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 .
Employee Rate Information 2021
DeltaCare USA 1
Delta Dental Low Option PPO 2
Delta Dental High Option PPO 2
Coverage Level Bi-weekly Annual Bi-weekly Annual Bi-weekly Annual
Employee Only $ 5.19 $ 134.97 $ 6.71 $ 174.46 $ 16.20 $ 421.20
Employee + 1 $ 10.47 $ 272.22 $ 13.30 $ 345.80 $ 32.07 $ 833.82
Employee + Family $ 15.72 $ 408.72 $ 23.41 $ 608.66 $ 56.43 $ 1,467.18
1
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 .
2
Delta Dental PPO products offer freedom of choice of any dentist and you can maximize savings by utilizing PPO ( in-network ) dentists .
Benefit Description
DeltaCare ® USA
TX15BDHMO 1
Co-Payment ( What You Pay )
Delta Dental Low Option PPO 2
Delta Dental Pays
Delta Dental High Option PPO 2
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 )
Simpleoralsurgery ( simple extractions )
Complex oral surgery ( complex extractions and other oralsurgery )
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 |
Fixed co-pay according to fee schedule ( Adults and Children ) |
Not Covered |
50 % ( eligible children only ) |
DEDUCTIBLE-waivedondiagnostic & preventive services |
|
|
|
N / A |
$ 50 per person $ 150 per family |
|
$ 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
City of Arlington / EMPLOYEE BENEFITS GUIDE 2021
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