City and County of San Francisco 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 | None | ||
| Plan Year Maximum | None | None | $2,500 per person, per calendar year, excluding orthodontia benefits, diagnostic and preventive 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 | $0 co-pay 1 every 6 months | $0 co-pay 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 | $0 co-pay, limitations apply | $0 co-pay | 100% covered | 100% covered | 80% covered |
| Extractions | $0 co-pay | $0 co-pay | 90% covered | 80% covered | 60% covered |
| Fillings | $0 co-pay, limitations apply | $0 co-pay, limitations apply | 90% covered | 80% covered | 60% covered |
| Crowns | $0 co-pay, limitations apply | $0 co-pay, limitations apply | 90% covered | 80% covered | 50% covered |
| Dentures, Pontics, and Bridges | $0 co-pay, limitations apply | $0 co-pay, limitations apply | 50% covered | 50% covered | 50% covered |
| Endodontic/ Root Canals | $0 co-pay | $0 co-pay | 90% covered | 80% covered | 60% covered |
| Oral Surgery | $0 co-pay authorization required | $0 co-pay authorization required | 90% covered | 80% covered | 60% covered |
| Implants | Not covered | Covered; refer to co-pay schedule | 50% covered | 50% covered | 50% covered |
| Orthodontia | Employee pays: $1,600/child $1,800/adult $350 startup fee; limitations apply | Employee pays: $1,250/child $1,250/adult $350 startup fee; limitations apply | 50% covered child $2,500 lifetime max; adult $2,500 lifetime max. | 50% covered child $2,000 lifetime max; adult $2,000 lifetime max. | 50% covered child $1,500 lifetime max; adult $1,500 lifetime max. |
| Night Guards | $100 co-pay | 100% covered | 80% covered (1x3yr.) | 80% covered (1x3yr.) | 80% covered (1x3yr.) |
¹For DELTA DENTAL PPO Members 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.