8
Dental Coverage
To help you manage dental costs, PR&C provides all full-time Team Members with two different dental plan options
from which to choose, Delta Dental DHMO plan and Delta Dental DPPO plan. Both options provide coverage for
preventive, basic, major and orthodontia services.
Similar to a medical HMO, the Delta Dental DHMO plan offers low out of pocket costs but only covers services from
dental providers participating in the Delta Dental DHMO provider network, DeltaCare USA. You and your enrolled
dependents must select a DHMO dentist/dental practice to manage your care.
Delta Dental PPO Plan allows you to receive treatment from PPO network dentists/dental practices and take advantage
of their fee discounts. The PPO provider network consists of Delta Dental PPO providers and Delta Dental Premier
providers. PPO providers are contracted In-network providers while the Premier providers are contracted Out-of-
network providers. The PPO Contracted Fees are calculated differently for each group so your costs will vary depending
on the network you select. You also have the freedom to receive treatment from a non-network dentist, but you are
responsible for any fees above the Delta Dental Program Allowance for those services.
Locate participating Delta Dental providers at
. Under the Dental Plan drop down menu, select DeltaCare
USA for the DHMO plan. For the DPPO plan you can select Delta Dental PPO (for the greatest savings) or Delta Dental Premier.
Review the plan comparison below to help determine which plan is right for your needs.
Delta Dental Plan Summaries
Benefit and
Covered Services
DHMO/DeltaCare USA
Delta Dental PPO
In-Network ONLY
In-Network
Premier Network/Non-Network**
Deductible
None
$50 per person, $150 per family
Calendar Year Max Benefit
None
$1,800 per person (not including
preventive services costs and
lifetime orthodontia maximum)
$1,800 per person (not including
lifetime orthodontia maximum)
Preventive Services
Cleanings, bitewing x-rays,
exams, fluoride, sealants
Fee schedule
No charge
You pay 10% of allowed charge*
Basic Services
Fillings, extractions,
periodontics, endodontics
Fee schedule
You pay 10% after deductible
You pay 30% of allowed charge*
after deductible
Major Services
Crowns, bridges, dentures,
inlays, onlays & cast, implants
Fee schedule
You pay 40% after deductible You pay 50% of allowed charge*
after deductible
Orthodontia
Adult and dependent child(ren) Fee schedule
You pay 50% up to
$1,000/person/lifetime
You pay 50% of allowed charge*
up to $600/person/lifetime
In-PPO Network
Out-of-PPO Network
Delta Dental PPO
SM
Dentists
Delta Dental Premier* Dentists & Non-Delta Dental Dentists
You will usually pay the lowest amount
for services when you visit a Delta Dental
PPO dentist.
PPO dentists agree to accept a reduced fee
for PPO Patients.
You are responsible for the difference between the amount Delta Dental pays and the
amount your non-Delta Dental dentist bills. You will usually have the highest out-of-
pocket costs when you visit a non-Delta Dental dentists.
Premier dentists may not balance bill above Delta Dental's approved amount, so your
out-of-pocket costs may be lower than with non-Delta Dental dentists' charges.
You are charged only the patient's share* at
the time of treatment. Delta Dental pays its
portion direct to the dentist.
Non-Delta Dental dentists may require you to pay the entire amount of the bill in
advance and wait for reimbursement.
Premier dentists charge you only the patient's share* at the time of treatment.
PPO dentists will complete claim forms and
submit them for you at no charge.
You may have to complete and submit your own claim forms, or pay your non-Delta
Dental dentist a service fee to submit them for you.**
Premier dentists will complete claim forms and submit them for you at no charge.
* Patient's share is the coinsurance/copayment, any remaining deductible, any amount over the annual maximum and any services your plan does not cover.
** If you visit a non-network dentist, Delta Dental will send the benefit payment directly to you. You are responsible for paying the non-network dentist's total fee, which
may include amounts in excess of your share of your plan's contract allowance.
