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Administration and Enrollment Fees
( These fees are waived on groups of 20 or more) |
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Monthly
Administration Fee - $10 |
Rate
Tables for NEW groups enrolling
July 1, 2010 through June 1, 2011 effective dates.
Clients that enroll July 1
through December 1 will renew July 1.
Clients that enroll January 1 through June 1 will renew January 1.
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Follow this link to Delta Dental Benefits
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Plan Name |
EE |
EE + 1 |
EE + 2 |
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Plan 1500 |
$69.00 |
$132.10 |
$196.40 |
$50 deductible, 100, 80, 50 plan with $1500 maximum benefit. |
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DPO Option II |
$47.40 |
$93.00 |
$128.70 |
DPO $50 deduct, 100/80, 80/ 50 50/50 plan with $1500 maximum
benefit. |
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Plan III |
$38.40 |
$74.40 |
$109.40 |
$50 deductible, 80, 80, 50 plan with $1500 maximum benefit |
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add Ortho |
$2.20 |
$3.60 |
$12.20 |
50% with a maximum of $1500 lifetime |
Delta
Dental, Services Not Covered
The Delta Dental programs do not cover: Orthodontia, unless the option is
selected; Service for injuries or conditions which are compensable under
Workers' Compensation or Employer's 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 provided in Section 1373(a) of the
California Health and Safety Code; Services with respect to congenital
(heredity) or developmental (following birth) malformations or cosmetic
surgery or dentistry for purely cosmetic reasons, including but not limited
to: cleft palate, 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);
Services for restoring tooth structure lost from wear, for rebuilding or
maintaining chewing surfaces due to teeth out of alignment or occlusions, or
for stabilizing the teeth. Such services including but are not limited to:
equilibration and periodontal splinting; Prosthodontic services or any
Single Procedure started prior to the date the person became eligible for
such services under this contract; Prescribed or applied therapeutic drugs,
premedication or analgesia; Experimental procedures; Prophylaxis, if the
eligible patient has received two prophylaxes covered by the Program in the
immediately preceding eleven months; All hospital costs and any additional
fees charged by the Dentist for hospital treatment; Charges for anesthesia
other than general anesthesia administered by a licensed Dentist in
connection with covered Oral Surgery Services; Extra-oral grafts (grafting
of tissues from outside the mouth to oral tissues) or implants (materials
implanted into or on bone or soft tissue or the removal of implants, except
as provided under Limitations on Prosthodontics Benefits; Services with
respect to any disturbance of the temporomandibular joint (jaw joint);
Replacement of existing restorations for any purpose other than restoring
active tooth decay; Charges for cost of replacement and/or repairs of an
orthodontic appliance furnished in whole or in part under this program;
Surgical procedures for correction of misalignment of teeth and/or jaws.
Only the first two oral examinations, including office visits for
observation and specialist consultations, or combination thereof, provided
to a patient in a calendar year while he or she is an Enrollee under any
Delta Program are Benefits under this program. Direct composite (resin)
restorations are Benefits on anterior teeth and the facial surface of
bicuspids. Any other posterior direct composite (resin) restorations are
optional services and Delta's payment is limited to the cost of equivalent
amalgam restorations.
This brochure
constitutes only a summary of the Plans. The Plan Contract must be
consulted to determine the exact terms and conditions of coverage. |
