Delta Dental Plan
Rate Sheet

Enrollment/Change Forms

Silver (Base) Plan Summary

Gold (Buy Up) Plan Summary

Bronze (EPO) Summary

Preferred Provider Network (PPO), which allows you to have services performed either in or out of the Delta Dental’s network of dentists.

Silver (Base) plan provides a wide network of dentists; covers 100% of preventive exams and cleaning, 50% of X-rays, and has a $1,000 of Annual Maximum of coverage from Delta Dental.

Gold (Buy Up) plan provides a wide network of dentists; covers 100% of preventative services, child & adult orthodontics and has a $1,500 of Annual Maximum of coverage from Delta Dental.

Bronze (EPO) plan has an exclusive network of providers – it works like an HMO so that you do not need to choose a primary dentist and there is no Annual Maximum for general services. Preventive services are covered 100% in-network.

Silver (Base) plan with Gold (Buy Up) plan option Large network of dentists and dental specialists. Caregivers are able to choose their own dental provider within the PPO network

Search the Delta Dental Provider directory to find providers; choose PPO for Silver (Base) and Gold (Buy Up) plans, and EPO for the new Bronze (EPO) plan.

Bronze (EPO) Plan

Find a Bronze (EPO) dentist here: http://search.providers4you.com/epo

The Dental and Vision plans are no longer linked. If you elect a dental plan, you will no longer automatically be enrolled in a vision plan. Likewise, if you elect a vision plan, you no longer are required to elect a dental plan.

The following coverage enhancements apply to the Bronze (EPO) Plan only:

– Posterior Composite Resin Fillings
– Posterior Porcelain Crowns/Bridges
– Occlusal Guards: 1 in 5 years
– Special Health Care Needs Benefit