Overview

Dental coverage is available through Delta Dental. The Delta Dental network is made up of a national group of providers that have contracted to deliver their services at a reduced cost. Participating providers are screened and selected by Delta Dental and must meet pre-established certification standards.

The dental PPO plan is a “passive” PPO. This means you can go to any dentist you choose, but you must pay the difference between charges from an out-of-network dentist and the contracted rate for in-network dentists. Using in-network dentists lowers your out-of-pocket costs; using out-of-network services gives you more flexibility to choose your providers but requires you to pay more of the cost of care.

Your dental plan options are:

  • Basic PPO Plan, designed for participants who expect only routine annual or preventive care
  • Comprehensive PPO Plan, designed for participants who want comprehensive dental coverage

Key features at a glance:

  • Flexible PPO designs that let you go to any dentist you choose.
  • Affordable coverage that helps you manage the cost of dental treatment.
  • Wide network of providers that have agreed to negotiated rates, which helps you save money.
  • In-network cost savings — using in-network providers will lower your out-of-pocket costs; you may see out-of-network providers, but you will pay the difference between the amount your provider charges and the contracted rate for in-network dentists.
Find a network dentist and receive maximum plan benefits for your care. Visit Delta Dental for more information.

Coverage Details

Services covered under both the Basic PPO Plan and Comprehensive PPO Plan include:

  • Preventive/Diagnostic — including periodic exams, certain x-rays and cleanings
  • Basic — fillings, root canal therapy for anterior and bicuspids, periodontal treatment, and extractions

Services only covered under the Comprehensive PPO Plan include:

  • Major — crowns and dentures, molar root canal, osseous surgery, partial and full bone impactions, crown-lengthening and core build-up
  • Orthodontia — corrective dentistry for children and adults
 Basic PPO PlanComprehensive PPO Plan
Individual/family deductible$100/$300$50/$150
Annual maximum benefit$1,000 for basic care$2,000 for basic and major care
Services
Preventive100% covered by plan; not subject to deductible and annual maximum benefit100% covered by plan; not subject to deductible and annual maximum benefit
BasicYou pay 50% after deductibleYou pay 20% after deductible
Major servicesNot coveredYou pay 50% after deductible*
Orthodontia coinsurance/lifetime maximumNot covered$2,000

*Note that the replacement of, addition to, or modification of existing dentures, crowns, casts or bridgework is subject to certain conditions and limitations. Contact Delta Dental at 1-800-932-0783 if you need dental work for a pre-existing condition, or visit Delta Dental.

Using Your Dental Plan

Here’s how to make the most of your dental benefits:

  • Choose any provider. Each time you need dental care, you have a choice of providers. Selecting a Delta Dental participating dentist will ensure you receive the highest benefits from your plan. To find a provider, go to Delta Dental.
  • Present your plan identification information at your provider’s office. The Dental Plan group number is 04811.
  • If your service will exceed $500, submit for a pre-treatment estimate. You should always submit a request for a pre-treatment estimate for procedures and services your dentist believes will exceed $500 (procedures such as crowns, inlays, bridges, and periodontics). For more information about pre-treatment estimates, call Delta Dental at 1-800-932-0783 or visit Delta Dental.
  • Check your claim status and other information at Delta Dental. You can review Explanation of Benefits (EOB) statements, check if claims have been paid, and more.
  • Nominate your dentist to join the Delta Dental network. If your dentist is not in the Delta Dental provider network and you wish to benefit from the reduced costs that come with in-network benefits, you can nominate your dentist to join. To get started, visit Delta Dental and select either the PPO or Premier option to access an online form you can complete and submit. A representative from Delta Dental will reach out to your dentist to facilitate the process. (Note, however, that following the nomination process is not a guarantee that your dentist will join the network.)
Member Support

For a listing of dentists in your area who participate in the Delta Dental network, call toll-free 1-800-932-0783 or visit the Delta Dental website. Your plan number is 04811.