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Welcome to Delta Dental!
2021-22 Open Enrollment
A dental election is REQUIRED if you want dental
insurance coverage for yourself and your family in the
new plan year!
Delta Dental
PPO™
The Delta Dental Difference®
Delta Dental PPO Delta Dental Premier® Non–Delta Dental
• Visit a PPO dentist to
save the most.
• You can visit any
licensed dentist.
• You won’t be charged
more than your
expected share of
the bill.
Delta Dental PPO –
BASE PLAN
DeductiblePer calendar year
$75 per person, PPO
providers
$100 per person, Premier
& Non-Contracted
providers
Waived for D&P
Annual maximumPer calendar year
$1,500 per person
Orthodontic Lifetime maximum
$1,500 per person
In-Network
PPO
Premier &
Non-Delta
Employee Pays
Diagnostic and
preventive care (exams, cleanings,
x-rays, sealants)
0% 50%
Basic services(Fillings, simple
extractions, root
canals, gum
treatment)
20%
(after deductible)
30%
(after
deductible)
Major services(Crowns, oral
surgery, bridges,
dentures)
70%
(after deductible)
80%
(after
deductible)
Delta Dental PPO –
BASE PLAN
Employee Pays
Comprehensive
orthodontics – CHILD
ONLY
50%
Comprehensive
orthodontics (Adult)Not covered
Lifetime Maximum $1,500
Your PPO coverageBUY-UP PLAN
Delta Dental PPO –
BUY-UP PLAN
DeductiblePer calendar year
$50 per person
$150 per family
Waived for D&P
Annual maximumPer calendar year $2,000 per person
Orthodontic Lifetime maximum
$2,000 per person
In-Network
PPO
Premier &
Non-Delta
Employee Pays
Diagnostic and
preventive care (exams, cleanings,
x-rays, sealants)
0% 20%
Basic services(Fillings, simple
extractions, root
canals, gum
treatment)
20%
(after deductible)
50%
(after deductible)
Major services(Crowns, oral
surgery, bridges,
dentures)
50%
(after deductible)
70%
(after deductible)
Delta Dental PPO –
BUY-UP PLAN
Employee Pays
Comprehensive
orthodontics (child)50%
Comprehensive
orthodontics (adult)50%
Lifetime Maximum $2,000
Pre-treatment estimate
DeltaCare® USA DHMO
• Alabama
• Arizona
• Arkansas
• Delaware
• Florida
• Illinois
• Indiana
• Kansas
• Michigan
• Mississippi
• Missouri
• New Jersey
• New York
• North Carolina
• Pennsylvania
• South Carolina
• Tennessee
• Texas
• Virginia
• Washington DC
• Wisconsin
*The Delta DHMO is only available in approved states – the following are pending approval:
• California (pending)
• Colorado (pending
• Maryland (pending)
• Ohio (pending)
• Oregon (pending)
• Washington (pending)
The DHMO is available in the following states:
*Pending as of 12/14/2020
Comprehensive coverageDeltaCare USA DHMO: a prepaid, fixed copayment plan
Once enrolled, select a primary dentist from the DeltaCare USA network to start enjoying:
• Set copays
• No annual maximums
• No deductibles
• No claims
• Low premiums
DHMO benefit enhancements include:
• 178 more covered DHMO procedures; all-inclusive copays
• Posterior composite fillings covered
• No missing tooth exclusion
• Implants covered
• Tooth whitening covered
How DeltaCare USA DHMO worksGetting dental care is easy
Specialty and emergency careDeltaCare USA DHMO
• If you need specialty care, your
primary care dentist will refer you
• Your primary care dentist requests
authorization for specialty services
• Plan includes out-of-network coverage
for emergencies
All about bracesDeltaCare USA DHMO
• Orthodontic coverage for children and adults
• All phases of orthodontic treatment are covered
• Pre-and post-records
• Tooth extractions
• Coverage for in-progress treatment
• Sampling of pre-set copays (please refer to full summary for additional details):
Teeth Whitening & ImplantsNew with the DeltaCare USA DHMO
DeltaCare USAYour copayment*
Teeth Whitening
External bleaching for home application,
per arch; includes materials and
fabrication of custom trays
$125 copayment
Implants
Surgical placement of implant body:
endosteal implant$1,005 copayment
Custom fabricated abutment – includes
placement$425 copayment
Abutment supported porcelain/ceramic
crown$740 copayment
*Limitations and exclusions may apply. Sample listing of procedure codes. Please reference plan booklet for complete listing of covered
procedure codes.
Submit your request
• Online: Create an online account at deltadentalins.com
• By phone: Call Customer Service at 800-422-4234
Go to deltadentalins.com to browse the DeltaCare USA dentists in your area.
Write down the facility number of the primary care dentist you would like.
Each member school will document dentist election and communicate to Delta Dental. If no election is made, a provider will be auto assigned. Providers can be changed anytime throughout the year.
Web and mobile
resources
Sign up for an online accountCheck your benefits information online –
deltadentalins.com
• Check your plan details: eligibility, covered
services and level of benefits.
• Look up claim statements for recent dental visits.
• View or print your ID card.
• Estimate the cost of your next procedure.
• Submit questions to Customer Service.
Go mobile
To find the app, visit the App Store or Google Play and search for “Delta Dental.” Then download the Delta Dental app by Delta Dental Plans Association.
What can you do with the app?
Find a network dentist
• Go to deltadentalins.com.
• Look for the Find a Dentist tab.
• Search by name, address, landmark, city or ZIP code.
• Select your network plan.
• Click Search.
• Narrow your search by location, specialty, network and
language.
• Your search results will include a dentist’s Yelp rating,
address and phone number.
Cost EstimatorBudget for dental expenses with personalized
estimates
Personalized. Estimates are based on your
benefits, including maximums and deductibles.
Insightful. Compare the cost of the same
procedure at different dentists.
Economical. See how choosing an in-network
dentist can help you save.
Value Added Service: Savings you can hear!
Access hearing aid and LASIK discountsNow available to you and your dependents
62% average savings off retail hearing aid pricing
Amplifon Hearing Health Care
40-50% off traditional LASIK eye surgery
QualSight