Dental Plan Summary
This comparison of benefits is a basic summary only . Refer to the Human Resources portal for the plan document . Dental coverage terminates the last day of the month in which you are no longer eligible for benefits .
Benefit Description
DeltaCare ® USA TX15BDHMO *
Delta Dental PPO SM Low Option PPO **
Delta Dental PPO SM High Option PPO **
Co-payment Delta Dental Pays *** Delta Dental Pays *** Office Visit Co-pay $ 5 N / A N / A DIAGNOSTIC - oral examinations , x-rays $ 0 80 % 100 %
PREVENTIVE - routine cleanings , fluoride treatment , space maintainers , sealants
Fillings
Endodontics ( root canals )
Periodontics ( gum treatment & periodontal cleanings )
Simple Oral Surgery ( simple extractions )
Complex Oral Surgery ( complex extractions and other oral surgery )
MAJOR BENEFITS - crowns , inlays , onlays , cast restorations , bridges , dentures
Fixed co-pay according to fee schedule
Fixed co-pay according to fee schedule
Fixed co-pay according to fee schedule
Fixed co-pay according to fee schedule
Fixed co-pay according to fee schedule
Fixed co-pay according to fee schedule
Fixed co-pay according to fee schedule
80 % 100 %
60 % 80 %
50 % 80 %
50 % 80 %
50 % 80 %
50 % 50 %
50 % 50 %
IMPLANTS Not a covered benefit 50 % 50 % ORTHODONTIC BENEFITS
DEDUCTIBLE - waived on Diagnostic & Preventive Services
Fixed co-pay according to fee schedule ( adults & eligible dependent children )
N / A
Not Covered
$ 50 per person $ 150 per family
50 % ( eligible dependent children )
$ 50 per person $ 150 per family
PLAN YEAR MAXIMUM N / A $ 750 per person $ 1,750 per person
LIFETIME MAXIMUM FOR ORTHODONTIC
N / A Not Covered $ 1,000 per person
* If you choose a DeltaCare USA plan , you must use a DeltaCare USA dentist for treatment . Your selected contract dentist will take care of your dental care needs . If you require treatment from a specialist , your contract dentist will handle the referral for you . DeltaCare USA DHMO providers are located exclusively in Texas . ** Delta Dental PPO products offer freedom of choice of any dentist and you can maximize savings by utilizing PPO ( in-network ) dentists .
*** Low Plan – Reimbursement is based on PPO contracted fees for PPO dentists , PPO contracted fees for Premier dentists and PPO contracted fees for non-Delta Dental dentists ; High Plan – Reimbursement is based on PPO contracted fees for PPO dentists , Premier contracted fees for Premier dentists and 90th percentile for non-Delta Dental dentists .
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