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Dental
DeltaCare USA provides you and your family with quality dental benefits and is designed to
encourage you to visit the dentist regularly to maintain your dental health. When you enroll,
you select a contract dentist to provide services. Your dentist will take care of your dental care
needs. If you need treatment from a specialist, your dentist will handle the referral for you.
Note: Dental services that are not performed by your selected contract dentist, or are not
covered under provisions for emergency care, must be preauthorized by Delta Dental to be
covered under your DeltaCare USA plan.
Under the DeltaCare USA plan, many services are covered at no cost, while others have
copayments. See the “
Description of Benefits and Copayments
” for a detailed list of benefits.
SEA/Confidential, SEIU, SMA, PSMA, Unrepresented Management, Department Directors
Dental Benefits
DeltaCare USA DHMO
In-Network
Calendar Year Deductible
$0
Annual Plan Maximum
Unlimited
Diagnostic and Preventive
$0-$10 copay* (varies by services; see contract for fee schedule)
Basic Services
Fillings
$0-$420 copay* (varies by services; see contract for fee schedule)
Root Canals
$0-$140 copay* (varies by services; see contract for fee schedule)
Periodontics
$0-$150 copay* (varies by services; see contract for fee schedule)
Major Services
$0-$160 copay* (varies by services; see contract for fee schedule)
Orthodontic Services
Orthodontia
$1,600-$1,800 copay (see contract for fee schedule)
Lifetime Maximum
Unlimited
Dependent Children
Covered to age 19
*The copay for each service is based upon the diagnostic codes determined by the American Dental Association (ADA).
Please consult the Description of Benefits and Copayments for the actual copay amount based on the ADA diagnostic codes
for each procedure. Limitations may apply for some benefits; some services may be excluded. Please refer to your Evidence
of Coverage or Summary Plan Description for waiting periods and a list of benefit limitations and exclusions.