For eligible employees in the following categories: Units 1, 2, 3, 4, 5, 6, 7, 9 and C99, M98,
M80 and FERP Annuitants
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DeltaCare Enhanced Plan Charges: |
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Delta Dental PPO of
Enhanced Level
II Plan Pays: |
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Preventive and Diagnostic Dentistry Prophylaxis
(cleaning) Fluoride
Application Oral
Exams Space
Maintainers Emergency
Office Visits X-rays |
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(No Deductible)* No
charge – limit 2 per 12 months No
charge – only to age 19 No
charge No
charge No
charge No
charge (Full mouth X-rays: 1 set per 24 consecutive months. Bitewings: 1 set (4 films) per every
6-month period.) |
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(No Deductible)* 100%
of UCR – limit 2 per 12 months+ 100%
of UCR 100%
of UCR – limit 2 per 12 months 100%
of UCR (without deductible) 100%
of UCR 100%
of UCR (Full mouth X-rays: 1 set in a 3-year period. Bitewings: 1 set per 12 months for age
18 and over.**) |
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Basic Dentistry Fillings Anesthesia Injection
of Antibiotics Extractions Oral
Surgery Endodontics Periodontics Denture
Relining |
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(No Deductible)* No
charge for amalgam Local
– no charge; General – covered for extractions only and only when
medically necessary Not
covered No
charge No
charge No
charge No
charge No
charge |
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(Deductible)* 80%
of UCR 80%
of UCR – limited to required anesthesia applied by dentist during oral
surgery. 80%
of UCR 80%
of UCR 80%
of UCR 80%
of UCR 80%
of UCR 80%
of UCR |
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Prosthetic Dentistry Crowns Prosthetic
Appliance Repair Dentures Bridges |
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(No Deductible)* No
charge, except lab cost of precious metals No
charge No
charge No
charge, except lab cost of precious metals |
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(Deductible)* 80%
of UCR 80%
of UCR 80%
of UCR 80%
of UCR |
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Maximum Benefit for Preventive,
Basic and Prosthetic Dentistry |
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No maximum* |
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$2,000 per calendar year per person |
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Orthodontics |
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(No Deductible)* $1,400
maximum co-payment (for covered children up to age 23). $1,600 maximum co-payments for
adults. Plus $350 start-up costs
for 24-month treatment plan. |
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(No Deductible)* 50%
of UCR. $1,000 maximum per
patient per case (for employees, spouse and dependent children). |
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Special Provisions,
Limitations, Exclusions Work
in progress when you join Predetermination
of benefits Alternative
to treatment provision Referral
to specialist Missing
teeth Out-of-area
emergency Deductible Prosthetic
replacements |
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Not covered. (Examples: in-progress orthodontics,
root canals started, teeth prepped for crowns, etc.) Not
required May
be additional cost. Approval is subject to review by dental
consultant. No exclusion against replacing missing teeth. Maximum of $100 No deductible Limited
to one each 5 years. |
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Only covers charges for
services the member receives on and after effective date of coverage. Not required; however,
suggested for services proposed over $100. If
dentist determines alternative treatment is necessary, approval is subject to
Delta review. N/A No
exclusion against replacing missing teeth. Out
of $50/person up to maximum of $150/family deductible per calendar year for both basic and prosthetic dentistry. Any part of deductible satisfied during last 3 months of calendar year is credited toward the next calendar year deductible. Limited
to one each 5 years. |
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*Refer to the Evidence of Coverage (EOC)
booklet. **Children under
18 are eligible for 2 sets of bitewing x-rays in a 12-month period. There
is a $500 maximum, per year, per child for pedodontic procedures only when
performed by a specialist (applies to DeltaCare +Under
certain guidelines Delta Dental participants who are pregnant are eligible to
receive an additional cleaning and/or periodontal examination in a calendar
year. |
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