2021 | Dental
Delta Dental PPO Option (Indemnity)Highlights
Under this option, you can receive services from a PPO Dentist or the dentist of your choice. PPO Dentists will file claims on your behalf and have agreed to charge no more than the predetermined PPO fee schedule. You may be required to pay up-front costs and file a claim form if you use a non-Delta Dental dentist.
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How It Works
The Delta Dental PPO Option Plan allows each person covered under the plan to have the freedom to visit any dentist. There may be a savings advantage to receiving care from a PPO Dentist because your out-of-pocket costs tend to be lower than visiting a non-Delta Dental dentist.
When you visit a PPO Dentist, payment is based on the PPO fee schedule. The PPO Dentist has agreed to accept this fee as the approved amount. Although you are responsible for deductibles, coinsurances and any expenses above the maximum, a PPO Dentist cannot bill you for any covered charges above the approved amount.
In addition to PPO Dentists, Delta Dental has Participating Delta Dental Premier Dentists. PPO dental providers provide the most savings. Although you are responsible for deductibles, coinsurances and any expenses above the maximum, Premier dentists have an agreement with Delta Dental not to charge you more than the approved amount. In Florida, the Delta Dental PPO is underwritten and administered by Delta Dental Insurance Company.
Accident Injury Benefit
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 1-888-670-1848.
- 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* | $11.78 | $9.82 | $26.45 | $22.04 |
| Employee + One* | $19.74 | $16.45 | $52.66 | $43.88 |
| Employee + Family* | $29.04 | $24.20 | $68.63 | $57.20 |
| *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 Benefit 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.
| BENEFITS | DELTACARE USA | DELTA DENTAL PPO |
|---|---|---|
| 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 | YOU PAY | PLAN PAYS |
| Office Visit | $0 - $20 | 100% |
| Routine Exams | No Cost | 100% |
| Prophylaxis (Cleaning) | Basic - No Cost (2 Per Calendar Yr.) | Basic - 100% (Limit 2 In 12 Months) |
| Emergency Palliative Treatment | $10 (Regular Office Hours) | 80% |
| X-Ray and Complete Series | No Cost (Including Bitewings)1 | 100% (1 Per 36 Months- Full), Under 18: 2 Per 12 Months - Bitewing, Over 18: 1 Per 12 Months - Bitewing |
| Fluoride Application | No Charge To Age 19 (One Per 6 Months) | 100% (2 Per 12 Months, Children Under 19 Only) |
| BASIC/RESTORATIVE PROCEDURES | YOU PAY | PLAN PAYS |
| 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 | YOU PAY | PLAN PAYS |
| Crowns | Crowns - Porcelain, Base Metal $195; Crowns - Porcelain, $295 High Noble Metal | 50% |
| Dentures | Upper/Lower $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% |
| Orthodontics | Start Up Fee: $350, Routine 24 Month Fully Banded Case: Adult $2,000, Child $1,800 | 50% Up To $1,000 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 | YOU PAY | PLAN PAYS |
| TMJ | N/A | 50% Up To $1,000 Lifetime Maximum (Effective October 2006) 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. 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 can use the Dental Care Cost Estimator at www.deltadental.com to get an estimate on your potential procedure expenses.
- You have access to a Member Online Portal.