Health BenefitTabs-Dental

On This Page: Dental Plan Coverage Options, Delta Preferred, DeltaCare

Dental Plan Coverage Options	Delta Dental provides dental benefits. All active participants regardless of the medical plan option selected will have dental coverage. California participants will have a choice of coverage between Delta Preferred and Delta Care.

Delta Preferred (All participants)	This plan is a comprehensive dental care program, which provides reimbursement of covered dental expenses after satisfaction of a $75.00 per individual or $150.00 per family annual deductible for services received from the dentist of your choice. The deductible is waived for diagnostic and preventive benefits. The level of reimbursement is dependent upon the nature of the services provided (diagnostic and preventive, basic, major, or orthodontia) with certain annual and lifetime maximum benefit limitations.

DeltaCare (California participants only)	This plan is a dental HMO. You must enroll in this plan and select a dental office from the DeltaCare dental list. There is no annual deductible and no cost for covered services except for co-payments for certain procedures. Benefits are not available when services are obtained from a non-DeltaCare provider. Refer to the description of benefits and co-payments in the DeltaCare brochure.

DELTA PREFERRED

	In Network	Out of Network

Calendar Year Deductible	$75 per person $150 per family (does not apply to diagnostic and preventive services)	$75 per person $150 per family (does not apply to diagnostic and preventive services)

Diagnostic and Preventive Benefits	100% of Delta Preferred Option (DPO) approved fee (no deductible applies)	80% of DPO approved fee (no deductible applies)

Basic and Major Benefits	80% of DPO approved fee	70% of DPO approved fee

Orthodontia Benefits for individuals up to age 19 ($25 calendar year deductible)	70% of DPO approved fee (subject to a $2,000 lifetime max. per person)	70% of DPO approved fee (subject to a $2,000 lifetime max. per person)

Pedodontist*	80% of DPO approved fee	70% of DPO approved fee

Maximums

Diagnostic, Preventative, Basic and Major Services	$2,500 per Calendar Year	$2,500 per Calendar Year

Orthodontia	$1,000 per Calendar Year $2,000 lifetime maximum	$1,000 per Calendar Year $2,000 lifetime maximum

DELTACARE	In Network	Out of Network

Calendar Year Deductible	None	Service received from a non-DeltaCare dentist are not covered unless you have an accidental injury or emergency illness while you are temporarily out of town and more than 35 miles from a DeltaCare dental office. (Coverage is limited to $100 per occurrence.)

Diagnostic and Preventive Benefits	100%

Basic and Major Benefits	100%

Orthodontia Benefits for individuals up to age 19 ($25 calendar year deductible)	Up to age 19 – 100% after $350 startup fee – maximum co-pay of $1,600; Adults and verified full-time students 100% after $350 startup fee – maximum co-pay of $1,800.

Pedodontist*	Pedodontic referrals must be pre-authorized by DeltaCare. 100% of approved fee (less any applicable copayments) for ages 0-3 years, 50% of approved fee (less any applicable copayments for ages 4 and older.)



*	A pedodontist is a dentist that specializes in the growth and development of children’s teeth.

Disclaimer	NOTE: This is only a brief summary of your benefits. All benefit descriptions contained herein are governed by the limitations and other information contained in your SPD.