of Delta dentist’s fee
CROWNS, JACKETS AND CAST RESTORATIONS*70% - 100% of Delta dentist’s fee
PROSTHODONTIC BENEFITS* - Bridges, partial dentures, full dentures50% of Delta dentist’s fee (subject to maximum allowance)
DENTAL ACCIDENT BENEFITS100% 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.
  • You must be enrolled in this dental program for 12 continuous months before receiving these benefits.

Under the Delta Premier program, you may visit any licensed dentist you wish. More than 17,000 dentists in California – 94% of all dentists statewide – are Delta dentists. There are several advantages to choosing a Delta dentist:

Delta Dentist Non Delta Dentist
Claim forms are completed and submitted for you at no chargeYou may have to complete and submit your own claim forms or pay a service fee
Your dentist’s fees have been certified by Delta as usual, customary and reasonable – you’re responsible only for the patient share*Delta has not certified the dentist’s fees – you are responsible for the difference if your dentist charges more than Delta’s preapproved fees
You may be charged only the patient share* at the time of treatment, not Delta’s portionYou may have to pay the entire bill at the time of treatment and wait for reimbursement

“Patient share” is the copayment, any 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.

Delta PPO Plan #6749 Preferred Provider Program

The Delta PPO Plan is a preferred provider program. The program provides the maximum benefit when you visit a PPO dentist. PPO dentists are Delta dentists that have agreed to charge PPO patients reduced fees

Principal Benefits And Covered Services

WHEN TREATMENT IS PROVIDED BY…AN IN-NETWORK DENTISTAN OUT-OF-NETWORK DENTIST
WHO’S COVEREDPrimary enrollee and spouse as well as dependent children to age 26Primary 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 consultation100% 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, sealants100% of PPO approved fee50% of Delta approved fee
CROWNS, JACKETS AND CAST RESTORATIONS*100% of PPO approved fee50% of Delta approved fee
PROSTHODONTIC BENEFITS* - Bridges, partial dentures, full dentures50% 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 feesYou will be charged no more than the fees approved by Delta as customary and reasonableYou 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 chargeClaim forms will be completed and submitted for you at no chargeYou 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 portionYou may be charged only the patient share* at the time of treatment, not Delta’s portionYou 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