California Group Plans
Rates
Contact us for lower rates on groups of 50 or more eligible employees. (888) 492-7245
Administration and Enrollment Fees
(These fees are waived on groups of 20 or more)
Monthly Administration Fee - $10
Rate Tables NEW group enrolling
- July 1, 2017 through June 30, 2018 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
| Plan Name | EE | EE+1 | EE+2 | |
|---|---|---|---|---|
| Plan 1500 | $69.40 | $132.80 | $197.30 | $50 deductible, 100, 80, 50 plan with $1500 maximum benefit. |
| PPO Option II | $48.10 | $92.00 | $130.80 | PPO $50 deduct, 100/80, 80/50 50/50 plan with $1500 maximum benefit. |
| PPO Option III | $39.00 | $75.60 | $111.20 | $50 deductible, 80, 80, 50 plan with $1500 maximum benefit. |
| add Ortho | $2.60 | $4.20 | $14.50 | 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.