Copyright © 2020 Delta Dental. All rights reserved.
HL_PPO #128472EA (rev. 5/20)
In Texas, Delta Dental Insurance Company provides a dental provider organization (DPO) plan.
You can still visit any licensed dentist, but your out-of-pocket costs may be higher if you choose a non-PPO dentist. Network dentists are paid contracted fees.
You are responsible for any applicable deductibles, coinsurance, amounts over annual or lifetime maximums and charges for non-covered services. Out-of-network
dentists may bill the difference between their usual fee and Delta Dental’s maximum contract allowance.
Applies only to procedures covered under your plan. If you began treatment prior to your effective date of coverage, you or your prior carrier is responsible for
any costs. Group- and state-specific exceptions may apply. If you are currently undergoing active orthodontic treatment, you may be eligible to continue treatment
under Delta Dental PPO. Review your Evidence of Coverage, Summary Plan Description or Group Dental Service Contract for specific details about your plan.
Vision corrective services and Amplifon’s hearing health care services are not insured benefits. Delta Dental makes the vision corrective services program and
hearing health care services program available to you to provide access to the preferred pricing for LASIK surgery and for hearing aids and other hearing health
services.
Save with PPO
Visit a dentist in the PPO
1
network to maximize
your savings.
2
These dentists have agreed to
reduced fees, and you won’t get charged more
than your expected share of the bill.
3
Find a PPO
dentist at deltadentalins.com.
Set up an online account
Get information about your plan, check benefits
and eligibility information, find a network dentist
and more. Sign up for an online account at
deltadentalins.com.
Check in without an ID card
You don’t need a Delta Dental ID card when you
visit the dentist. Just provide your name, birth
date and enrollee ID or Social Security number.
If your family members are covered under your
plan, they’ll need your information. Prefer to have
an ID card? Simply log in to your account to view
or print your card.
Coordinate dual coverage
If you’re covered under two plans, ask your dental
oce to include information about both plans
with your claim — we’ll handle the rest.
Understand transition of care
Generally, multi-stage procedures are covered
under your current plan only if treatment began
after your plan’s eective date of coverage.
4
Log in to your online account to find this date.
Get LASIK and hearing aid discounts
With access to QualSight and Amplifon Hearing
Health Care
5
, you can save as much as 50%
on LASIK procedures and more than 60% on
hearing aids.
Save with a
PPO dentist
PPO
NON–PPO
Keep Smiling
Delta Dental PPO™
Eligibility
Primary enrollee, spouse (includes domestic partner) and eligible
dependent children to the end of the month dependent turns age 26
Deductibles
$25 per person / $75 per family each calendar year
Deductibles waived for
Diagnostic & Preventive (D & P),
Sealants and Orthodontics?
Yes
Maximums
D & P counts toward maximum?
Delta Dental PPO dentists: $2,500 per person each calendar year
Non-Delta Dental PPO dentists:
$2,000 per person each calendar year
Yes
Waiting Period(s)
Basic Services
None
Major Services
None
Prosthodontics
None
Orthodontics
None
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and
program allowance for non-Delta Dental dentists.
Delta Dental of California
560 Mission St., Suite 1300
San Francisco, CA 94105
Customer Service
888-335-8227
Claims Address
P.O. Box 997330
Sacramento, CA 95899-7330
deltadentalins.com/cos
This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan
Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your
company’s benefits representative.
HLT_PPO_2COL_DDC (Rev. 07/21/2020)
Plan Benefit Highlights for:
County of Sacramento
Group No:
02476
Benefits and
Covered Services*
Delta Dental PPO
dentists**
Non-Delta Dental PPO
dentists**
Diagnostic & Preventive
Services (D & P)
Exams, cleanings and x-rays
100 % 80 %
Basic Services
Fillings, posterior composites and
sealants
90 % 80 %
Endodontics (root canals)
Covered Under Basic Services
90 % 80 %
Periodontics
(gum treatment)
Covered Under Basic Services
90 % 80 %
Oral Surgery
Covered Under Basic Services
90 % 80 %
Major Services
Crowns, inlays, onlays and cast
restorations
80 % 80 %
Prosthodontics
Bridges, dentures and implants
80 % 80 %
Temporomandibular Joint
(TMJ) Benefits
90 % 80 %
Orthodontic Benefits
Adults and dependent children
50 % 50 %
Orthodontic Maximums
$1,500 Lifetime $1,500 Lifetime
Dental Accident Benefits
100 %
(No Maximums)
100 %
(No Maximums)
