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Small Business Program
We keep you smiling
®
Delta Dental Insurance Company
Businesses of all sizes are big on value.
Delta Dental Insurance Company’s (Delta Dental) small
business program affords small businesses a wide variety of
choices. Our PPO plans offer an attractive range of plan designs
with different options for maximums and out-of-network
claims reimbursement. Our prepaid plans offer a broad choice
of covered procedures at reasonable copayment amounts to fit
any budget.
Together, these choices add up to one thing — the ability
to select the best fit in premium levels and enrollee
copayment/coinsurance amounts. You can rely on Delta
Dental to provide cost management, comprehensive care
and superior access to dentists.
No matter which Delta Dental plan you choose, you can feel
confident knowing that you’ve chosen a plan that protects
your employees and offers your business big value.
Delta Dental PPOSM
Delta Dental’s small business plans offers PPO plan designs
to meet the needs of employers in Alabama, Florida, Georgia,
Louisiana, Nevada and Utah. In Texas, Delta Dental offers a
Dental Provider Organization plan (DPO).
The Delta Dental small business programs affords our clients
and their employees access to the nationwide Delta Dental
PPO and Premier networks, which are among the largest
networks in the U.S. Three out of every four dentists in the
United States are contracted Delta Dental dentists. PPO
dentists agree to accept reduced fees for covered procedures
when treating PPO patients. This means enrollees receive
their best benefits when visiting a PPO dentist.
DeltaCare® USA
DeltaCare USA is our prepaid plan that features set
copayments, no annual deductibles and no maximums for
covered benefits. Enrollees must select a primary care dentist
in the DeltaCare USA network from whom they receive
treatment as in a traditional DHMO. With DeltaCare USA,
businesses enjoy higher cost controls, while still providing
employees with comprehensive dental benefits.
DeltaCare USA delivers quality care for less cost than traditional
fee-for-service plans. DeltaCare USA dentists undergo a
comprehensive credentialing process to ensure they meet highquality standards. Most diagnostic and basic restorative services
are covered at little or no cost to the enrollee.
DeltaCare USA plans are available in Alabama, Florida, Georgia
and Texas.
Table of Contents
PPO
Delta Dental PPO Plans
2
Delta Dental PPO Table of Allowance Plan
4
Delta Dental PPO Program Guidelines
Getting To Know Delta Dental PPO
5-6
7
Limitations and Exclusions
13
Eligible/Ineligible Industries — Employer Paid
15
Eligible/Ineligible Industries — Voluntary
16
DeltaCare USA
Sample Procedures of DeltaCare USA Plans
8-9
Getting To Know DeltaCare USA
10
DeltaCare USA Program Guidelines
11-12
Limitations and Exclusions
17-21
Eligible/Ineligible Industries
22
Delta Dental’s Value Proposition
23
Delta Dental’s Mission Statement
24
Delta Dental PPO Plans
Sample of Benefits1
Program A
Program B
Program C
In/Out-of-Network
In/Out-of-Network
In/Out-of-Network
50% to 100%
50% to 100%
50% to 100%
Diagnostic and Preventive Services
Oral examinations
X-rays
Prophylaxis (cleanings)
Fluoride treatment
100%
100%
100%
Basic Services
Fillings
Denture repair
Sealants
80%
80%
100%
Major Services
Crowns, jackets and cast restorations
Prosthodontic services (dentures and bridges)
50%
50%
50%
Endodontics/Periodontics (covered under)
Basic
Major
Major
Oral Surgery (covered under)
Basic
Major
Major
Waiting Period
None
None
None
$50/$150
Yes
$50/$150
Yes
$25/$75
No
$1,000 or $1,500
$1,000 or $1,500
$1,000 or $1,500
50%
$1,000 or $1,5002
Not Applicable
50%
$1,000 or $1,5002
Not Applicable
50%
$1,000 or $1,5002
Not Applicable
Employer Contributions
Deductible
– Waived for diagnostic and preventive services
Annual Maximum (select one option)
Child Orthodontic Benefit (Optional – if selected, choose maximum)
Coverage level
Lifetime ortho maximum – select one option
Calendar year maximum
Available Reimbursement (choose one)
Available Rate Tier Options
1
2
3
4
2
PPO3
PPO3
PPO3
or
or
or
PPO Plus Premier4 PPO Plus Premier4 PPO Plus Premier4
2, 3 or 4 tier
2,3 or 4 tier
2, 3 or 4 tier
Subject to Limitations and Exclusions listed on page 13.
$1,500 ortho maximum is available for employer contributions of 75% or more.
Delta Dental’s benefit payment for a PPO provider will be based on the lesser of the submitted charge or the PPO provider allowed fee.
Delta Dental’s benefit payment will be based on the lesser of the submitted charge or the contracted dentist’s provider allowed fee. Non-contracted dentists are
paid the lessor of the submitted fee or the fee charged by dentists of similar training in the same geographical area.
Delta Dental PPO Plans (continued)
Program D5
Program E6
In/Out-of-Network
In/Out-of-Network
Hi Plan
Low Plan
In/Out-of-Network
5
6
7
8
Program VOL 1
Program VOL 2
In/Out-of-Network
In/Out-of-Network
50% to 100%
50% to 100%
50% to 100%
50% to 100%
0% to 49.9%
0% to 49.9%
100%
80%
100%
100%
100%
100%
80%
60%
80%
50%
80%
80%
50%
40%
50%
50%
50%
50%
Basic
Basic
Basic
Basic
Major
Basic
Basic
Basic
Basic
Basic
Major
Major
None
None
None
None
12 months7
12 months7
$50/$150
Yes
$50/$150
Yes
$75/$225
Yes
$50/$150
Yes
$50/$150
Yes
$1,000 or $1,500
$1,000 or $1,500
$750 or $1,000
$1,000 or $1,500
$1,000 or $1,500
50%
$1,000 or $1,5002
Not Applicable
50%
$1,000 or $1,5002
Not Applicable
50%
$750 or $1,0002
Not Applicable
50%
$1,000
$3508
50%
$1,000
$3508
PPO3
or
PPO Plus Premier4
PPO3
or
PPO Plus Premier4
PPO3
or
PPO Plus Premier4
PPO3
or
PPO Plus Premier4
2, 3 or 4 tier
2, 3 or 4 tier
2 or 3 tier
2 or 3 tier
Available in Alabama, Florida, Nevada and Utah.
The combined total of enrollees in both the Hi and Low plan must meet the minimum participation requirement of 5 primary enrollees. See participation
requirement listed on page 5. Enrollees can switch between plans only during the group’s annual open enrollment.
Applies to major and orthodontic services (if covered). Waiting period is waived for initial employees and their eligible dependents if covered under the
group’s prior dental plan.
Orthodontic maximum is included in annual maximum. Amounts applied towards orthodontic maximums are also applied to calendar year maximum.
3
Delta Dental PPO Table of Allowances Plan
Florida only1
Sample of Benefits2
Procedure Code3
Family Plan (TF)4
Child-Only Plan (TC)4
Delta Dental Pays
Diagnostic
Bitewing x-ray – single film
D0270
$11
$11
Bitewings x-rays – two films
D0272
$18
$18
Bitewings x-rays – three films
D0273
$23
$23
Bitewings x-rays – four films
(1 series every 6-months)
D0274
$27
$27
D1110
$34
$34
Prophylaxis cleaning child – to age 14
(1 per 6-month period)
D1120
$26
$26
Sealant – per tooth (limited through age 8
on first molars, and through age 15 on second
molars; the fee includes any necessary repair or
replacement within two years)
D1351
$20
$20
D2150
$38
$60
D2792
$78
$105
Endodontics
Root canal – molar (excluding final
restoration)
D3330
$79
$106
Periodontics
Periodontal scaling and root planing – one
to three teeth per quadrant
D4342
$10
$14
D5110
$101
$135
D5120
$101
$135
D7111
$16
$16
D8070
N/A
N/A
D8090
N/A
N/A
Calendar Year Deductible (per patient)
$50
None
Calendar Year Maximum (per patient)
$500
$500
Preventive
Prophylaxis cleaning – adult
(1 per 6-month period)
Restorative
Amalgam – two surfaces, primary or
permanent
Crown – full cast noble metal
Prosthodontics, Removable
Complete denture – maxillary
Complete denture – mandibular
Oral & Maxillofacial Surgery
Coronal remnants – deciduous tooth
Orthodontics
Comprehensive orthodontic treatment of
the transitional dentition – child or adolescent
to age 19
Comprehensive orthodontic treatment
of the adult dentition – adults, including
dependents and adult children covered
from ages 19
1 Available only to employers headquartered in Florida.
2 Subject to Limitations and Exclusions listed on page 13.
3 2009 Current Dental Terminology codes under copyright by the American Dental Association (ADA).
4 See brochure insert for complete description of the PPO table of allowances.
4
PPO Program Guidelines
Programs A, B, C, D, E, VOL 1 and VOL 2
Group size
Groups with five to 299 eligible employees. Available to new groups only.
Employer
contribution
The employer can contribute 0% to 49.9% or 50% to 100% of the primary employee premium. Separate rates are
established according to the employer contribution level.
Participation
requirement
Employee
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t 'PSFNQMPZFSDPOUSJCVUJPOTPGUPBNJOJNVNPGPSGJWFQSJNBSZFNQMPZFFTXIJDIFWFSJTHSFBUFSNVTUFOSPMM
t 'PSFNQMPZFSDPOUSJCVUJPOTPGUPBNJOJNVNPGPSGJWFQSJNBSZFNQMPZFFTXIJDIFWFSJTHSFBUFSNVTUFOSPMM
t 'PSFNQMPZFSDPOUSJCVUJPOBMMFNQMPZFFTNVTUFOSPMMBOEUIFHSPVQNVTUNBJOUBJOBNJOJNVNFOSPMMNFOUPGGJWF
eligible enrollees.
Dependents
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t *GFNQMPZFSDPOUSJCVUJPOJTFNQMPZFFTNVTUFOSPMMFFBMMUIFJSFMJHJCMFEFQFOEFOUT
Employer is required to provide a copy of the group’s quarterly wage statement or, if unavailable, the group’s payroll
listing to verify the number of eligible employees and to confirm compliance with the minimum participation
requirement.
Plan waiting
period
t
t
t
IFSFJTOPXBJUJOHQFSJPEGPSQMBOTXIFSFUIFFNQMPZFSDPOUSJCVUFTPSNPSFPGUIFQSJNBSZFNQMPZFFTQSFNJVN
5
5IFSFJTBNPOUIXBJUJOHQFSJPEPONBKPSBOEPSUIPEPOUJDTFSWJDFTJGDPWFSFE
GPSQMBOTXIFSFUIFFNQMPZFS
contributes less than 50% of the primary employees premium. The waiting period may be waived for initial enrollees
and eligible dependents, if covered under the group’s prior dental plan with no break in coverage. New hires,
regardless of prior coverage, must satisfy the waiting period.
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Eligible
employees
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NBZCFFMJHJCMFUPSFDFJWFCFOFmUTGPMMPXJOHUIF
employer’s eligibility requirement.
t $POUSBDUFNQMPZFFTDBUFHPSZFNQMPZFFT
BSFOPUFMJHJCMF
Eligible
dependents
t
t
t
t
-FHBMTQPVTF
ONBSSJFEEFQFOEFOUDIJMESFOBSFDPWFSFEUPUIFGPMMPXJOHBHFT"MBCBNB(FPSHJB/FWBEBo-PVJTJBOBo
6
Florida – to the end of the year the child turns 25; Texas – 25 and Utah – 26.
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where coverage is to age 26. Full-time students must be enrolled in an accredited school, college or university.
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Enrollment
For 100% employer contribution:
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t %FQFOEFOUTNVTUCFFOSPMMFEBUUIFTBNFUJNFBTUIFFNQMPZFFPSXJUIJOEBZTPGBRVBMJGZJOHFWFOU
For less than 100% employer contribution:
t &NQMPZFFTNVTUCFFOSPMMFEXJUIJOEBZTPGTBUJTGZJOHUIFFNQMPZFSTFMJHJCJMJUZSFRVJSFNFOU&NQMPZFFTOPU
enrolled when eligible may enroll only during the group’s annual open enrollment or within 30 days of a qualifying
event.
t %FQFOEFOUTDBOCFFOSPMMFEXIFOUIFFNQMPZFFCFDPNFTFMJHJCMF%FQFOEFOUTOPUFOSPMMFEXIFOFMJHJCMFNBZFOSPMM
only during the group’s annual open enrollment or within 30 days of a qualifying event.
Waive coverage
Applies only to groups with less than 100% employer contribution.
t &NQMPZFFBOEPSFMJHJCMFEFQFOEFOUTXIPEFDMJOFEUPFOSPMMXIFOFMJHJCMFNBZFOSPMMPOMZEVSJOHUIFHSPVQTBOOVBM
open enrollment or within 30 days of a qualifying event.
Termination
t
t
Dual choice
Available in Alabama, Florida, Georgia and Texas.
t *GUIFFNQMPZFSTFMFDUTB110QMBOXJUIB%FMUB$BSF64"QMBOFBDIQMBONVTUNFFUUIFNJOJNVNQBSUJDJQBUJPO
requirement (as stated above) and a minimum enrollment of five primary employees in the PPO plan and three
primary employees (two in Texas) in the DeltaCare USA plan.
t &OSPMMFFTNBZPOMZTXJUDICFUXFFOQMBOTEVSJOHUIFHSPVQTBOOVBMPQFOFOSPMMNFOU
t 110QMBOTBSFOPUWBMJEBTQBSUPGBEVBMDIPJDFPGGFSJOHXJUIBOPUIFSDBSSJFS
t Services under the DeltaCare USA plan must be rendered in the state in which the contract is issued.
Open enrollment
t
Employees and their eligible dependents may enroll, terminate or change coverage during the group’s annual open
enrollment.
Out-of-state
employees
t
t
Groups with five to 49 eligible employees: no more than 25% of eligible employees residing out-of-state are allowed.
Groups with 50 to 99 eligible employees: no more than 10% of eligible employees residing out-of-state are allowed, unless
all business locations are within situs state; then, up to 25% of eligible employes residing out-of-state are allowed.
Groups with 100 to 299 eligible employees: no more than 10% of eligible employees residing out-of-state are allowed.
t
%FOUBMDPWFSBHFXJMMFOEPOUIFMBTUEBZPGUIFNPOUIXIFOBOFNQMPZFFJTOPMPOHFSFMJHJCMFGPSDPWFSBHF
%FQFOEFOUDPWFSBHFXJMMFOEBUUIFTBNFUJNFBTUIFFNQMPZFFTPSXIFOUIFEFQFOEFOUJTOPMPOHFSFMJHJCMF
5
PPO Program Guidelines
PPO Table of Allowances Plan — Florida only
Family Plans (TF)
Child-Only Plans (TC)
Group size
t(SPVQTIFBERVBSUFSFEJO'MPSJEBXJUImWFUPFMJHJCMFFNQMPZFFT
tAvailable to new groups only.1
Employer
contribution
Employer can choose any level of contribution.
Participation
requirement
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enrollees for duration of contract.
t*GFNQMPZFFTFMFDUTEFQFOEFOUDPWFSBHFBOEFNQMPZFS
contribution is 100% of the dependent premium, then
all eligible dependents must be enrolled.
t&OSPMMBOENBJOUBJOBNJOJNVNPGmWFDIJMESFOGPS
duration of contract.
t*GFNQMPZFSTFMFDUTBOEQBZTPGQSFNJVNBMM
eligible children must be enrolled.
Plan waiting period No waiting periods.
Eligible
employees
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employer) may be eligible to receive benefits following
the employer’s eligibility requirement.
t$POUSBDUFNQMPZFFTDBUFHPSZFNQMPZFFT
BSFOPU
eligible.
t$PWFSBHFJTQSPWJEFEGPSFMJHJCMFDIJMESFOPOMZBOEJTOPU
provided for employees.
Eligible
dependents
t-BXGVMTQPVTF
t6ONBSSJFEDIJMESFOUPUIFFOEPGUIFZFBSJOXIJDI
they turn 25.
tDependents in military service are not eligible.
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which they turn 25.
t$IJMESFOPGDPOUSBDUFNQMPZFFTDBUFHPSZ
employees) are not eligible.
t$IJMESFOJONJMJUBSZTFSWJDFBSFOPUFMJHJCMF
Enrollment
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the employer’s eligibility requirement.
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employee or within 30 days of a qualifying event.
t6ONBSSJFEEFQFOEFOUDIJMESFONVTUCFFOSPMMFE
within 30 days of satisfying the employer’s eligibility
requirement or within 30 days of a qualifying event.
Waive coverage
Applies only to groups with less than 100% employer
contribution.
t&NQMPZFFBOEPSFMJHJCMFEFQFOEFOUTXIPEFDMJOFE
to enroll when eligible may enroll only during the
group’s annual open enrollment or within 30 days of a
qualifying event.
Applies only to groups with less than 100% employer
contribution.
t&NQMPZFFTXIPEFDMJOFUPFOSPMMUIFJSDIJMESFOXIFO
they become eligible may enroll during the group’s
annual open enrollment or within 30 days of a
qualifying event.
Termination
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when an employee is no longer eligible.
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employee’s or when the dependent is no longer eligible.
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the employee is no longer eligible or when the enrolled
child is no longer eligible.
Dual choice
Employer can select either the PPO family plan or the PPO child-only plan along with the DeltaCare USA family plan
(M92) or the DeltaCare USA child-only plan (M93).
t3FRVJSFTBNJOJNVNQBSUJDJQBUJPOSFRVJSFNFOUPGmWFQSJNBSZFOSPMMFFTGPSUIF110QMBOBOEUISFFQSJNBSZFOSPMMFFT
for the DeltaCare USA plan.
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t4FSWJDFTVOEFSUIF%FMUB$BSF64"QMBONVTUCFSFOEFSFEJOUIFTUBUFJOXIJDIUIFDPOUSBDUJTJTTVFE
Open enrollment
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terminate or change coverage during the group’s annual
open enrollment.
Out-of-state
employees
tGroups with five to 49 eligible employees: no more than 25% of eligible employees residing out-of-state are allowed.
tGroups with 50 to 99 eligible employees: no more than 10% of eligible employees residing out-of-state are allowed. If all
business locations are within the state of Florida, up to 25% of eligible employees residing out-of-state are allowed.
tGroups with 100 to 299 eligible employees: no more than 10% of eligible employees residing out-of-state are allowed.
1 Available only to employers headquartered in Florida.
6
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their children during the group’s annual open enrollment.
Getting To Know Delta Dental PPO
Free choice of dentists
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t$IBOHFEFOUJTUTBUBOZUJNFXJUIPVUQSFBQQSPWBM
t(PUPBOZEFOUBMTQFDJBMJTUXJUIPVUQSFBQQSPWBM
Special advantages from Delta Dental PPO dentists
Enrollees usually experience lower out-of-pocket expense when visiting a PPO dentist; however, if enrollees cannot visit a PPO dentist,
the best alternative is to choose a dentist from the Delta Dental Premier® network.
Delta Dental dentists agree to handle all claim forms and to charge no more than the fees allowed by Delta Dental.
For a comparison of out-of-pocket costs that enrollees will incur when visiting either a PPO, Premier or non-Delta Dental dentist, please
see the chart below.
Dentist Chosen
by the Enrollee
Best Choice
Next Best Choice
Least Favorable Choice
Delta Dental PPO Dentist
Delta Dental Premier Dentist
Non-Delta Dental Dentist
Fee
Arrangement
with Dentist
A PPO dentist agrees to accept Delta
Dental’s determination of the PPO
provider allowed fee as payment in
full for services provided.
A Premier dentist usually charges
higher fees than a PPO dentist, but
a Premier dentist agrees to accept
their allowed fee as payment in full
for services provided.
No contract arrangement.
Delta Dental
Pays
Delta Dental will pay the applicable
benefit level (percentage or fixed
dollar amount according to the
group’s plan) of the PPO provider
allowed fee, less any applicable
deductible, patient copayment/
coinsurance and charges for noncovered services, up to the annual
plan maximum.
Delta Dental will pay the applicable
benefit level (percentage or fixed
dollar amount) of the PPO provider
allowed fee or the Premier provider
allowed fee (according to the group’s
plan), less any applicable deductible,
patient copayment/coinsurance and
charges for non-covered services, up
to the annual plan maximum.
Delta Dental will reimburse the
enrollee, or the non-contracted
dentist (if benefits are assigned), the
applicable benefit level (percentage
or fixed dollar amount) of the fees
charged by dentists of similar training
in the same geographical area
(according to the group’s plan), less
any applicable deductible, patient
copayment/coinsurance and charges
for non-covered services, up to the
annual plan maximum.
Amounts the
Enrollee Pays
Enrollee potentially has the lowest
cost when visiting a PPO dentist since
the PPO dentist charges are usually
lower than those charged by a Premier
dentist or a non-contracted dentist.
Enrollee may have a higher cost by
visiting a Premier dentist but the cost
is usually lower then visiting a noncontracted dentist. Premier dentists
will not charge more than their
Premier provider allowed fee.
Enrollee generally has the highest
cost when visiting a non-contracted
dentist as there are no contract
limitations preventing the dentist
from charging any amount for
services provided.
The enrollee pays the difference
between the PPO or Premier provider
allowed fee (according to the group’s
plan) and the amount paid by Delta
Dental.
The enrollee pays the difference
between the non-contracted dentist’s
submitted charges and the amount
paid by Delta Dental. The dentist
may request payment in full at
the time of treatment and wait for
reimbursement from Delta Dental.
The enrollee pays the difference
between the PPO provider allowed fee
and the amount paid by Delta Dental.
At the time of treatment, the dentist
may require payment of the patient’s
portion (applicable deductible,
patient’s copayment/coinsurance,
charges for non-covered services and
any amount over the annual plan
maximum).
At the time of treatment, the dentist
may require payment of the patient’s
portion (applicable deductible,
patient’s copayment/coinsurance,
charges for non-covered services and
any amount over the annual plan
maximum).
Locating a Delta Dental PPO dentist
Enrollees may visit our national online directory at www.deltadentalins.com to find a Delta Dental PPO dentist anywhere nationwide.
7
Sample Procedures of DeltaCare USA Plan Benefits
Alabama, Florida, Georgia and Texas
Sample Procedure Description1
Sample Patient Copayments
Procedure
Code2
Plan
13A
Plan
14B
Plan
15B
Plan
15C3
Diagnostic Services
Intraoral – complete series (including bitewings)
Office visit
D0210
D9430
$0
$0
$0
$5
$0
$5
$0
$5
Preventive Services
Prophylaxis (cleaning) – adult
Prophylaxis (cleaning) – child
Sealants – per tooth
D1110
D1120
D1351
$0
$0
$10
$0
$0
$10
$5
$5
$15
$5
$5
$15
Restorative Services
Amalgam – one surface, primary or permanent
Resin-based composite – one surface, anterior
Resin-based composite – one surface, posterior
Crown – porcelain fused to high noble metal
Crown – full cast high noble metal
Crown – full cast noble metal
Post and core in addition to crown, indirectly fabricated – includes
canal preparation
D2140
D2330
D2391
D2750
D2790
D2792
D2952
$0
$0
$45
$355
$355
$295
$95
$0
$5
$55
$380
$380
$320
$95
$8
$22
$65
$395
$395
$335
$110
$8
$22
$65
$395
$395
$335
$110
Endodontics
Root canal – endodontic therapy – anterior tooth (excluding final restoration)
Root canal – endodontic therapy – molar (excluding final restoration)
D3310
D3330
$95
$335
$110
$350
$125
$365
$125
$365
D4260
$300
$345
$385
$385
D4341
$50
$55
$60
$60
D5110
D5211
$285
$245
$335
$295
$365
$325
$365
$325
D5213
$315
$365
$395
$395
D5750
$85
$90
$95
$95
D7140
D7210
$5
$45
$8
$50
$14
$55
$14
$55
D7240
$95
$110
$120
$120
Orthodontics
Comprehensive orthodontic treatment of the transitional dentition –
child or adolescent to age 19
D8070
$1,900
$1,900
$1,900
4
Comprehensive orthodontic treatment of the adult dentition – adults,
including dependent adult children covered from age 19
D8090
$2,100
$2,100
$2,100
4
None
None
None
Periodontics – endodontic therapy –
Osseous surgery (including flap entry and closure) – four or more
contiguous teeth or bounded teeth spaces per quadrant
Periodontal scaling and root planing – four or more teeth per quadrant
Prosthodontics (Removable)
Complete denture – maxillary
Maxillary partial denture – resin base (including any conventional clasps,
rests and teeth)
Maxillary partial denture – cast metal framework with resin denture
bases (including any conventional clasps, rests and teeth)
Reline complete maxillary denture (laboratory)
Oral and Maxillofacial Surgery
Extraction, erupted tooth or exposed root (elevation and/or forceps
removal)
Surgical removal of erupted tooth requiring elevation of mucoperiosteal
flap and removal of bone and/or section of tooth
Removal of impacted tooth – completely bony
Deductible/Annual Lifetime Maximums
Available Rate Tier Options
1
2
3
4
5
None
2, 3 or 4 tier
Subject to limitations and exclusions listed on pages 15, 17, 18 and 19.
(2009) Current dental terminology codes under copyright by American Dental Association (ADA).
When referable services are provided by a contract specialist, the enrollee pays 75% of the dentist’s allowed fee or 75% of the submitted fee, whichever is less.
Enrollee pays 75% of the contract orthodontist’s allowed fee or 75% of the submitted fee, whichever is less.
Not a covered benefit (child-only plan)
8
Sample Procedures of DeltaCare USA Benefits (continued)
Plans M73 and M74 — available only in Alabama, Florida and Georgia
Plans M92 and M93 — available only in Florida
Sample Procedure Description1
Sample Patient Copayments
Procedure
Code2
Plan
M733
Plan
M743
Plan
M92
Plan M93
(Child-only)
Diagnostic Services
Intraoral – complete series (including bitewings)
Office visit
D0210
D9430
$0
$10
$0
$5
$0
$45
$0
$5
Preventive Services
Prophylaxis (cleaning) – adult
Prophylaxis (cleaning) – child
Sealants – per tooth
D1110
D1120
D1351
$0
$0
$15
$0
$0
$0
$20
$20
$36
$0
$0
$10
Restorative Services
Amalgam – one surface, primary or permanent
Resin-based composite – one surface, anterior
Resin-based composite – one surface, posterior
Crown – porcelain fused to high noble metal
Crown – full cast high noble metal
Crown – full cast noble metal
Post and core in addition to crown, indirectly fabricated – includes
canal preparation
D2140
D2330
D2391
D2750
D2790
D2792
D2952
$44
$40
$70
$485
$485
$465
$140
$0
$28
$65
$485
$485
$465
$85
$25
$37
$65
$560
$535
$510
$125
$3
$12
Endodontics
Root canal – endodontic therapy – tooth anterior (excluding final restoration)
Root canal – endodontic therapy – molar (excluding final restoration)
D3310
D3330
$300
$470
$110
$245
$390
$570
5
5
D4260
$435
$360
$650
D4341
$78
$50
$138
D5110
D5211
$600
$440
$510
$535
$700
$650
5
5
D5213
$630
$610
$800
5
D5750
$145
$125
$225
5
D7140
$70
$18
$40
$7
D7210
$115
$30
$150
5
D7240
$160
$80
$260
5
D8070
4
$2,100
$2,200
$2,200
D8090
4
$2,250
$2,400
5
None
None
None
Periodontics
Osseous surgery (including flap entry and closure) – four or more
contiguous teeth or bounded teeth spaces per quadrant
Periodontal scaling and root planing – four or more teeth per quadrant
Prosthodontics (Removable)
Complete denture – maxillary
Maxillary partial denture – resin base (including any conventional clasps,
rests and teeth)
Maxillary partial denture – cast metal framework with resin denture
bases (including any conventional clasps, rests and teeth)
Reline complete maxillary denture (laboratory)
Oral and Maxillofacial Surgery
Extraction, erupted tooth or exposed root (elevation and/or forceps
removal)
Surgical removal of erupted tooth requiring elevation of mucoperiosteal
flap and removal of bone and/or section of tooth
Removal of impacted tooth – completely bony
Orthodontics
Comprehensive orthodontic treatment of the transitional dentition –
child or adolescent to age 19
Comprehensive orthodontic treatment of the adult dentition – adults,
including dependent adult children covered from age 19
Deductible/Annual Lifetime Maximums
None
5
5
5
5
5
5
5
9
Getting To Know DeltaCare USA
The DeltaCare USA plans provide enrollees with quality dental benefits at an affordable cost. The plans are designed to encourage
regular preventive dental visits in order to maintain good oral health. Enrollees must select a contract DeltaCare USA dentist for their
dental care. DeltaCare USA dental facilities have been carefully screened for quality.
Some services are covered at no cost, while others have copayments (the amount enrollees pay the DeltaCare USA dentist at the time
of treatment) for certain services. See the Description of Benefits and Copayments inserts of the brochure for a list of benefits and the
limitations and exclusions starting on page 17.
The DeltaCare USA plans give enrollees quality, convenience and cost savings
t/PEFEVDUJCMFTPSBOOVBMEPMMBSNBYJNVN
t$MFBSMZTFUDPQBZNFOUT
t/PSFTUSJDUJPOTPOQSFFYJTUJOHDPOEJUJPOTFYDFQUGPSXPSLJOQSPHSFTTBOEPSUIPEPOUJDTPOTPNFQMBOT
t&BTZBDDFTTUPTQFDJBMUZDBSF1
t0VUPGBSFBEFOUBMFNFSHFODZCFOFGJUNJMFTNBYJNVNQFSFNFSHFODZQFSFOSPMMFF
5FYBTFOSPMMFFTNBZ
be reimbursed for emergency services (refer to the group’s contract for complete details)
t7FSZMPXUVSOPWFSPGDPOUSBDUEFOUJTUTTPFOSPMMFFTDBOFTUBCMJTIBMPOHUFSNSFMBUJPOTIJQXJUIUIFJSEFOUJTU
t/PDMBJNGPSNTUPDPNQMFUF
t5PMMGSFFDVTUPNFSTFSWJDFGSPNBNUPQN&BTUFSOUJNF.POEBZUISPVHI'SJEBZ
How the DeltaCare USA plans work
Employees in a DeltaCare USA plan will receive an enrollment packet with complete instruction on how to select a DeltaCare USA
dentist.
The selected DeltaCare USA dentist will take care of the enrollee’s dental care needs. If enrollees require treatment from a specialist,
the DeltaCare USA dentist will handle the referral.1
Locating a DeltaCare USA dentist
Enrollees may visit our online directory at www.deltadentalins.com to find a DeltaCare USA dentist.
1 Specialty care provisions are not available in the child-only plan; however, there is a provision for pediatric referral,
subject to the plans limitations and exclusions.
10
DeltaCare USA Program Guidelines
For plans 13A, 14B, 15B, 15C, M731, and M741
Group size
t *O"MBCBNB'MPSJEBBOE(FPSHJBHSPVQTXJUIUISFFFMJHJCMFFNQMPZFFT
t *O5FYBTHSPVQTXJUIUXPFMJHJCMFFNQMPZFFT
t Available to new groups only.
Eligible industries
See page 22 for a complete list of eligible/ineligible industries
Employer contribution
The employer can contribute 0% to 49.9% or 50% to 100% of the eligible employee’s premium.
For plan M73 — 100% employer contribution for eligible employees and dependent is required in
Jefferson County, Alabama.
Participation requirement
Employee
t "NJOJNVNFOSPMMNFOUPGUISFFQSJNBSZFNQMPZFFTJTSFRVJSFEJO"MBCBNB'MPSJEBBOE(FPSHJBBOE
two primary employees in Texas. DeltaCare USA plans are not available in Louisiana, Nevada or Utah.
Dependent
t *GFNQMPZFSDPOUSJCVUJPOJTFNQMPZFFTNVTUFOSPMMBMMUIFJSFMJHJCMFEFQFOEFOUT
Employer is required to provide a copy of the group’s quarterly wage statement, or if unavailable,
the group’s payroll listing to verify the number of primary employees and to confirm compliance
with the minimum participation requirement.
Plan waiting period
t 5IFSFJTOPXBJUJOHQFSJPE
Eligible employees
t "MMQFSNBOFOUGVMMUJNFFNQMPZFFTBTEFmOFECZUIFFNQMPZFS
NBZCFFMJHJCMFUPSFDFJWF
benefits following the employer’s eligibility requirement.
t $POUSBDUFNQMPZFFTDBUFHPSZFNQMPZFFT
BSFOPUFMJHJCMF
Eligible dependents
t
t
t
t
-FHBMTQPVTF
6ONBSSJFEEFQFOEFOUDIJMESFOBSFDPWFSFEUPUIFGPMMPXJOHBHFT"MBCBNBBOE(FPSHJBo
Florida – end of the year in which child turns 25 and Texas – 25.
6ONBSSJFEEFQFOEFOUDIJMESFOXIPBSFGVMMUJNFTUVEFOUTBSFDPWFSFEUPBHFJO
Georgia). Full-time students must be enrolled in an accredited school, college or university.
%FQFOEFOUTJONJMJUBSZTFSWJDFBSFOPUFMJHJCMF
Enrollment
For 100% employer contribution:
t &NQMPZFFTNVTUCFFOSPMMFEXJUIJOEBZTPGTBUJTGZJOHUIFFNQMPZFSTFMJHJCJMJUZSFRVJSFNFOU
t %FQFOEFOUTNVTUCFFOSPMMFEBUUIFTBNFUJNFBTUIFFNQMPZFFPSXJUIJOEBZTPGB
qualifying event.
For less than 100% employer contribution:
t &NQMPZFFTNVTUCFFOSPMMFEXJUIJOEBZTPGTBUJTGZJOHUIFFNQMPZFSTFMJHJCJMJUZSFRVJSFNFOU
Employees not enrolled when eligible may enroll only during the group’s annual open
enrollment or within 30 days of a qualifying event.
t %FQFOEFOUTDBOCFFOSPMMFEXIFOUIFFNQMPZFFCFDPNFTFMJHJCMF%FQFOEFOUTOPUFOSPMMFE
when eligible may enroll only during the group’s annual open enrollment or within 30 days of
a qualifying event.
Waive coverage
Applies only to groups with less than 100% employer contribution.
t &NQMPZFFBOEPSFMJHJCMFEFQFOEFOUTXIPEFDMJOFEUPFOSPMMXIFOFMJHJCMFNBZFOSPMMPOMZ
during the group’s annual open enrollment or within 30 days of a qualifying event.
Termination
t %FOUBMDPWFSBHFXJMMFOEPOUIFMBTUEBZPGUIFNPOUIXIFOBOFNQMPZFFJTOPMPOHFSFMJHJCMF
for coverage.
t %FQFOEFOUDPWFSBHFXJMMFOEBUUIFTBNFUJNFBTUIFFNQMPZFFPSXIFOUIFEFQFOEFOUJTOP
longer eligible.
Dual choice
Available in Alabama, Florida, Georgia and Texas only.
t *GFNQMPZFSTFMFDUTB110QMBOXJUIB%FMUB$BSF64"QMBOFBDIQMBONVTUNFFUUIFNJOJNN
participation requirements as follows:
PPO plan:
t UPFNQMPZFSQBJE‰BNJOJNVNPGmWFQSJNBSZFNQMPZFFTNVTUFOSPMM
t UPFNQMPZFSQBJE‰PSmWFQSJNBSZFNQMPZFFTXIJDIFWFSJTHSFBUFSNVTUFOSPMM
t UPFNQMPZFSQBJE‰PSmWFQSJNBSZFNQMPZFFTXIJDIFWFSJTHSFBUFSNVTU
enroll.
DeltaCare USA plan:
t "NJOJNVNPGUISFFUXPJO5FYBT
FMJHJCMFFNQMPZFFTNVTUFOSPMM
If 100% employer paid, all eligible employees and dependents must be enrolled in either the PPO
plan or the DeltaCare USA plan.
t &OSPMMFFTNBZTXJUDICFUXFFOQMBOTPOMZEVSJOHUIFHSPVQTBOOVBMPQFOFOSPMMNFOU
t %FMUB$BSF64"QMBOTBSFOPUBWBJMBCMFBTQBSUPGBEVBMDIPJDFPGGFSJOHXJUIBOPUIFSDBSSJFS
t 4FSWJDFTVOEFSUIF%FMUB$BSF64"QMBONVTUCFSFOEFSFEJOUIFTUBUFJOXIJDIUIFDPOUSBDUJTJTTVFE
Open enrollment
Employers may enroll, terminate or change coverage during the group’s annual open enrollment.
Out-of-state employees
Out-of-state employees are covered provided services are rendered in the state where the contract
is issued.
1 Plans M73 and M74 are not available in Texas.
11
DeltaCare USA Program Guidelines
For plans M92 and M93 — Florida only
Family Plans (M92)
Child-Only Plans (M93)
Group size
t(SPVQTIFBERVBSUFSFEJO'MPSJEBXJUIUISFFUPFMJHJCMFFNQMPZFFT
t"WBJMBCMFUPOFXHSPVQTPOMZ
Employer
contribution
Employer can choose any level of contribution.
Participation
requirement
t&OSPMMBOENBJOUBJOBNJOJNVNPGUISFFQSJNBSZ
employees for duration of contract.
Plan waiting period
t/PXBJUJOHQFSJPET
Primary employees
t"MMQFSNBOFOUGVMMUJNFFNQMPZFFTBTEFmOFECZUIF
employer) are eligible to receive benefits following the
employer’s eligibility requirement.
t$POUSBDUFNQMPZFFTDBUFHPSZFNQMPZFFT
BSFOPU
eligible.
Coverage is provided for eligible children only and is not
provided for employees.
Eligible dependents
t4QPVTFVOMFTTMFHBMMZTFQBSBUFEPSEJWPSDFE
t6ONBSSJFEDIJMESFOUPUIFFOEPGUIFZFBSJOXIJDI
they turn 25.
t%FQFOEFOUTJOBDUJWFNJMJUBSZTFSWJDFBSFOPUFMJHJCMF
t6ONBSSJFEDIJMESFOBSFFMJHJCMFUPUIFFOEPGUIFZFBS
in which they turn 25.
t$IJMESFOPGDPOUSBDUFNQMPZFFTDBUFHPSZ
employees) are not eligible.
t$IJMESFOJOBDUJWFNJMJUBSZTFSWJDFBSFOPUFMJHJCMF
Enrollment
t&NQMPZFFTBSFTVCKFDUUPBPOFZFBSNJOJNVN
enrollment period.
t/FXFNQMPZFFTNVTUFOSPMMXJUIJOEBZTPG
becoming eligible.
t%FQFOEFOUTNVTUFOSPMMXJUIJOEBZTPGCFDPNJOH
eligible or during an open enrollment.
t$IJMESFOBSFSFRVJSFEUPFOSPMMGPSBNJOJNVNPGPOF
year.
t$IJMESFONVTUCFFOSPMMFEXJUIJOEBZTPGCFDPNJOH
eligible or during an open enrollment.
Waive coverage
t&NQMPZFFTPSEFQFOEFOUTXIPEFDMJOFUPFOSPMMXIFO
t&NQMPZFFTXIPEFDMJOFUPFOSPMMUIFJSDIJMESFOXIFO
they become eligible may enroll at any open enrollment
they become eligible may enroll them at any open
or within 30 days of a qualifying event.
enrollment or within 30 days of a qualifying event.
Termination
t*GDPWFSBHFJTUFSNJOBUFEEVSJOHBOPQFOFOSPMMNFOU
period, employee or dependents are eligible to re-enroll
during any open enrollment period.
t*GDPWFSBHFJTUFSNJOBUFECFUXFFOPQFOFOSPMMNFOU
periods and employee or dependent subsequently
desires to re-enroll, all premium must be paid
retroactive to date of cancellation (not to exceed 12
months) prior to being reinstated.
t$PWFSBHFXJMMFOEPOUIFMBTUEBZPGUIFNPOUIXIFO
the employee is no longer eligible.
t%FQFOEFOUDPWFSBHFXJMMFOEBUUIFTBNFUJNFBTUIF
employee’s or when the dependent is no longer eligible.
Dual choice
Employer can select the PPO table of allowances family plan or child-only plan along with the DeltaCare USA
family plan (M92) or the DeltaCare USA child-only plan (M93). Each plan must meet the minimum participation
requirement.
t110QMBOSFRVJSFTBNJOJNVNPGmWFQSJNBSZFNQMPZFFT%FMUB$BSF64"SFRVJSFTBNJOJNVNFOSPMMNFOUPG
three primary employees in Alabama, Florida and Georgia and two in Texas.
t&OSPMMFFTNBZOPUTXJUDICFUXFFOQMBOTFYDFQUEVSJOHUIFHSPVQTBOOVBMPQFOFOSPMMNFOU
t4FSWJDFTVOEFSUIF%FMUB$BSF64"QMBONVTUCFSFOEFSFEJOUIFTUBUFJOXIJDIUIFDPOUSBDUJTJTTVFE
Open enrollment
Employees and their eligible dependents may enroll,
terminate or change coverage during the group’s annual
open enrollment.
Employees may enroll, terminate or change coverage for
their children during the group’s annual open enrollment.
Out-of-state
employees
All services must be rendered in the state of Florida.
All services must be rendered in the state of Florida.
12
t&OSPMMBOENBJOUBJOBNJOJNVNPGUISFFDIJMESFOGPS
duration of the contract.
t*GDPWFSBHFJTUFSNJOBUFEEVSJOHBOPQFOFOSPMMNFOU
period, children are eligible to be re-enrolled at any
open enrollment period by the employee.
t*GDPWFSBHFJTUFSNJOBUFECFUXFFOPQFOFOSPMMNFOU
periods and the employee subsequently desires to reenroll children, all premium must be paid retroactive
to date of cancellation (not to exceed 12 months) prior
to being reinstated.
t$PWFSBHFXJMMFOEPOUIFMBTUEBZPGUIFNPOUIXIFO
the employee is no longer eligible or when the child is
no longer eligible.
Delta Dental PPO Limitations and Exclusions
Limitations on Diagnostic and Preventive Benefits:
t%FMUB%FOUBMXJMMOPUQBZGPSNPSFUIBOUXPPSBMFYBNT
and cleanings, including periodontal cleaning, done in any
calendar year that the enrollee is covered by any Delta
Dental program.
t'VMMNPVUIYSBZTPSQBOPHSBQIJDYSBZTXJMMCFQSPWJEFE
when required by the dentist, but no more than once each
five years will be paid by Delta Dental.
t#JUFXJOHYSBZTBSFMJNJUFEUPUXJDFJOBOZDBMFOEBSZFBS
when provided to dependent child enrollees and once in
any calendar year for primary enrollees and dependent
spouse enrollees.
t5IFPCMJHBUJPOPG%FMUB%FOUBMUPNBLFQFSJPEJDQBZNFOUT
for orthodontic treatment will terminate on the payment
due-date next following the date the dependent or primary
enrollee loses coverage, or upon termination of the contract,
whichever occures first.
t%FMUB%FOUBMXJMMOPUNBLFBOZQBZNFOUGPSSFQBJSPS
replacement of an orthodontic appliance furnished, in whole
or in part, while enrolled under this program.
t0SUIPEPOUJDCFOFGJUTBSFMJNJUFEUPEFQFOEFOUDIJME
enrollees.
t9SBZTPSFYUSBDUJPOTBSFOPUTVCKFDUUPUIFPSUIPEPOUJD
maximum.
t%FMUB%FOUBMXJMMOPUQBZGPSUPQJDBMBQQMJDBUJPOPGGMVPSJEF
for an enrollee 19 years or older.
t4VSHJDBMQSPDFEVSFTBSFOPUTVCKFDUUPUIFPSUIPEPOUJD
maximum.
Sealant Benefit Limitations:
Optional Services
t4FBMBOUCFOFGJUTBSFBWBJMBCMFPOMZUPEFQFOEFOUFOSPMMFFT
through age 15.
If an eligible person selects a more expensive plan of treatment
than is customarily provided, or chooses specialized techniques
rather than standard procedures, Delta Dental will pay benefits
for the least costly procedure. The enrollee is responsible for the
remainder of the dentist’s fee. (Examples: electing a crown where
an amalgam filling would restore the tooth; a precision denture
where a standard denture would suffice; a composite restoration
instead of an amalgam restoration on posterior teeth.)
t4FBMBOUTBSFMJNJUFEUPBQQMJDBUJPOUPQFSNBOFOUNPMBSTXJUI
no caries (decay), without restorations and with the occlusal
surface intact.
t4FBMBOUCFOFGJUTEPOPUJODMVEFUIFSFQBJSPSSFQMBDFNFOU
of a sealant on any tooth within two years of its application.
Limitations on Crowns, Jackets and Cast Restorations:
Exclusions:
t Delta Dental will not pay to replace any crown, jacket or cast
restoration which the patient received in the previous five years.
Delta Dental does not pay benefits for:
Limitations on Prosthodontic Benefits:
t Delta Dental will not pay to replace prosthodontic appliances
including, but not limited to, fixed bridges and partial or
complete dentures, until five years have elapsed following
any prior provision of such appliance under any Delta Dental
program or dental care program provided by the employer,
unless there is such extensive loss of remaining teeth or
change in supporting tissues that the existing appliance
cannot be made satisfactory.
t Replacement of a prosthodontic appliance not covered
under a Delta Dental or any dental care program provided
by the employer shall be covered only if the appliance is
unsatisfactory and cannot be made satisfactory.
t Delta Dental limits benefits for dentures to a standard
partial or complete denture. A “standard” partial or complete
denture means a removable appliance to replace missing
natural, permanent teeth that is made from acceptable
materials by conventional means.
Limitations on Orthodontic Benefits; if covered:
t5IFNBYJNVNBNPVOUQBZBCMFGPSFBDIFOSPMMFFEVSJOHUIF
enrollee’s lifetime is shown on the Group Highlights page.
t"MMQBZNFOUTXJMMCFPOBNPOUIMZCBTJT5IFPCMJHBUJPOPG
Delta Dental to make periodic payments for an orthodontic
treatment plan begun prior to the date the patient becomes
covered will commence with the first payment due following
the date the patient’s coverage is effective.
t4FSWJDFTGPSJOKVSJFTPSDPOEJUJPOTXIJDIBSFDPNQFOTBCMF
under Workers’ Compensation or Employers’ Liability Laws;
services which are provided to the eligible person by any federal
or state government agency or are provided without cost to the
eligible person by any municipality, county or other political
subdivision, except as exclusion may be prohibited by law.
t4FSWJDFTXJUISFTQFDUUPDPOHFOJUBMIFSFEJUBSZ
PS
developmental (following birth) malformations or cosmetic
surgery or dentistry for purely cosmetic reasons, including
but not limited to cleft palate (unless services for cleft palate
are provided to a covered child under age 18), maxillary
and mandibular (upper and lower jaw) malformations,
enamel hypoplasia (lack of development), fluorosis (a type of
discoloration of the teeth), and anodontia (congenitally missing
teeth). This does not exclude services provided to newborn
children for congenital defects or birth abnormalities or those
services provided under the orthodontic benefits, if covered.
t4FSWJDFTGPSSFTUPSJOHUPPUITUSVDUVSFMPTUGSPNXFBSFSPTJPO
or abrasion, for rebuilding or maintaining chewing surfaces
due to teeth out of alignment or occlusion, or for stabilizing
the teeth. Such services include but are not limited to
equilibration, occlusal adjustment and periodontal splinting.
t"OZTJOHMFQSPDFEVSFTUBSUFEQSJPSUPUIFEBUFUIFFOSPMMFF
became eligible for such services under the contract.
t1SFTDSJCFEESVHTNFEJDBUJPOPSBOBMHFTJB
t&YQFSJNFOUBMQSPDFEVSFT
13
Exclusions (continued)
t$IBSHFTCZBOZIPTQJUBMPSPUIFSTVSHJDBMPSUSFBUNFOUGBDJMJUZ
and any additional fees charged by the dentist for treatment
in any such facility.
t$IBSHFTGPSBOFTUIFTJBPUIFSUIBOHFOFSBMBOFTUIFTJB
administered by a licensed dentist in connection with
covered oral surgery services.
t&YUSBPSBMHSBGUTHSBGUJOHPGUJTTVFTGSPNPVUTJEFUIFNPVUI
to oral tissues).
t%JBHOPTJTPSUSFBUNFOUPGBOZDPOEJUJPOSFMBUFEUPUIF
temporomandibular (jaw) joint or associated musculature,
nerves and other tissues (MPD-TMJ).
t4FSWJDFTQFSGPSNFECZBOZQFSTPOPUIFSUIBOBEFOUJTU%%4
DMD) or auxiliary personnel legally authorized to perform
services under the supervision of a dentist.
t0SUIPEPOUJDTFSWJDFT
t*NQMBOUTQSPTUIFUJDBQQMJBODFTQMBDFEJOUPPSPOUIF
bone of the upper or lower jaw to retain or support dental
prosthesis), their removal or other associated procedures.
t6OEFSUIF1105BCMFPG"MMPXBODFTQMBO%FMUB%FOUBM
will not pay for services not included on the PPO
table of allowances.
14
PPO Program Eligible/Ineligible Industries — Employer Paid
Level One
Agriculture, Forestry, Fishing (except
seasonal employees)
Mining, Oil and Gas Extraction
Construction Contractors
Manufacturing (except Jewelry Manufacturing)
Transportation
Communication (Radio, Telephone, TV/
Radio Broadcasting)
Utilities
Wholesale Trade
Retail Trade (Bldg. Materials, Hardware,
Mobile Homes)
Retail (Apparel, Accessories, Home Furnishings)
Miscellaneous Retail
Public Administration (Cities, Counties, Police)
Level Two
Auto Dealerships (New & Used) and Service
Stations
Restaurants
Finance (Banks, Securities, Credit Agencies)
Insurance Carriers/Brokers
Real Estate
Hotels
Laundry/Garment Services
Photographic Studios
Beauty & Barber Shops
Shoe Repair Shops
Funeral Services & Crematories
Tax Return Preparation Services/
Misc. Personal Services
Advertising
Advertising, Misc. not classified
Collection Agencies & Credit Reporting Services
Direct Mailing, Reproductions,
Secretarial Services
SIC Code
0100-0999
1000-1499
1500-1799
2000-3999
4000-4799
4800-4899
4900-4999
5000-5199
5200-5499
5600-5799
5912-5999
9000-9999
SIC Code
5511-5599
5800-5899
6000-6299
6300-6499
6500-6799
7000-7099
7211-7219
7221
7231-7241
7251
7261
7291-7299
7311-7313
7319
7322-7323
Level Two (Continued)
SIC Code
Disinfecting & Pest Control Services
Building Maintenance/Equipment Rental
Computer Programming & Related Services
Misc. Computer Services
Security Systems, Detectives, Armored Cars
News Syndicates
Photofinishing Labs
Misc. Business Services
Auto Rental Agencies
Automobile Parking Services
Independent Auto Repair & Services
Electrical Repair (Radio, TV, A/C, Refrigerator)
Watch, Clock & Jewelry Repair
Furniture Repair/Reupholstery
Misc. Repair Shops
Repair Services, not elsewhere classified
Motion Picture Production, Distribution
and Services
Medical Groups/Offices (except 8021 –
Dental Offices)
Educational Services/Schools/Libraries
Nursing and Personal Care Facilities/Hospitals/
Outpatient Care (except 8072 – Dental Labs)
Engineering & Management Services
7342
7349-7359
7370-7378
7379
7381-7382
7383
7384
7389
7513-7519
7521
7532-7549
7622-7629
7631
7641
7692-7694
7699
Ineligible Industries
SIC Code
Employment Agencies/Employee Leasing Firms
Amusement, Recreation & Entertainment
Dentist offices
Dental Labs
Legal
Community Service Organizations
Associations, Membership Organizations
and Trusts
7361-7363
7900-7999
8021
8072
8100-8199
8300-8499
7800-7841
8011-8049
8200-8299
8050-8099
8700-8799
8600-8699
7331-7338
15
PPO Program Eligible/Ineligible Industries — Voluntary
Delta Dental PPO
Eligible Industries
Level One
Agriculture, Forestry, Fishing (except seasonal
employees)
Mining, Oil and Gas Extraction
Construction Contractors
Manufacturing (except Jewelry Manufacturing)
Transportation
Communication (Radio, Telephone, TV/Radio
Broadcasting)
Utilities
Wholesale Trade
Retail Trade (Bldg. Materials, Hardware,
Mobile Homes)
Retail (Apparel, Accessories, Home Furnishings)
Miscellaneous Retail
Public Administration (Cities, Counties, Police)
SIC Code
0100-0999
1000-1499
1500-1799
2000-3999
4000-4799
4800-4899
4900-4999
5000-5199
5200-5499
5600-5799
5912-5999
9000-9999
Level Two
SIC Code
Finance (Banks, Securities, Credit Agencies)
Insurance Carriers/Brokers
Real Estate
Hotels
Laundry/Garment Services
Photographic Studios
Beauty & Barber Shops
Shoe Repair Shops
Funeral Services & Crematories
Tax Return Preparation Services/Misc.
Personal Services
Advertising
Advertising, Misc. not classified
Collection Agencies & Credit Reporting Services
Direct Mailing, Reproductions, Secretarial
Services
Disinfecting & Pest Control Services
Building Maintenance/Equipment Rental
Computer Programming & Related Services
Misc. Computer Services
6000-6299
6300-6499
6500-6799
7000-7099
7211-7219
7221
7231-7241
7251
7261
16
7291-7299
7311-7313
7319
7322-7323
7331-7338
7342
7349-7359
7370-7378
7379
Level Two (Continued)
SIC Code
Security Systems, Detectives, Armored Cars
News Syndicates
Photofinishing Labs
Misc. Business Services
Auto Rental Agencies
Automobile Parking Services
Independent Auto Repair & Services
Electrical Repair (Radio, TV, A/C, Refrigerator)
Watch, Clock & Jewelry Repair
Furniture Repair/Reupholstery
Misc. Repair Shops
Repair Services, not elsewhere classified
Motion Picture Production, Distribution
and Services
Medical Groups/Offices (except 8021 Dental Offices)
Educational Services/Schools/Libraries
Engineering & Management Services
7381-7382
7383
7384
7389
7513-7519
7521
7532-7549
7622-7629
7631
7641
7692-7694
7699
Level Three
SIC Code
Nursing and Personal Care Facilities/Hospitals/
Outpatient Care (except 8072 – Dental Labs)
8050-8099
Level Four
SIC Code
Auto Dealerships (New & Used) and
Service Stations
Restaurants
5511-5599
5800-5899
Ineligible Industries
SIC Code
Employment Agencies/Employee Leasing Firms
Amusement, Recreation & Entertainment
Dentist Offices
Dental Labs
Legal
Community Service Organizations
Associations, Membership Organizations
and Trusts
7361-7363
7900-7999
8021
8072
8100-8199
8300-8499
7800-7841
8011-8049
8200-8299
8700-8799
8600-8699
DeltaCare USA Limitations and Exclusions — Plans 13A, 14B, 15B and 15C
Limitations
Exclusions
(Plans available only in Florida, Georgia and Texas)
Any procedure not specifically listed in the “Description Of
Benefits and Copayments.”
THIS IS ONLY A BRIEF SUMMARY OF THE PLAN. The group
dental service contract must be consulted to determine the exact
terms and conditions of coverage. Benefits, limitations and
exclusions may vary by state. An evidence of coverage booklet will
be sent upon enrollment.
1. The frequency of certain benefits is limited. All frequency
limitations are listed in the “description of benefits and
copayments.” (Frequency limitations do not apply in Texas
when services are needed more frequently due to medical
necessity as determined by the contracting dentist.)
2. If the enrollee accepts a treatment plan from the general
dentist that includes any combination of more than six crowns,
bridge pontics and/or bridge retainers, the enrollee may be
charged an additional $100.00 above the listed copayment for
each of these services after the sixth unit has been provided.
3. General anesthesia and/or intravenous sedation/analgesia
is limited to treatment by a contracted oral surgeon and in
conjunction with an approved referral for the removal of one
or more partial or full bony impactions, (procedures D7230,
D7240, and D7241).
4. Benefits under plan 13A, 14B or 15B provided by a pediatric
dentist are limited to children through age seven following an
attempt by the assigned contracting dentist to treat the child
and upon authorization by the Administrator, less applicable
copayments. Exceptions for medical conditions, regardless of age
limitation, will be considered on an individual basis.
5. Benefits under plan 15C provided by a contract pediatric
dentist are available at 75 percent of the contract specialist’s
filed fees. Referral by the assigned contracting dentist is
required before services are rendered.
5. The cost to an enrollee receiving orthodontic treatment
whose coverage is cancelled or terminated for any reason
will be based on the contract orthodontist’s usual fee for the
treatment plan. The contract orthodontist will prorate the
amount for the number of months remaining to complete
treatment. The enrollee makes payment directly to the contract
orthodontist as arranged.
6. Orthodontic treatment in progress is limited to new enrollees
who, at the time of their original effective date, are in active
treatment started under their previous employer sponsored
dental plan as long as they continue to be eligible under
the DeltaCare USA program. Active treatment means tooth
movement has begun. Enrollees are responsible for all
copayments and fees subject to the provisions of their prior
dental plan. The administrator is financially responsible only
for amounts unpaid by the prior dental plan for qualifying
orthodontic cases.
1. Any procedure that in the professional opinion of the
contracting dentist:
a. has poor prognosis for a successful result and reasonable
longevity based on the condition of the tooth or teeth and/or
surrounding structures
1. b. is inconsistent with generally accepted standards for
dentistry.
2. Services solely for cosmetic purposes, with the exception
of procedure D9972, external bleaching, per arch, or for
conditions that are a result of hereditary or developmental
defects, such as cleft palate, upper and lower jaw
malformations, congenitally missing teeth and teeth that are
discolored or lacking enamel, except for treatment of newborn
children with congenital defects or birth abnormalities.
3. Porcelain crowns, porcelain fused to metal, cast metal or resin
with metal type crowns and fixed partial dentures (bridges) for
children under age 16.
4. Lost or stolen appliances including, but not limited to, full or
partial dentures, space maintainers and crowns and fixed
partial dentures (bridges).
5. Procedures, appliances or restoration to change vertical
dimension, or to diagnose or treat abnormal conditions of the
temporomandibular joint (TMJ).
6. Precious metal for removable appliances, metallic or
permanent soft bases for complete dentures, porcelain denture
teeth, precision abutments for removable partials or fixed
partial dentures (overlays, implants, and appliances associated
therewith) personalization and characterization of complete
and partial dentures.
7. Implant-supported dental appliances and attachments,
implant placement, maintenance, removal and all other
services associated with a dental implant.
8. Under plans 13A, 14B and 15B, dental services received from
any dental facility other than the assigned contracting dentist,
a authorized dental specialist, or a contract orthodontist are
excluded, except for Emergency Services as described in the
contract and/or evidence of coverage (EOC).
9. Under plan 15C, dental services received from any dental
facility other than the assigned contracting dentist,
including the services of an out-of-network dentist who
provides specialized services are excluded unless expressly
authorized by the administrator, or as covered under
emergency services as described in the contract and/or
evidence of coverage (EOC).
9. Consultations for non-covered benefits.
17
Exclusions (continued)
10. All related fees for admission, use, or stays in a hospital,
out-patient surgery center, extended care facility, or other
similar care facility.
11. Prescription drugs.
12. Dental expenses incurred in connection with any dental
or orthodontic procedure started before the enrollee’s
eligibility with the DeltaCare USA program. Examples
include - teeth prepared for crowns, root canals in
progress, full or partial dentures for which an impression
has been taken and orthodontics, unless qualified for the
orthodontic treatment in progress provision.
13. Lost, stolen or broken orthodontic appliances.
14. Changes in orthodontic treatment necessitated by
accident of any kind.
15. Myofunctional or parafunctional appliances and/or
therapies.
16. Composite or ceramic brackets, lingual adaptation of
orthodontic bands and other specialized or cosmetic
alternatives to standard fixed and removable orthodontic
appliances.
17. Treatment or appliances that are provided by a dentist
whose practice specializes in prosthodontic services.
18
DeltaCare USA Limitations and Exclusions — Plans M73 and M74
Limitations
hereditary or developmental defects, such as
cleft palate, upper and lower jaw malformations,
congenitally missing teeth and teeth that are
discolored or lacking enamel, except for the
treatment of newborn children with congenital
defects or birth abnormalities;
(Plans available only in Florida)
THIS IS ONLY A BRIEF SUMMARY OF THE PLAN.
The group dental service contract must be consulted to
determine the exact terms and conditions of coverage.
Benefits, limitations and exclusions may vary by state. An
evidence of coverage booklet will be sent upon enrollment.
1.
The frequency of certain Benefits is limited. All
frequency limitations are listed in the Description of
Benefits and Copayments;
2.
If the enrollee accepts a treatment plan from the
contract dentist that includes any combination of
more than six crowns, bridge pontics and/or bridge
retainers, the enrollee may be charged an additional
$75.00 above the listed copayment for each of
these services after the sixth unit has been provided;
3.
General anesthesia and/or intravenous sedation/
analgesia is limited to treatment by a contract oral
surgeon and in conjunction with an approved
referral for the removal of one or more partial or
full bony impactions, (Procedures D7230, D7240,
D7241);
4.
Benefits provided by a contract pediatric dentist are
available at 75 percent of the contract specialist’s
“filed fees.” Referral by the assigned contract dentist
is required before services are rendered.
5.
6.
The cost to an enrollee receiving orthodontic
treatment whose coverage is cancelled or terminated
for any reason will be based on the contract
orthodontist’s usual fee for the treatment plan.
The contract orthodontist will prorate the amount
for the number of months remaining to complete
treatment. The enrollee makes payment directly to
the contract orthodontist as arranged.
Orthodontic treatment in progress is limited to
new DeltaCare USA enrollees who, at the time of
their original effective date, are in active treatment
started under their previous employer sponsored
dental plan, as long as they continue to be eligible
under the DeltaCare USA program. Active treatment
means tooth movement has begun. Enrollees are
responsible for all copayments and fees subject
to the provisions of their prior dental plan. Delta
Dental is financially responsible only for amounts
unpaid by the prior dental plan for qualifying
orthodontic cases.
4.
Porcelain crowns, porcelain fused to metal, cast metal
or resin with metal type crowns and fixed partial
dentures (bridges) for children under 16 years of age;
5.
Lost or stolen appliances including, but not limited
to, full or partial dentures, space maintainers and
crowns and fixed partial dentures (bridges);
6.
Procedures, appliances or restoration if the
purpose is to change vertical dimension, or to
diagnose or treat abnormal conditions of the
temporomandibular joint (TMJ);
7.
Precious metal for removable appliances, metallic
or permanent soft bases for complete dentures,
porcelain denture teeth, precision abutments
for removable partials or fixed partial dentures
(overlays, implants, and appliances associated
therewith) and personalization and characterization
of complete and partial dentures;
8.
Implant-supported dental appliances and attachments,
implant placement, maintenance, removal and all
other services associated with a dental implant;
9.
Consultations for non-covered benefits;
10.
Dental services received from any dental facility
other than the assigned contracting dentist,
including the services of an out-of-network dentist
who provides specialized services are excluded
unless expressly authorized by the administrator, or
as covered under emergency services as described in
the contract and/or certificate of coverage (EOC);
11.
All related fees for admission, use, or stays in a
hospital, out-patient surgery center, extended care
facility, or other similar care facility;
12.
Prescription drugs;
13.
Dental expenses incurred in connection with any
dental or orthodontic procedure started before the
enrollee’s eligibility with the DeltaCare USA program.
Examples include: teeth prepared for crowns, root
canals in progress, full or partial dentures for which
an impression has been taken and orthodontics
unless qualified for the orthodontic treatment in
progress provision.
14.
Lost, stolen or broken orthodontic appliances;
15.
Changes in orthodontic treatment necessitated by
accident of any kind;
16.
Myofunctional and parafunctional appliances and/or
therapies;
17.
Composite or ceramic brackets, lingual adaptation
of orthodontic bands and other specialized
or cosmetic alternatives to standard fixed and
removable orthodontic appliances;
18.
Treatment or appliances that are provided by a
dentist whose practice specializes in prosthodontic
services.
Exclusions
1.
Any procedure that is not specifically listed under
the Description of Benefits and Copayments;
2.
Any procedure that in the professional opinion of
the contract dentist:
a. has poor prognosis for a successful result
and reasonable longevity based on the
condition of the tooth or teeth and/or
surrounding structures, or
b. is inconsistent with generally accepted standards
for dentistry;
3.
Services solely for cosmetic purposes, with the
exception of procedure D9972, External bleaching,
per arch, or for conditions that are a result of
19
DeltaCare USA Limitations and Exclusions — Plan M92
Limitations
4.
Porcelain crowns, porcelain fused to metal, cast
metal or resin with metal type crowns and fixed
partial dentures (bridges) for children under 16
years of age;
5.
Lost or stolen appliances including, but not limited
to, full or partial dentures, space maintainers and
crowns and fixed partial dentures (bridges);
6.
Procedures, appliances or restoration if the
purpose is to change vertical dimension, or to
diagnose or treat abnormal conditions of the
temporomandibular joint (TMJ);
7.
Precious metal for removable appliances, metallic
or permanent soft bases for complete dentures,
porcelain denture teeth, precision abutments
for removable partials or fixed partial dentures
(overlays, implants, and appliances associated
therewith) and personalization and characterization
of complete and partial dentures;
8.
Implant-supported dental appliances and
attachments, implant placement, maintenance,
removal and all other services associated with a
dental implant;
Benefits provided by a pediatric dentist are limited
to children through age seven following an attempt
by the assigned contract dentist to treat the child
and upon authorization by Delta Dental, less
applicable copayments. Exceptions for medical
conditions, regardless of age limitation, will be
considered on an individual basis;
9.
Consultations for non-covered benefits;
10.
Dental services received from any dental facility other
than the assigned contract dentist, an authorized
dental specialist, or a contract orthodontist except for
emergency services as described in the contract and/or
certificate of coverage;
The cost to an enrollee receiving orthodontic
treatment whose coverage is cancelled or terminated
for any reason will be based on the contract
orthodontist’s usual fee for the treatment plan.
The contract orthodontist will prorate the amount
for the number of months remaining to complete
treatment. The enrollee makes payment directly to
the contract orthodontist as arranged.
11.
All related fees for admission, use, or stays in a
hospital, out-patient surgery center, extended care
facility, or other similar care facility;
12.
Prescription drugs;
13.
Dental expenses incurred in connection with any
dental or orthodontic procedure started before
the enrollee’s eligibility with the DeltaCare USA
program. Examples include: teeth prepared for
crowns, root canals in progress, full or partial
dentures for which an impression has been taken
and orthodontics;
14.
Lost, stolen or broken orthodontic appliances;
15.
Changes in orthodontic treatment necessitated by
accident of any kind;
16.
Myofunctional and parafunctional appliances and/or
therapies;
17.
Composite or ceramic brackets, lingual adaptation
of orthodontic bands and other specialized
or cosmetic alternatives to standard fixed and
removable orthodontic appliances;
18.
Treatment or appliances that are provided by a
dentist whose practice specializes in prosthodontic
services.
(Plan available only in Florida)
THIS IS ONLY A BRIEF SUMMARY OF THE PLAN.
The group dental service contract must be consulted to
determine the exact terms and conditions of coverage.
Benefits, limitations and exclusions may vary by state. An
evidence of coverage booklet will be sent upon enrollment.
1.
The frequency of certain Benefits is limited. All
frequency limitations are listed in the Description of
Benefits and Copayments;
2.
If the enrollee accepts a treatment plan from the
contract dentist that includes any combination of
more than six crowns, bridge pontics and/or bridge
retainers, the enrollee may be charged an additional
$125.00 above the listed copayment for each of
these services after the sixth unit has been provided;
3.
4.
5.
General anesthesia and/or intravenous sedation/
analgesia is limited to treatment by a contract oral
surgeon and in conjunction with an approved
referral for the removal of one or more partial or
full bony impactions, (Procedures D7230, D7240,
D7241);
Exclusions
1.
Any procedure that is not specifically listed under
the Description of Benefits and Copayments;
2.
Any procedure that in the professional opinion of
the contract dentist:
a. has poor prognosis for a successful result
and reasonable longevity based on the
condition of the tooth or teeth and/or
surrounding structures, or
b. is inconsistent with generally accepted standards
for dentistry;
3.
20
Services solely for cosmetic purposes, with the
exception of procedure D9972, External bleaching,
per arch, or for conditions that are a result of
hereditary or developmental defects, such as
cleft palate, upper and lower jaw malformations,
congenitally missing teeth and teeth that are
discolored or lacking enamel, except for the
treatment of newborn children with congenital
defects or birth abnormalities;
DeltaCare USA Limitations and Exclusions — Plan M93 (Child-Only Plan)
Limitations
(Plan available only in Florida)
5.
Prescription drugs;
THIS IS ONLY A BRIEF SUMMARY OF THE PLAN.
The group dental service contract must be consulted to
determine the exact terms and conditions of coverage.
Benefits, limitations and exclusions may vary by state. An
evidence of coverage booklet will be sent upon enrollment.
6.
Restorations placed solely due to cosmetics,
abrasions, attrition, erosion, restoring or altering
vertical dimension, congenital or developmental
malformation of teeth;
7.
Appliances or restorations necessary to increase
vertical dimension, replace or stabilize tooth
structure loss by attrition, realignment of teeth,
periodontal splinting, gnathologic recordings,
equilibration or treatment of disturbances of the
temporomandibular joint (TMJ);
8.
Extraction of teeth, when teeth are asymptomatic/
non-pathologic (no signs or symptoms of pathology
or infection), including but not limited to the
removal of third molars and orthodontic extractions;
9.
Treatment or extraction of primary teeth when
exfoliation (normal shedding and loss) is imminent;
10.
Any procedure that in the professional opinion of
the contract dentist: a) has poor prognosis for a
successful result and reasonable longevity based
on the condition of the tooth or teeth and/or
surrounding structures, or b) is inconsistent with
generally accepted standards for dentistry;
11.
Dental services received from any dental facility
other than the assigned contract dentist or
authorized pediatric dentist except for emergency
services as described in the contract and/or certificate
of coverage;
12.
Dental expenses incurred in connection with any
dental or orthodontic procedure started before
the enrollee’s eligibility with the DeltaCare USA
program;
13.
Lost, stolen or broken orthodontic appliances;
14.
Changes in orthodontic treatment necessitated by
accident of any kind;
15.
Myofunctional and parafunctional appliances and/or
therapies;
16.
Composite or ceramic brackets, lingual adaptation
of orthodontic bands and other specialized
or cosmetic alternatives to standard fixed and
removable orthodontic appliances.
1.
The frequency of certain Benefits is limited. All
frequency limitations are listed in the Description of
Benefits and Copayments;
2.
Benefits for sealants include the application of
sealants only to the permanent first and second
molars with no decay, with no restorations and
with the occlusal surface intact and do not include
the repair or replacement of a sealant on any tooth
within three years of its application;
3.
Amalgams and composites are benefits for the
removal of decay, for minor repairs of tooth
structure or to replace a lost or failing restoration.
4.
A therapeutic pulpotomy on a permanent tooth is
limited to palliative treatment when the contract
dentist is not performing root canal therapy;
5.
Benefits provided by a pediatric dentist are limited
to children through age seven following an attempt
by the assigned contract dentist to treat the child
and upon authorization by Delta Dental, less
applicable copayments. Exceptions for medical
conditions, regardless of age limitation, will be
considered on an individual basis;
6.
The cost to an enrollee receiving orthodontic
treatment whose coverage is cancelled or terminated
for any reason will be based on the contract
orthodontist’s usual fee for the treatment plan.
The contract orthodontist will prorate the amount
for the number of months remaining to complete
treatment. The enrollee makes payment directly to
the contract orthodontist as arranged.
Exclusions
1.
Any procedure that is not specifically listed under
the Description of Benefits and Copayments;
2.
All related fees for admission, use, or stays in a
hospital, out-patient surgery center, extended care
facility, or other similar care facility;
3.
Dental expenses incurred in connection with any
dental procedures started after terminations of
eligibility for coverage;
4.
Congenital malformations (e.g. congenitally
missing teeth, supernumeray teeth, enamel and
dentinal dysplasias, etc.), except for the treatment
of newborn children with congenital defects
or birth abnormalities;
21
DeltaCare USA Eligible/Ineligible Industries
Eligible Industries
All except for those identified as ineligible below.
Ineligible Industries
Employment agencies/Employee
leasing firms
Amusement, Recreation & Entertainment
Dentist Offices
Dental Labs
Legal
Educational Services/Schools/Libraries
Community Service Organizations
Associations, Membership Organizations
and Trusts
22
SIC Code
7361 - 7363
7900 - 7999
8021
8072
8100 - 8199
8200 - 8299
8300 - 8499
8600 - 8699
We Keep You Smiling®
Why do 54 million enrollees trust their smiles
to Delta Dental?1
Most of our enrollees stay with us year after year2,
and it’s no wonder. Delta Dental sets the industry
standard by doing whatever it takes and then some.
We deliver:
œMore savings. The Delta Dental Difference®
saves clients and enrollees billions of dollars
a year.3 Because Delta Dental dentists agree
to our determination of fees, clients enjoy
extensive cost controls, and enrollees pay
less out-of-pocket.
œMore dentists. Three out of four dentists
nationwide are contracted Delta Dental
dentists, giving enrollees convenient access
and quality assurance through the nation’s
largest dentist network.
œMore satisfaction. Clients and enrollees rate
Delta Dental more favorably on reputation,
value, quality of care and customer service than
any other brand.4 We deliver an exceptional
customer experience with our fast and
accurate claims processing, ease of use and
administration, and personalized service.
1 Delta Dental of California, Delta Dental of Pennsylvania
and Delta Dental Insurance Company, together with
our affiliate companies and Delta Dental of New
York, form one of the nation’s largest dental benefits
delivery systems, covering 24 million enrollees. All of
our companies are members, or affiliates of members,
of the Delta Dental Plans Association, a network of 39
Delta Dental companies that together provide dental
coverage to more than 54 million people in the U.S.
2 Delta Dental retained 97 percent of our enrollees in
2008.
3 Savings due to reduction of premiums or claims
liability and patient out-of-pocket costs, as reported by
the Delta Dental Plans Association.
4 Based on a nationwide survey “Brand Awareness and
Perception Survey” by The Long Group for Delta Dental
Plans Association (2008).
23
Delta Dental’s Mission Statement
To advance dental health and access
through exceptional dental benefits service,
technology and professional support.
24
Call your broker, participating general agent or one of these Delta Dental sales offices:
Main Office and Regional Sales Office
Delta Dental Insurance Company (Alabama, Georgia)
1130 Sanctuary Parkway, Suite 600
Alpharetta, GA 30022
888-858-5252
E-mail: ATL-GAsales@delta.org
Regional Sales Office
(Texas, Louisiana)
Delta Dental Insurance Company
700 Parker Square, Suite 150
Flower Mound, TX 75028
800-775-0523
E-mail: DAL-TX-sales@delta.org
Regional Sales Office
(Nevada)
Delta Dental Insurance Company
5920 South Rainbow, Suite 10
Las Vegas, NV 89118
800-791-5653
E-mail: NVsales@delta.org
Regional Sales Office
(Utah)
Delta Dental Insurance Company
257 East 200 South, Suite 375
Salt Lake City, UT 84111
800-453-5577
E-mail: UTsales@delta.org
Regional Sales Office
(Florida)
Delta Dental Insurance Company
258 Southhall Lane, Suite 350
Maitland, FL 32751
800-662-9034
E-mail: FLsales@delta.org
Visit Delta Dental’s web site at www.deltadentalins.com
Delta Dental PPO is underwritten by Delta Dental Insurance Company in AL, DC, FL, GA, LA, NV and UT. In Texas, Delta Dental provides a
Dental Provider Organization (DPO) plan.
Product administration
DeltaCare USA is underwritten in these states by these entities: AL — Alpha Dental of Alabama, Inc.; AZ — Alpha Dental of Arizona, Inc.;
CA — Delta Dental of California; AR, CO, IA, ME, MI, OK, OR, RI, SC, SD, WA, WI, WY — Dentegra Insurance Company; NH and VT
— Dentegra Insurance Company of New England; AK, CT, DE, FL, GA, KS, LA, MS, MT, TN, WV and Washington, D.C. — Delta Dental
Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH, TX — Alpha Dental Programs, Inc.; NV — Alpha Dental of Nevada, Inc.; UT —
Alpha Dental of Utah, Inc.; NM — Alpha Dental of New Mexico, Inc.; NY — Delta Dental of New York; PA — Delta Dental of Pennsylvania.
Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states, except CA. These companies are financially
responsible for their own products.
© Delta Dental Insurance Company
E DDIC #57131 (rev. 12/09)