This plan provides dental care services at a fixed cost when you go to a dentist who is a member of Delta Dental's DHMO network. Similar to a medical HMO, the plan requires you and each of your covered dependents to choose a primary care dentist from Delta Dental's network. You must receive all your non-emergency dental care from your Delta Dental DHMO network dentist.
This plan is a preferred provider program that gives you the option of receiving treatment from any licensed dental provider you choose. If you go to a dentist who is a member of Delta Dental's DPPO network, you will receive a higher level of benefits and reduce your out-of-pocket costs. If you decide to go to a dentist outside of the DPPO network, the plan's benefits will be based on the Usual and Customary (U&C) charge for a particular dental service in your area. If your out-of-network dentist charges more than the U&C amount allowed by the plan, you have to pay the difference.
|Dental Benefits||Dental HMO|
(In & out-of-network)
|* deductible waived|
|Annual Deductible||No deductible||$50 per individual
$150 per family
|Annual Maximum||Unlimited||$1,750 per person
|Diagnostic & Preventive Services
||100% covered||100% covered*|
|Basic Services||Copay varies||80%|
|Endodontic & Periodontic Services||Copay varies||80%|
|Major Services||Copay varies||50%|
|Orthodontia||$1,700 child copay|
$1,900 adult copay
|50% up to $1,500 lifetime maximum benefit*
(adults and dependent children)
|Employee + Spouse||$7.13||$44.27|
|Employee + Child(ren)||$7.07||$54.27|
|Employee + Family||$14.52||$79.85|
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. This typically occurs when utilizing out-of-network or non-preferred providers.
The information contained in this website should in no way be construed as a promise or guarantee of employment. The company reserves the right to modify, amend, suspend, or terminate any plan at any time for any reason. If there is a conflict between the information in this website and the actual plan documents or policies, the documents or policies will always govern. Complete details about the benefits can be obtained by reviewing current plan descriptions, contracts, certificates, policies and plan documents available from your Human Resources Office.