Plan Information

Dental and Vision for Everyone

Vision

  • $15 copayment for WellVision  Exam that focuses on your eye health and overall wellness
  • Prescription Glasses discounts
    • Lenses-20% discount when complete pair of glasses is purchased
    • Frames-20% discount when complete pair of glasses is purchase
    • Contacts-15% discount off the contact lens fitting and evaluation exam
    • Click here to see complete benefits

Dental

This is a PPO plan. Delta Dental PPO participating dentists have agreed to file the claim for you and to accept the amount approved by Delta. Amount of claims are based on a percentage of the Usual, Customary and Reasonable Fees (UCR) charged by dentists in your area.

Dental Insurance Policy benefits and Vision Coverage are provided through different carriers. These companies are financially responsible for their own products.

Delta Dental Fee Schedule
  Plan Pays
Year 1 Year 2 Year 3
Diagnostic & Preventive Procedures* Diagnostic:
Routine periodic examinations once in a 6 month period.

Preventive:
Dental prophylaxis (teeth cleaning) once in a 6 month period.

Radiography:
Bitewing and full mouth x-rays.
60% 80% 100%
Basic Procedures*
(6 month waiting period)
Restorative:
Amalgam fillings.

Other:
Space Maintainers, recementation of crowns.
50% 65% 80%
Major Procedures*
(12 month waiting period)
Endodontics:
Pulpal therapy and root canals.

Periodontics:
Treatment of diseases of the gums.

Oral Surgery:
Extractions and other oral surgery, including pre and post operative care.

Prosthetics:
Gold restorations, crowns, bridges, partials and complete dentures.

Other:
Pontics, repair of crowns and bridges, repair of full and partial dentures.
0% 30% 50%
* Combined Deductible for Diagnostic, Basic and Major Procedures: $50 per person per calendar year.