Download Delta Dental Classic Summary of Benefits

Delta Dental Classic
Summary of Benefits
Administered by
Delta Dental Premier 100
(UCR)
Delta Dental Premier 50
(UCR)
100/80/50
50/50/50
$50
No Deductible
No Family Max
No Deductible
$1,000, $1,500 or $2,000
$1,000, $1,500 or $2,000
Diagnostic & Preventive
Oral exams, x-rays, consultation, cleanings, emergency relief of pain,
fluoride treatments
100% UCR
50% UCR
Basic
Oral Surgery:
Extractions and other oral procedures
Restorations:
Amalgams and fillings
Endodontics:Pulpal therapy and root canals (treatment for non-vital teeth)
Periodontics:Treatment of the gum & bones supporting the teeth
Sealants:
Protective coating for posterior molar teeth
80% UCR
50% UCR
Major Dental (No Waiting Period)
Crowns, jackets and cast restorations
Prosthodontics: Fixed bridges, partial or complete dentures, implants
50% UCR
50% UCR
50%
(Group size of 10 or more)
50%
(Group size of 10 or more)
Delta Dental Premier (UCR)
Plan Options for Groups of 5-99 Employees
Annual Calendar Year Deductible per Patient
(Deductible waived for Diagnostic & Preventive)
Family Maximum
(Deductible waived for Diagnostic & Preventive)
Annual Maximum per Patient
Optional Orthodontic Benefits
For dependents up to age 19 (to 25 if full-time student). Lifetime maximum $1,000
per patient. NO WAITING PERIOD
Participating Dental Offices
In California
Nationwide
23,400
161,000
23,400
161,000
Initial Rate Guarantee
12 Months
12 Months
CKD-003 11/07
Delta Dental PPO
Plan Options for Groups of 5-99 Employees
Annual Calendar Year Deductible per Patient
Family Maximum
(Deductible waived for Diagnostic & Preventive)
PPO
PPO
Non PPO
$50
$50
Not Applicable
Not Applicable
Annual Maximum per Patient
$1,000, $1,500 or $2,000
Diagnostic & Preventive
Oral exams, x-rays, consultation, cleanings, emergency relief of pain,
fluoride treatments
100%*
100%** of PPO approved fee
Basic
Oral Surgery:
Extractions and other oral procedures
Restorations:
Amalgams and fillings
Endodontics:Pulpal therapy and root canals (treatment for non-vital teeth)
Periodontics:Treatment of the gum & bones supporting the teeth
Sealants:
Protective coating for posterior molar teeth
80%*
80%** of PPO approved fee
Major Dental (No Waiting Period)
Crowns, jackets and cast restorations
Prosthodontics: Fixed bridges, partial or complete dentures, implants
50%*
50%** of PPO approved fee
50%*
(Group size of
10 or more)
50%** of PPO approved fee
(Group size of
10 or more)
12,300
86,000
N/A
N/A
Optional Orthodontic Benefits
For dependents up to age 19 (to 25 if full-time student). Lifetime maximum $1,000
per patient. NO WAITING PERIOD
Participating Dental Offices
In California
Nationwide
Initial Rate Guarantee
12 Months
- *An in network dentist agrees to charge PPO enrollees the approved PPO fee.
**If an out-of-network dentist charges more than PPO approved fee, the patient is responsible for the difference.
- You may choose any PPO dentist for PPO dentist benefits. For non-PPO dentist benefits, you may choose any dentist.
PLEASE NOTE: For the PPO plans please refer to your Evidence of Coverage booklet or highlights of benefits regarding coverage for out-of-state employees.
- Refer to Limitations and Exclusions section for services which may not be covered.
DeltaCare (HMO)
Plan Options for Groups of 5-99 Employees
Patient CoPayment
HMO 10A*
HMO 11A**
HMO 12A***
Diagnostic & Preventative
Oral exams, x-rays, cleanings
 Consultations
 After hours office visits
No Cost
No Cost
$20
No Cost
$10
$25
No Cost
$10
$25
Basic
Oral Surgery:
Restorations:
Endodontics:
Periodontics:
No Cost
No Cost
$25
No Cost
No Cost
$45
$90
$50
No Cost
$5
$50
No Cost
$5
$55
$120
$80
$5
$8
$55
$5
$10
$85
$150
$80

Extractions (coronal remnants - deciduous tooth)
Extractions (erupted tooth or exposed root)
 Removal of impacted tooth - soft tissue
 Amalgams - one surface, primary or permanent
 Sedative filling
 Root canal therapy - anterior
 Root canal therapy - bicuspid
 Gingivectomy, one to three contiguous teeth


Major Dental (No Waiting Period)
 Crowns**** - resin with predominantly base metal
- resin with noble metal
- porcelain/ceramic
 Denture - complete upper or lower
$55
$95
$195
$100
$95
$135
$240
$145
$145
$185
$295
$215
Orthodontic Benefits (does not include pre or post treatment fees)
 Individual Copays: Dependent children to age 19
 Individual Copays: Adults & covered full-time students
$1,700
$1,900
$1,700
$1,900
$1,700
$1,900
Participating Dental Offices
In California
2,400
2,400
2,400
No Deductible & No Annual Maximum
-
*The Classic 10A plan was formerly named the Classic A22 plan.
**The Classic 11A plan was formerly named the Classic A26 plan.
***The Classic 12A plan was formerly named the Classic A29 plan.
****Precious and semi-precious metals, if used, will be charged to the enrollee at the additional cost of the metal. This applies to crowns, bridges, and cast post and cores.
Please note, DeltaCare plans are administered by Delta’s HMO affiliate, PMI Delta Health Plan.
Due to the nature of an HMO program, please allow 2-4 weeks for appointments (with the exception of emergencies).
Law firms, associations, groups with seasonal employment (groups in which the number of employees hired during the last year exceeds 20% of the average number of
employees over the same year), and groups without an employer/employee relationship are not eligible for the DeltaCare programs.
- Refer to Limitations and Exclusions section for services which may not be covered.
Sales - LISI
San Mateo 800.944.5474
Sacramento 800.573.5474
Fresno 800.449.5474
Los Angeles 800.970.5474
Orange 888.567.5597
San Diego 800.442.9846