Welcome to Delta Dental!

2021-22 Open Enrollment

A dental election is REQUIRED if you want dental

insurance coverage for yourself and your family in the

new plan year!

Delta Dental

PPO™

The Delta Dental Difference®

Delta Dental PPO Delta Dental Premier® Non–Delta Dental

• Visit a PPO dentist to

save the most.

• You can visit any

licensed dentist.

• You won’t be charged

more than your

expected share of

the bill.

Delta Dental PPO –

BASE PLAN

DeductiblePer calendar year

$75 per person, PPO

providers

$100 per person, Premier

& Non-Contracted

providers

Waived for D&P

Annual maximumPer calendar year

$1,500 per person

Orthodontic Lifetime maximum

$1,500 per person

In-Network

PPO

Premier &

Non-Delta

Employee Pays

Diagnostic and

preventive care (exams, cleanings,

x-rays, sealants)

0% 50%

Basic services(Fillings, simple

extractions, root

canals, gum

treatment)

20%

(after deductible)

30%

(after

deductible)

Major services(Crowns, oral

surgery, bridges,

dentures)

70%

(after deductible)

80%

(after

deductible)

Delta Dental PPO –

BASE PLAN

Employee Pays

Comprehensive

orthodontics – CHILD

ONLY

50%

Comprehensive

orthodontics (Adult)Not covered

Lifetime Maximum $1,500

Your PPO coverageBUY-UP PLAN

Delta Dental PPO –

BUY-UP PLAN

DeductiblePer calendar year

$50 per person

$150 per family

Waived for D&P

Annual maximumPer calendar year $2,000 per person

Orthodontic Lifetime maximum

$2,000 per person

In-Network

PPO

Premier &

Non-Delta

Employee Pays

Diagnostic and

preventive care (exams, cleanings,

x-rays, sealants)

0% 20%

Basic services(Fillings, simple

extractions, root

canals, gum

treatment)

20%

(after deductible)

50%

(after deductible)

Major services(Crowns, oral

surgery, bridges,

dentures)

50%

(after deductible)

70%

(after deductible)

Delta Dental PPO –

BUY-UP PLAN

Employee Pays

Comprehensive

orthodontics (child)50%

Comprehensive

orthodontics (adult)50%

Lifetime Maximum $2,000

Pre-treatment estimate

DeltaCare® USA DHMO

• Alabama

• Arizona

• Arkansas

• Delaware

• Florida

• Illinois

• Indiana

• Kansas

• Michigan

• Mississippi

• Missouri

• New Jersey

• New York

• North Carolina

• Pennsylvania

• South Carolina

• Tennessee

• Texas

• Virginia

• Washington DC

• Wisconsin

*The Delta DHMO is only available in approved states – the following are pending approval:

• California (pending)

• Colorado (pending

• Maryland (pending)

• Ohio (pending)

• Oregon (pending)

• Washington (pending)

The DHMO is available in the following states:

*Pending as of 12/14/2020

Comprehensive coverageDeltaCare USA DHMO: a prepaid, fixed copayment plan

Once enrolled, select a primary dentist from the DeltaCare USA network to start enjoying:

• Set copays

• No annual maximums

• No deductibles

• No claims

• Low premiums

DHMO benefit enhancements include:

• 178 more covered DHMO procedures; all-inclusive copays

• Posterior composite fillings covered

• No missing tooth exclusion

• Implants covered

• Tooth whitening covered

How DeltaCare USA DHMO worksGetting dental care is easy

Specialty and emergency careDeltaCare USA DHMO

• If you need specialty care, your

primary care dentist will refer you

• Your primary care dentist requests

authorization for specialty services

• Plan includes out-of-network coverage

for emergencies

All about bracesDeltaCare USA DHMO

• Orthodontic coverage for children and adults

• All phases of orthodontic treatment are covered

• Pre-and post-records

• Tooth extractions

• Coverage for in-progress treatment

• Sampling of pre-set copays (please refer to full summary for additional details):

Teeth Whitening & ImplantsNew with the DeltaCare USA DHMO

DeltaCare USAYour copayment*

Teeth Whitening

External bleaching for home application,

per arch; includes materials and

fabrication of custom trays

$125 copayment

Implants

Surgical placement of implant body:

endosteal implant$1,005 copayment

Custom fabricated abutment – includes

placement$425 copayment

Abutment supported porcelain/ceramic

crown$740 copayment

*Limitations and exclusions may apply. Sample listing of procedure codes. Please reference plan booklet for complete listing of covered

procedure codes.

Submit your request

• Online: Create an online account at deltadentalins.com

• By phone: Call Customer Service at 800-422-4234

Go to deltadentalins.com to browse the DeltaCare USA dentists in your area.

Write down the facility number of the primary care dentist you would like.

Each member school will document dentist election and communicate to Delta Dental. If no election is made, a provider will be auto assigned. Providers can be changed anytime throughout the year.

Web and mobile

resources

Sign up for an online accountCheck your benefits information online –

deltadentalins.com

• Check your plan details: eligibility, covered

services and level of benefits.

• Look up claim statements for recent dental visits.

• View or print your ID card.

• Estimate the cost of your next procedure.

• Submit questions to Customer Service.

Go mobile

To find the app, visit the App Store or Google Play and search for “Delta Dental.” Then download the Delta Dental app by Delta Dental Plans Association.

What can you do with the app?

Find a network dentist

• Go to deltadentalins.com.

• Look for the Find a Dentist tab.

• Search by name, address, landmark, city or ZIP code.

• Select your network plan.

• Click Search.

• Narrow your search by location, specialty, network and

language.

• Your search results will include a dentist’s Yelp rating,

address and phone number.

Cost EstimatorBudget for dental expenses with personalized

estimates

Personalized. Estimates are based on your

benefits, including maximums and deductibles.

Insightful. Compare the cost of the same

procedure at different dentists.

Economical. See how choosing an in-network

dentist can help you save.

Value Added Service: Savings you can hear!

Access hearing aid and LASIK discountsNow available to you and your dependents

62% average savings off retail hearing aid pricing

Amplifon Hearing Health Care

40-50% off traditional LASIK eye surgery

QualSight