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Delta Access/DPO Dental Insurance

& Plan Design Summary

Click Here for Full Plan Summary (pdf)

Click Here for Delta Dental Privacy Policy (pdf)

Freedom of Choice is yours with the Delta Dental Program. You may select any dentist of your choice; however, you may reduce your costs by selecting a dentist who participates with Delta Dental. You may reduce your costs further by selecting an Access/DPO provider from the list. Participating dentists agree to:

File your claim forms for you

Charge you no more than the amount approved by Delta Dental

Accept payment directly from Delta Dental

Waive sterilization fees

You may choose to go to any Dentist. If a Dentist is not a Contracting Access Dentist, the amount charged to you may be above that charged by our Contracting Access Dentists. When Delta pays Benefits for services provided by Non-Contracting Access Dentists, Delta will allow the Customary fee or the fee which satisfies the majority of the Contracting Access Dentists. You will then be responsible for any extra amount charged by this Dentist over what Benefits Delta will pay in addition to any deductibles and maximums specified by the plan. This is called balance billing, that is, the Dentist may bill you for the balance after Delta's payment is made.

This page provides a brief description of the dental benefits available to all eligible employees and their dependents that include spouse, same sex domestic partner, children up to age 25 and grandchildren. Employees are eligible to enroll as a new hire, during the annual open enrollment periods or within 30 days of a valid family status change.

Calendar year deductible - $50 per person/$150 per family

No deductible on Diagnostic and Preventative Services

Calendar year maximum - $1,500 per person

Diagnostic & Preventive - 100%

Procedures to assist the dentist in determining required dental treatment (oral examinations and x-rays); Prophylaxis (cleaning; periodontal cleaning in the presence of gingival inflammation is considered to be periodontal); topical application of fluoride solutions; space maintainers.

Basic- 80%

Oral surgery (extractions and certain other surgical procedures, including pre- and post-operative care); General Anesthesia when administered by a dentist for a covered oral surgery procedure; Endodontics (treatment of the tooth pulp); Periodontics (treatment of gums and bone supporting teeth); Palliative (treatment to relieve pain); Sealants (topically applied acrylic, plastic or composite materials used to seal developmental grooves and pits in permanent molars for the purpose of preventing decay).

Restorative and Denture Repair - 80%

Amalgam, synthetic porcelain, plastic fillings and prefabricated stainless steel restorations for treatment of carious lesions (visible destruction of hard tooth structure); repair to partial or complete dentures including rebase procedures and relining.

Crowns, Jackets and Cast Restorations - 50%

For treatment of carious lesions (visible decay of the hard tooth structure) when teeth cannot be restored with amalgam, synthetic porcelain, plastic restorations or prefabricated stainless steel restorations.

Prosthodontic Benefits - 50%

Procedures to construct or repair fixed bridges and construction of partial or complete dentures.

Orthodontic Services - 50%

Procedures performed by a Dentist, involving the use of an active orthodontic appliance and post-treatment retentive appliances for treatment of malocclusion of teeth and/or jaws which significantly interferes with their functions.

Benefit levels are based on Delta Dental's usual, customary and reasonable charges.

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LIMITATIONS ON DIAGNOSTIC AND PREVENTIVE BENEFITS

Routine oral examinations and cleanings, including periodontal cleanings, are not provided more than twice in any 12 month period while the patient is an Enrollee under any Delta or any prepaid dental care program provided by the Contract holder.

Full mouth x-rays or panographic x-rays will be provided when required by the Dentist, but not more than one x-ray each 5 years will be paid by Delta.

Bitewings are limited to 2 bitewing procedures (4 films per bitewing) each 12 months when provided to Enrollees under age 18 and 1 bitewing procedure each 12 months for Enrollees age 18 and over.

Delta will not pay for topical application fluoride for anyone 19 years or older.

Space maintainers are limited to the initial appliance only and to Enrollees under age 14.

LIMITATIONS ON SEALANT BENEFITS

They are available only to Enrollees under the age of 15.

They are limited to application to permanent molars with no caries (decay), without restorations and with the occlusal surface intact.

They do not include the repair or replacement of a sealant on any tooth within 3 years of its application.

LIMITATIONS ON PROSTHODONTIC BENEFITS

Delta will not pay to replace any bridge or denture that the patient received in the previous 5 years. An exception is made if the bridge or denture cannot be made satisfactory due to a change in supporting tissues or because too many teeth have been lost.

Delta limits Benefits for dentures to a standard partial or complete denture. A "standard" denture means a removable appliance to replace missing natural, permanent teeth that is made from acceptable materials by conventional means.

Delta will not pay for implants (artificial teeth implanted into or on bone or gums) or their removal; but Delta will credit the cost of a standard complete or partial denture that would have been allowed under this plan toward the cost of an implant and related services (coinsurance applies).

LIMITATIONS ON ORTHODONTIC BENEFITS

All payments will be on a monthly basis. The obligation of Delta to make periodic payments for an Orthodontic treatment plan begun prior to the date the patient becomes covered will commence with the first payment due following the date the patient's coverage is effective.

The obligation of Delta to make periodic payments for Orthodontic treatment will terminate on the payment due date next following the date the Dependent Enrollee or the Primary Enrollee loses coverage, or upon termination of the Contract, whichever will occur first.

Delta will not make any payment for repair or replacement of an Orthodontic appliance furnished, in whole or in part, under this program.

Orthodontic Benefits are limited to Dependent Enrollee children under age 25.