Delta Dental Insurance Company
P.O. Box 1809
Alpharetta, GA 30023-1809 (800) 336-8264
Freedom of Choice is yours with the Delta Dental Program. You may select any dentist of your choice; however, you may reduce your costs by selecting a dentist who participates with Delta Dental. You may reduce your costs further by selecting an Access/DPO provider from the list. Participating dentists agree to:
You may choose to go to any Dentist. If a Dentist is not a Contracting Access Dentist, the amount charged to you may be above that charged by our Contracting Access Dentists. When Delta pays Benefits for services provided by Non-Contracting Access Dentists, Delta will allow the Customary fee or the fee which satisfies the majority of the Contracting Access Dentists. You will then be responsible for any extra amount charged by this Dentist over what Benefits Delta will pay in addition to any deductibles and maximums specified by the plan. This is called balance billing, that is, the Dentist may bill you for the balance after Delta's payment is made.
This page provides a brief description of the dental benefits available to all eligible employees and their dependents that include spouse, same sex domestic partner, children up to age 25 and grandchildren. Employees are eligible to enroll as a new hire, during the annual open enrollment periods or within 30 days of a valid family status change.
| Calendar year deductible | $50 per person $150 per family |
| No deductible on Diagnostic and Preventative Services | |
| Calendar year maximum | $1,500 per person |
Diagnostic & Preventive.....................................................................................................100%
Procedures to assist the dentist in determining required dental treatment (oral
examinations and x-rays); Prophylaxis (cleaning; periodontal cleaning in the
presence of gingival inflammation is considered to be periodontal); topical application of fluoride
solutions; space maintainers.
Basic.......................................................................................................................................80%
Oral surgery (extractions and certain other surgical procedures, including
pre- and post-operative care); General Anesthesia when administered by a dentist
for a covered oral surgery procedure; Endodontics (treatment of the tooth
pulp); Periodontics (treatment of gums and
bone supporting teeth); Palliative (treatment to relieve pain); Sealants
(topically applied acrylic, plastic or composite materials used to seal
developmental grooves and pits in permanent molars for the purpose of preventing
decay).
Restorative & Denture Repair...........................................................................................80%
Amalgam, synthetic porcelain, plastic fillings and prefabricated stainless
steel restorations for treatment of carious lesions (visible destruction of hard
tooth structure); repair to partial or complete dentures including rebase
procedures and relining.
Crowns, Jackets and Cast Restorations.............................................................................50%
For treatment of carious lesions (visible decay of the hard tooth structure)
when teeth cannot be restored with amalgam, synthetic porcelain, plastic restorationsor
prefabricated stainless steel restorations.
Prosthodontic
Benefits.........................................................................................................50%
Procedures to construct or repair fixed bridges and construction of partial
or complete dentures.
Orthodontic Services............................................................................................................50%
Procedures performed by a Dentist, involving the use of an active orthodontic
appliance and post-treatment retentive appliances for treatment of malocclusion
of teeth and/or jaws which significantly interferes with their functions.
Benefit levels are based on Delta Dental's usual, customary and
reasonable charges.
LIMITATIONS ON DIAGNOSTIC AND PREVENTIVE BENEFITS
a) Routine oral examinations and cleanings, including
periodontal cleanings, are not provided more than twice in any 12 month period
while the patient is an Enrollee under any Delta or any prepaid dental care
program provided by the Contractholder.
b) Full mouth x-rays or panographic x-rays will be provided when required by the Dentist, but not more than one x-ray each 5 years will be paid by Delta.
c) Bitewings are limited to 2 bitewing procedures (4
films per bitewing) each 12
months when provided to Enrollees under age 18 and 1 bitewing procedure each
12 months for Enrollees age 18 and over.
d) Delta will not pay for topical application fluoride for anyone 19
years or older.
e) Space maintainers are limited to the initial appliance only and to
Enrollees under age 14.
LIMITATIONS ON SEALANT BENEFITS
a) They are available only to Enrollees under the age of
15.
b) They are limited to application to permanent molars with no caries
(decay), without restorations and with the occlusal surface intact.
c) They do not include the repair or replacement of a sealant on any
tooth within 3 years of its application.
LIMITATIONS ON PROSTHODONTIC BENEFITS
a) Delta will not pay to replace any bridge or denture that the
patient received in the previous 5 years. An exception is made if the
bridge or denture cannot be made satisfactory due to a change in supporting
tissues or because too many teeth have been lost.
b) Delta limits Benefits for dentures to a standard partial or complete
denture. A "standard" denture means a removable appliance to replace
missing natural, permanent teeth that is made from acceptable materials by
conventional means.
c) Delta will not pay for implants (artificial teeth implanted into or
on bone or gums) or their removal; but Delta will credit the cost of a
standard complete or partial denture that would have been allowed under this
plan toward the cost of an implant and related services (coinsurance applies).
LIMITATIONS ON ORTHODONTIC BENEFITS
a) All payments will be on a monthly basis. The
obligation of Delta to make periodic payments for an Orthodontic treatment
plan begun prior to the date the patient becomes covered will commence with
the first payment due following the date the patient's coverage is effective.
b) The obligation of Delta to make periodic payments for Orthodontic
treatment will terminate on the payment due date next following the date the
Dependent Enrollee or the Primary Enrollee loses coverage, or upon termination
of the Contract, whichever will occur first.
c) Delta will not make any payment for repair or replacement of an
Orthodontic appliance furnished, in whole or in part, under this program.
d) Orthodontic Benefits are limited to Dependent Enrollee children under
age 25.
Delta Dental
P.O. Box 1809
Alpharetta, GA 30023
1-800-521-2651
