Dental Plans

Compare Delta Dental PPO and DeltaCare® USA side-by-side


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  Delta Dental PPO DeltaCare® USA
Features
Filing claims No claims filing paperwork. No claims filing paperwork.
Teeth whitening Not a covered service. Covered service with a member copayment.
Teeth cleaning 2 cleanings per year at no charge. Additional cleaning may be covered based on report by provider or for those that are pregnant. 2 cleanings a year at no charge plus 1 additional cleaning per year; $45 copayment for adults; $35 copayment for children.
Member savings You are only responsible for $50 deductible and coinsurance for most routine and major services. No coinsurance for preventive services. There is no deductible and no copayments for diagnostic services. Other services are based on a fee schedule.
Orthodontics Deductible does not apply. Delta Dental pays 50% of fees up to $1,500 Lifetime Maximum for those under age 26 and $500 Lifetime Maximum for those over age 26. You are responsible for $1,000 for either adult or child orthodontics.
Your maximum yearly benefit $1,700 ($1,500 for out of network providers). No maximums.

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  Delta Dental PPO DeltaCare® USA
Estimated Member Costs: Top 6 services
Adult cleaning No Cost No Cost
Fillings 20% after $50 deductible $65-$95
Extraction 20% after $50 deductible No Cost
Crowns 20% after $50 deductible $50-$150
Partial denture 50% after $50 deductible $65
Braces (adolescent) $1,500 benefit $1,000 benefit

The above fees are considered to be estimates only and based on visiting a PPO provider. Fees vary by region and dentist.


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  Delta Dental PPO DeltaCare® USA
Services
Service area Worldwide. California only.
Total benefit $1,700 PPO/$1,500 Out of PPO network. No maximum.
(Total benefit for preventive, basic, major dentistry, and prosthetic dentistry).
  Delta Dental PPO DeltaCare® USA
Preventative dentistry
Coverage No deductible. Copayments apply as noted.
Cleaning of teeth - prophylaxis No charge
(up to 2 times in a calendar year; additional cleaning by report or for pregnant women).
No charge
(up to 2 times in any 12-month period). Additional cleanings within the 12 month period: $45 copayment for adults, $35 copayment for children.
Oral examinations No charge
two routine exams per calendar year (second risk based)
No charge.
Emergency office visit for pain relief No charge Covered up to $100.
Topical fluoride treatment No charge
(up to 2 times in a calendar year through age 13).
No charge
(up to 2 times in any 12-month period through age 18).
Space maintainers No charge
(through age 12 once every 5 years).
No charge.
X-rays
(full mouth, bitewings, other films)
No charge
(full mouth x-rays limited to 1 set in 5 years).
No charge
(full mouth x-rays limited to 1 set in any 12-month period).
Pit and fissure sealants
(under age 16 only)
No charge PPO/25% Out of PPO network for first permanent molars through age 9 and second permanent molars through age 15. No charge for first permanent molars through age 9 and second permanent molars through age 15.
  Delta Dental PPO DeltaCare® USA
Basic dentistry
Coverage Deductible applies. Copayments apply as noted.
Fillings 20% PPO/25% Out of PPO network. No charge for standard benefit.
Anesthesia 20% PPO/25% Out of PPO network
(general anesthesia for covered oral surgery).
Local - no charge. General and intravenous sedation - no charge; limited to medically necessary extractions.
Prosthetic appliance repair 20% PPO/25% Out of PPO network. No charge.
Extractions 20% PPO/25% Out of PPO network. No charge if uncomplicated
(not covered if done only for orthodontics).
Oral surgery 20% PPO/25% Out of PPO network. $15 copayment for impactions; other covered services at no charge.
Endodontics 20% PPO/25% Out of PPO network. $20 copayment for each canal; other covered services ranging from $0 to $70.
Periodontics 20% PPO/25% Out of PPO network. $100 copayment per quadrant for surgery (mucogingival and osseous gingival); $150 copayment for soft tissue graft procedures; periodontal maintenance: no charge for 1 in each 6-month period; additional maintenance within the 6 month period: $55 copayment.
Denture relining and rebase 20% PPO/25% Out of PPO network. Relining - no charge (limited to 1 in any 12-month period). Rebase - $20 copay (limited to 1 in any 12-month period.
  Delta Dental PPO DeltaCare® USA
Major Dentistry
Coverage $50 Deductible applies. Copayments apply as noted.
Crowns 50% $50 per unit copayment ($100 extra charge for precious metals).
Inlays/onlays 50% No charge for standard benefit.
TMJ disorder benefits
Temporomandibular joint (TMJ) dysfunction: limited to occlusal devices/occlusal guards (night guards)
50% up to $500 for all benefits in a lifetime. $50 Deductible applies.
(not applied to calendar year maximum).
No charge.
  Delta Dental PPO DeltaCare® USA
Prosthetic dentistry
Coverage $50 Deductible applies. Copayments apply as noted.
Standard, full, or partial dentures 50% Upper or lower - $65 copayment per denture. Removable upper or lower partial denture with flexible base - $115.
Bridges 50% $50 per unit copayment
($100 extra charge for precious metals).
Dental Implants 50% Not a covered Service.
  Delta Dental PPO DeltaCare® USA
Orthodontics
Coverage No deductible. Copayments apply as noted.
Who is eligible for service All covered family members. All covered family members.
Benefit 50% up to $1,500 in a lifetime for covered individuals under age 26; up to $500 in a lifetime for covered individuals age 26 and over (not applied to calendar year maximum). $1,000 copayment (plan covers 36 months of usual and customary treatment - a monthly office visit fee of $75 applies after the 36 months).
  Delta Dental PPO DeltaCare® USA
Special provisions, limitations, exclusions
Work in progress when you join Only services that started on or after your effective date of coverage are covered (except for ongoing orthodontic treatment). Only services received from a DeltaCare® USA provider on or after your effective date of coverage are covered.
Predetermination of benefits If services are expected to be $350 or more, your dentist files a treatment plan first; Delta Dental reviews it and notifies you and your dentist of the benefits payable. Before any work is done, ask your DeltaCare® USA dentist what the charges will be. If you have any questions about what will be covered, call DeltaCare® USA.
Alternate treatment provision If more than one professionally acceptable and appropriate treatment can be used, Delta Dental benefits will be based on the least expensive method. If you select a treatment plan different from that customarily provided by DeltaCare® USA, you will pay the applicable copayment, plus the additional cost of the alternate treatment.
Replacement of crowns, dentures, partial dentures, and bridges Not covered if crown or prosthetic appliance is less than 5 years old. Not covered if crown or prosthetic appliance is less than 3 years old.
Out-of-area emergencies Coverage applies worldwide. Plan pays up to $100 per emergency in any 12-month period for pain relief when you are more than 25 miles from your dentist's office.
Teeth bleaching Not covered. $125 copayment per arch. External bleaching is limited to one bleaching tray per arch per 36-month period; bleaching gel for two weeks of patient self treatment.

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Limitations or waiting periods may apply for some benefits; some services may be excluded. Please refer to your Evidence of Coverage or Summary Plan Description for waiting periods and a list of benefit limitations and exclusions.