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Volusia County School District
Dental Program
Group Number: 10-1396
ABOUT DELTAPREFERRED OPTION
The DeltaPreferred Option (DPO) program allows you to:
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Save on out-of-pocket expense when you visit a network dental office
Visit any dentist of your choice — select a different dentist for each member of your family
Change dentists at any time
Go to a dental specialist of your choice
Receive dental care anywhere in the world
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Under the DPO program, you may visit any licensed dentist you wish. However, the greatest
cost savings are achieved by visiting a DPO dentist.
DELTAPREFERRED OPTION
DENTISTS (DPO)
NON-DPO DENTISTS*
Your out-of-pocket expense will probably
be less because DPO dentists have
agreed to charge DPO patients reduced
fees.
You may be responsible for the dentist’s
fees, which could be higher than those
approved by Delta.
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 have to pay the entire amount in
advance and wait for reimbursement.
DELTAPREFERRED OPTION IS EASY TO USE
DeltaPreferred Option (DPO) is Delta’s preferred provider program. The program
provides the maximum benefit when you visit a DPO dentist. DPO dentists are Delta
dentists who have agreed to charge DPO patients reduced fees.
To use your DPO program, just call the dental office and verify that the dentist is a
DPO dentist.
For a list of dentists in your area, visit our web site at www.deltadentalins.com and
click on dentist directory. Then, choose the DeltaPreferred Option (DPO/PPO) dentist’s
link.
Delta Dental offers you what no other dental plan can — the Delta Difference.®
♦ Delta dentists agree to charge you no more than the amount approved by Delta.
♦ A nationwide network of Delta dentists.
♦ We require professional treatment standards. Delta dentists must meet
professional standards for hygiene, radiation safety and other areas of quality
care.
*If you do not choose to visit a DPO dentist, you may benefit by choosing a DeltaPremier dentist over a nonDelta dentist, since DeltaPremier dentists agree not to balance bill.
**“Patient share” is the coinsurance, 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 procedure and services to correct congenital malformations.
Sample Claim Payment
Dentist Submitted Amount
Delta Approved Amount
Delta Allowed Amount
Delta Payment (80%)
Patient Payment**
DPO Dentist
$120.00
$75.00
$75.00
$60.00
$15.00
Non-DPO Dentist*
$120.00
$120.00
$90.00
$72.00
$48.00
*If you do not choose to visit a DPO dentist, you may benefit by choosing a DeltaPremier dentist over a non-Delta dentist, since DeltaPremier dentists agree not to balance bill. **The difference between the Approved Amount and the Delta Payment. Group Number: 10-1396
PRINCIPAL BENEFITS AND COVERED SERVICES
DPO Dentist
Non-DPO Dentist*
WHO’S COVERED
Primary enrollee and spouse as well as eligible dependent
children to age 25
DEDUCTIBLES
$50 per person, $100 per family, per plan year.
SERVICES THAT ARE NOT COVERED
Although your program covers 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 program:
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Services for injuries or conditions covered under Workers’ Compensation or
Employer’s Liability Laws
BENEFITS MAXIMUM
COMBINED MAXIMUM FOR
ORTHODONTICS AND
IMPLANTS
DIAGNOSTIC AND
PREVENTIVE BENEFITS** --oral
examinations, cleanings, x-rays,
biopsy/tissue examinations of tissue
biopsy, fluoride treatment, space
maintainers
The maximum benefit paid per plan year is $1,000 per
person.
$1,000 separate lifetime maximum for orthodontics per
enrollee and dependent child
80% of DPO fee schedule
(no deductible applies to
these services)
80% of UCR (Usual, Customary,
and Reasonable)
(no deductible applies to these
services)
80% of DPO fee schedule
80% of UCR (Usual, Customary,
and Reasonable)
MAJOR BENEFITS** -- crowns,
50% of DPO fee schedule
50% of UCR (Usual, Customary,
and Reasonable)
50% of DPO fee schedule
(no deductible applies to
these services)
50% of UCR (Usual, Customary,
and Reasonable)
(no deductible applies to these
services)
(extractions), fillings, restorations,
denture repairs, sealants, endodontics
(root canals), periodontics (gum
treatment)
jackets and cast restorations and
prosthodontics (bridges, partial
dentures, full dentures)
Adults and Children
Cosmetic surgery or dentistry or services to correct congenital malformation
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Experimental procedures
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Therapeutic drugs, premedication or pain relievers
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Hospital costs or extra charges for hospital treatment
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Anesthesia (except for general anesthesia for oral surgery)
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Extra-oral grafts, implants and implant removal
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
program.
BASIC BENEFITS** --oral surgery
ORTHODONTIC AND IMPLANT
BENEFITS**
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*If you do not choose to visit a DPO dentist, you may benefit by choosing a
DeltaPremier dentist over a non-Delta dentist, since DeltaPremier dentists agree not to
balance bill.
**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 plan year, and time limitations on filling and crown replacements. All
services are subject to plan year maximums.
This program is administered by Delta Dental Insurance Company. If you
have specific questions regarding benefit structure, limitations or
exclusions, consult the Evidence of Coverage.
Delta Dental Insurance Company
P.O. Box 1809
Alpharetta, GA 30023-1809
1-800-616-3629
Access Delta Dental's National
Dentist Directory on the Internet.
Our Internet address is: www.deltadentalins.com
DPO/UCRINS 3/06 FL
Y O U
C A N
F E E L
G O O D
A B O U T
YOUR CHOICE OF OPTIONS
Delta Dental Insurance Company offers employees of the Volusia County School District two
choices for maintaining proper dental health: DeltaCare and DeltaPreferred Option (DPO).
BENEFITS COMPARISON
Benefit
DeltaCare*
Annual
Deductible
NONE
Annual
Maximum
NONE
Diagnostic &
Preventive
Basic Care
Fillings
Extractions
Root Canals
Major Care
Crowns**
Bridge Pontic**
Dentures
Orthodontics
You pay copayments
according to a schedule:
NO COST- up to $48
NO COST
$8-$96
$90-$216
Delta Dental DPO
$50 per person/$100 per family
(No deductible on Diagnostic & Preventive, Orthodontics
and Implants)
$1,000 per person
80% of DPO Fee Schedule
Out of DPO Network
Usual, Reasonable,
Customary:
80% of UCR
80% of DPO Fee Schedule
80% of UCR
In DPO Network:
50% of DPO Fee Schedule
50% of UCR
$132-$234
$234
$270-$360
$1,000 Lifetime Maximum Per Person
$2,150 per child
$2,350 per adult
(includes start up fee)
* You must use a DeltaCare Contract Dentist for treatment. ** Precious and semi-precious metals, if used, will be charged to you at the additional cost of the metal. This applies to crowns, bridges and cast post and cores. This is only a brief summary of the plan. The procedures above are subject to limitations,
exclusions and governing administrative policies of the plan. The dental plan contract must be
consulted to determine the exact terms and conditions of coverage.