Retiree Dental Plans Benefits Summary
DELTACARE | UNITEDHEALTHCARE | DELTA DENTAL PPO | |||
|---|---|---|---|---|---|
| Choice of Dentist | DeltaCare USA network only | UnitedHealthcare network only | You may choose any licensed dentist. You will receive a higher level of benefit and lower out-of-pocket costs with Delta Dental PPO or Premier network dentists. | ||
| Deductible | None | None | $50 per person; $100 for family for Premier and out-of-network services, excluding diagnostic and preventative care. | ||
| Plan Year Maximum | None | None | $1,250 per person, per calendar year, excluding orthodontia benefits, diagnostic and preventive care services (i.e. cleanings, exams and/or x-rays). | ||
| Covered Services | In-Network Only | In-Network Only | PPO Dentists | Premier Dentists | Out-of-Network |
| Cleanings¹ and Exams | 100% covered 1 every 6 months | 100% covered 1 every 6 months | 100% covered annual - 2x/yr.; pregnancy - 3x/yr. | 100% covered annual - 2x/yr.; pregnancy - 3x/yr. | 80% covered annual - 2x/yr.; pregnancy - 3x/yr. |
| X-Rays | 100% covered Some limitations apply | 100% covered | 100% covered Full mouth or panoramic 1x/5 years; bitewing 1x/year over age 18; not subject to annual maximum | 100% covered Full mouth or panoramic 1x/5 years; bitewing 1x/year over age 18; not subject to annual maximum | 80% covered Full mouth or panoramic 1x/5 years; bitewing 1x/year over age 18; not subject to annual maximum |
| Extractions | 100% covered | 100% covered | 80% covered | 80% covered | 80% covered |
| Fillings | 100% covered limitations apply to resin materials | 100% covered limitations apply | 80% covered | 80% covered | 80% covered |
| Crowns | 100% covered limitations apply to resin materials | 100% covered limitations apply | 60% covered | 50% covered | 50% covered |
| Dentures, Pontics, and Bridges | 100% covered full and partial dentures 1x/5yrs.; fixed bridgework, limitations apply | 100% covered full and partial dentures 1x/5yrs.; fixed bridgework, limitations apply | 60% covered | 50% covered | 50% covered |
| Endodontic/ Root Canals | 100% covered excluding the final restoration | 100% covered | 60% covered | 50% covered | 50% covered |
| Oral Surgery | 100% covered authorization required | 100% required | 80% covered | 80% covered | 80% covered |
| Implants | Not covered | Covered; refer to co-pay schedule | 60% covered | 50% covered | 50% covered |
| Orthodontia | Employee pays: $1,600/child $1,800/adult $350 startup fee; limitations apply | Employee pays: $2,000/child $2,000/adult $350 startup fee; limitations apply | Not covered | Not covered | Not covered |
| Night Guards | $100 co-pay | 100% covered | 80% covered (1x3yr.) | 80% covered (1x3yr.) | 80% covered (1x3yr.) |
¹Members with chronic conditions (cardiovascular (heart) disease; diabetes; cerebrovascular disease (stroke); HIV/AIDS; rheumatoid arthritis; chronic kidney disease; Sjogren’s syndrome; lupus; Parkinson’s disease; amyotrophic lateral sclerosis; Huntington’s disease; opioid misuse and addiction; joint replacement; and cancer) may receive up to 4 cleanings per year, through the SmileWay® Wellness Benefits program (Calendar Year Benefit Maximum does not apply). In any instance where information in this chart conflicts with a plan’s Evidence of Coverage (EOC), the plan’s EOC shall prevail.