For eligible employees in the following categories: Unit 10, Unit 11 (Teaching Associates)
SFSU Headstart E99, and Unit 12
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DeltaCare Basic Plan Charges: |
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Delta Dental PPO of
Enhanced Level I
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 $10 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 – not covered Not
covered Uncomplicated
– no charge; $15-$25 for bony impactions (not covered for orthodontia) No
charge Root
canal – $20 anterior, $40 bicuspid, $60
molars $10
for curretage per quadrant $20
for gingivectomy per quadrant $80
for osseous surgery per quadrant Office
– no charge; Lab – $15 |
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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)* $35-$50
per crown + cost of precious metals Up
to $15 Full
– $60 each; Partials – $70 each $50
per unit + cost of precious metals |
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(Deductible)* 50%
of UCR 50%
of UCR 50%
of UCR 50%
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 plus $350 start-up costs for 24-month treatment plan (only
for covered children up to age 23).
Orthodontic extractions are not covered. |
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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 $50 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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