Dental
Delta Dental DeltaCare USA PlanHighlights
Click here for Delta DentalCare USA Plan
Under this option, you select a Primary Care Provider from the DeltaCare USA provider list. No claim forms to complete. No copays for basic cleanings.
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How It Works
The DeltaCare USA Plan features include:
- No maximum benefit, except for accidental injury
- No claim forms to complete
- Budgetable and predictable
- Copay for orthodontics – No waiting periods
- No copays for basic cleanings (two per calendar year)
- Specialty care is covered by referral from your primary dentist at the same defined copays as general dentists
Accident Injury Benefits
An accidental oral injury is damage to the hard and soft tissue of the mouth caused directly and independently of all other causes by external forces. Damage to the hard and soft tissue of the mouth from normal chewing function is covered under your Plan FLM08 Description of Benefits and Copayments.
Lasik and Hearing Discounts
- For more information regarding Hearing Aid discounts, contact Amplifon directly at 1-833-467-0058.
- For more information regarding Lasik discounts, contact QualSight directly at 1-855-800-2020.
Delta Dental Plans: Rate Comparison Chart
| RATES | DELTACARE USA | DELTA DENTAL PPO | ||
|---|---|---|---|---|
| 20 PAY | 24 PAY | 20 PAY | 24 PAY | |
| Employee* | $12.92 | $10.77 | $23.64 | $19.70 |
| Employee + One* | $21.64 | $18.03 | $47.22 | $39.35 |
| Employee + Family* | $31.84 | $26.53 | $62.32 | $51.93 |
| *Premiums may be deducted pretax or post-tax. |
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Important Notice
Limitations & Exclusions
All benefits are subject to limitations and exclusions and governing administrative policies of the plan. The dental health plan contract must be consulted to determine the exact terms and conditions of coverage. An Evidence of Coverage will be sent to you upon enrollment.
Family Coverage
These plans cover:
- Your spouse
- Your dependent children to the end of the month they reach age 26.
- Disabled dependent children are covered as long as disability remains total. A physician’s statement will be required.
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Access your insurance and the tools to help you use it anytime, anywhere with the mobile app.
Delta Dental Plan Benefits Comparison Chart
You have a Calendar Year plan and these benefits are for a Calendar Year, which is January 1st through December 31st of the current Plan Year.
| DELTACARE USA | DELTA DENTAL PPO | |
|---|---|---|
| YOU PAY | PLAN PAYS | |
| BENEFITS | ||
| Dentist | Choose A Panel Dentist | Use Dentist Of Choice** |
| Deductible* | None | $75 Per Year, Individual & $150 Per Year, Per Family |
| Calendar Year Maximum | None | $5,000 Per Person |
| Claim Forms | None | None If Using Delta Dental Dentists |
| PROCEDURES | ||
| Office Visit | $0 - $20 | 100% |
| Routine Exams | No Cost | 100% |
| Prophylaxis (Cleaning) | Basic - No Cost (1 Per 6 Months) | Basic - 100%(2 in a calendar year) |
| X-Ray and Complete Series | No Cost (Including Bitewings)1 | 100% (1 every 3 Years - Full), Under 18: 2 Per 12 Months - Bitewing, Over 18: 1 Per Calendar Year - Bitewing |
| Fluoride Application | No Charge To Age 19 (One Per 6 Months) | 100% (2 Per Calendar Year, Children Under 19 Only) |
| BASIC/RESTORATIVE PROCEDURES | ||
| Simple Extractions | $6 | 80% |
| Amalgam Fillings | No Cost - 1 Surface Perm, Resin Based Fillings - Posteriors $15 - $35 | 80% |
| Root Canal | Anterior2 $75; Molar2 $180 | 80% |
| MAJOR PROCEDURES | ||
| Crowns | Crowns - Porcelain, Base Metal $195; Crowns - Porcelain, $295 High Noble Metal | 50% |
| Dentures | Upper Maxillary: $225 / Lower Maxillary: $225 | 50% |
| Bridges | Porcelain, Base Metal $195 (Per Unit)Resin, High Noble Metal $295 (Per Unit) | 50% |
| Periodontics | Scaling And Root Planing $45 Per Quadrant | 50% |
| Implants | Covered*** | 50% Coins |
| Orthodontics | Start Up Fee: $350, Routine 24 Month Fully Banded Case: Adult $2,000, Child $1,800 | 75% Up To $1,500 Lifetime Maximum (After 1 Year Waiting Period Dependent Children Under Age 19 Only) |
| Waiting Period | N/A | Applies To New Participants (Orthodontics Only) |
| TMJ BENEFITS | ||
| TMJ | N/A | 50% Up To $1,000 Lifetime Maximum (Effective October 2006) |
| * Note the deductible does not apply to diagnostic and preventative services, orthodontics. **PPO Dentists are limited to the PPO fee. Delta Dental Premier® Dentists are limited to the least of: the dentist’s filed fee, submitted fee, or Delta Dental’s MPA (Maximum Plan Allowance) fee. Non-Delta Dental Dentists may balance bill for amounts over Delta Dental’s MPA-TJM Benefits (Maximum Plan Allowance) fee. ***See DeltaCare schedule of benefits for co-payment amounts 1Under the DeltaCare USA plan, bitewing X-rays (code D0274) are limited to not more than one series of four films in any six-month period. 2Excluding final restoration |
- You can locate a DeltaCare provider by calling 1-800-422-4234 or a PPO provider by calling 1-800-521-2651. You may also find a provider by using the app, or by going online at deltadentalins.com and clicking the “Find a Dentist” link on the homepage.
- To help you maintain your oral health, Delta Dental offers enhanced benefits for pregnant women. This coverage includes an additional exam, cleaning or periodontal procedure as needed, once pregnancy is confirmed.
- You have access to a Member Online Portal.