| Plan Name: DELTA PPO, | Option I | Option II | Option III | |||
| Calendar Year Deductible $50.00* *Deductible waived for items covered at 100% |
In Network | Out of Network | In Network | Out of Network | In Network | Out of Network |
| Preventive and Diagnostic
(frequencies shown below) Emergency treatment for relief of pain Routine Exams, Cleaning Bitewing X-rays, Full Mouth X-rays Fluoride Treatment Space Maintainers |
100% | 80% | 100% | 50% | 80% | 50% |
| Basic Dental Services
Restorative - Amalgam or Synthetic Fillings Sealants (frequencies shown below) Oral Surgery Extractions, Impacted Teeth, Cysts and Neoplasms, Alveolar/Gingival Reconstructions Periodontics-Includes treatment for diseases of the gums Endodontics-Root canals and Pulpal Therapy |
80% | 50% | 80% | 50% | 80% | 50% |
| Major Dental Services Subject to a 12 month waiting period Can this waiting period be waived? Effective March 1, 2002, All new groups with 20 or more employees enrolling in any Wolfpack Insurance Services Delta Dental plan will automatically have the waiting period for Major and Orthodontic services waived. For groups of 5 employees or more, the 12 month waiting period for Major Dental Services will be waived on all employees who had continuous dental coverage during the preceding 12 months. The 12 month Orthodontic waiting period will also be waived if the group had continuous orthodontic coverage during the preceding 12 months. Restorative - Inlays, Implants and Crowns Prosthodontics- Dentures and Partials |
50% | 50% | 50% | |||
| Calendar Year Maximum, Benefit per Individual | $1500 | $1500 | $1000 | |||
| Optional Orthodontic
Benefit Maximum lifetime benefit $1500. Subject to a 12 month waiting period. Utilize any provider. Can this waiting period be waived? |
50% | 50% | 50% | |||
|
Examinations: |
2 in a calendar year |
|
Bitewing X-Rays: |
Child: 2 in a calendar year for children to age 18 |
|
|
Adult: 1 in a calendar year for adults |
|
Full Mouth X-Rays: |
1 in 5 years |
|
Cleanings (including perio cleaning): |
2 in a calendar year |
|
Sealants: |
Benefit for permanent, unrestored 1st and 2nd molars without cavities for children to the age of 14. |
Follow this link for Plan Rates and Fees
Delta
Dental, Services Not Covered
The Delta Dental programs do not
cover: Orthodontia, unless the option is selected; Service for injuries or conditions
which are compensable under Workers' Compensation or Employer's Liability Laws; services
which are provided to the Eligible Person by any Federal or State Government Agency or are
provided without cost to the Eligible Person by any municipality, county or other
political subdivision, except as provided in Section 1373(a) of the California Health and
Safety Code; Services with respect to congenital (heredity) or developmental (following
birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons,
including but not limited to: cleft palate, maxillary and mandibular (upper and lower jaw)
malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration
of the teeth), and anodontia (congenitally missing teeth); Services for restoring tooth
structure lost from wear, for rebuilding or maintaining chewing surfaces due to teeth out
of alignment or occlusions, or for stabilizing the teeth. Such services including but are
not limited to: equilibration and periodontal splinting; Prosthodontic services or any
Single Procedure started prior to the date the person became eligible for such services
under this contract; Prescribed or applied therapeutic drugs, premedication or analgesia;
Experimental procedures; Prophylaxis, if the eligible patient has received two prophylaxes
covered by the Program in the immediately preceding eleven months; All hospital costs and
any additional fees charged by the Dentist for hospital treatment; Charges for anesthesia
other than general anesthesia administered by a licensed Dentist in connection with
covered Oral Surgery Services; Extra-oral grafts (grafting of tissues from outside the
mouth to oral tissues) except as provided under Limitations on Prosthodontics Benefits;
Services with respect to any disturbance of the temporomandibular joint (jaw joint);
Replacement of existing restorations for any purpose other than restoring active tooth
decay; Charges for cost of replacement and/or repairs of an orthodontic appliance
furnished in whole or in part under this program; Surgical procedures for correction of
misalignment of teeth and/or jaws.
Only the first two oral examinations, including office visits for observation
and specialist consultations, or combination thereof, provided to a patient in a
calendar year while he or she is an Enrollee under any Delta Program are
Benefits under this program. Direct composite (resin) restorations are
Benefits on anterior teeth and the facial surface of bicuspids. Any other
posterior direct composite (resin) restorations are optional services and
Delta's payment is limited to the cost of equivalent amalgam restorations.
This brochure constitutes only a summary of the Plans. The Plan
Contract must be consulted to determine the exact terms and conditions of coverage.
