2011 UC Dental Plan Chooser

	Delta Dental PPO	DeltaCare® USA
Dentists
Dentist Directory	Search the Delta Dental PPO Dentist Directory	Search the DeltaCare® USA Dentist Directory

	Delta Dental PPO	DeltaCare® USA
Features
Filing claims	No claims filing paperwork.	No claims filing paperwork.
Teeth whitening	Not a covered service.	Covered service with a member copayment.
Teeth cleaning	2 cleanings per year at no charge. Additional cleaning may be covered based on report by provider or for those that are pregnant.	2 cleanings a year at no charge plus 1 additional cleaning per year; $45 copayment for adults; $35 copayment for children.
Member savings	You are only responsible for deductible and coinsurance for most routine and major services. No coinsurance for preventive services.	There is no deductible and no copayments for diagnostic services. Other services are based on a fee schedule.
Orthodontics	Deductible does not apply. Delta Dental pays 50% of fees up to $1,500 Lifetime Maximum for those under age 26 and $500 Lifetime Maximum for those over age 26.	You are responsible for $1,000 for either adult or child orthodontics.
Your maximum yearly benefit	$1,700 ($1,500 for out of network providers).	No maximums.

	Delta Dental PPO	DeltaCare® USA
Estimated costs: Top 6 services
Adult cleaning	$0	$0
Resin based composite (filling)	$18 after deductible	$65-$95
Extraction	$15 after deductible	$0
Metal crown	$365 after deductible	$50-$150
Partial denture	$543 after deductible	$65
Braces (adolescent)	$2,059 (PPO pays $1,500)	$1,000

The above fees are considered to be estimates only and based on visiting a PPO provider. Fees vary by region and dentist.

	Delta Dental PPO	DeltaCare® USA
Services
Service area	Worldwide.	California only.
Total benefit	$1,700 PPO/$1,500 Out of PPO network.	No maximum.
Total benefit	(Total benefit for preventive, basic, major dentistry, and prosthetic dentistry).
	Delta Dental PPO	DeltaCare® USA
Preventative dentistry
Coverage	No deductible.	Copayments apply as noted.
Cleaning of teeth - prophylaxis	100% of Delta Dentist fee (up to 2 times in a calendar year; additional cleaning by report or for pregnant women).	No charge (up to 2 times in any 12-month period). Additional cleanings within the 12 month period: $45 copayment for adults, $35 copayment for children.
Oral examinations	100% of Delta Dentist fee (one routine and two non-routine exams per calendar year).	No charge.
Emergency office visit for pain relief	100% of Delta Dentist fee	Covered up to $100.
Topical fluoride treatment	100% of Delta Dentist fee (up to 2 times in a calendar year through age 13).	No charge (up to 2 times in any 12-month period through age 18).
Space maintainers	100% of Delta Dentist fee (through age 12 once every 5 years).	No charge.
X-rays (full mouth, bitewings, other films)	100% of Delta Dentist fee (full mouth x-rays limited to 1 set in 5 years).	No charge (full mouth x-rays limited to 1 set in any 12-month period).
Pit and fissure sealants (under age 16 only)	100% PPO/75% Out of PPO network for first permanent molars through age 9 and second permanent molars through age 15.	No charge for first permanent molars through age 9 and second permanent molars through age 15.
	Delta Dental PPO	DeltaCare® USA
Basic dentistry
Coverage	Deductible applies.	Copayments apply as noted.
Fillings	80% PPO/75% Out of PPO network.	No charge for standard benefit.
Anesthesia	80% PPO/75% Out of PPO network (general anesthesia for covered oral surgery).	Local - no charge. General and intravenous sedation - no charge; limited to medically necessary extractions.
Prosthetic appliance repair	80% PPO/75% Out of PPO network.	No charge.
Extractions	80% PPO/75% Out of PPO network.	No charge if uncomplicated (not covered if done only for orthodontics).
Oral surgery	80% PPO/75% Out of PPO network.	$15 copayment for impactions; other covered services at no charge.
Endodontics	80% PPO/75% Out of PPO network.	$20 copayment for each canal; other covered services ranging from $0 to $70.
Periodontics	80% PPO/75% Out of PPO network.	$100 copayment per quadrant for surgery (mucogingival and osseous gingival); $150 copayment for soft tissue graft procedures; periodontal maintenance: no charge for 1 in each 6-month period; additional maintenance within the 6 month period: $55 copayment.
Denture relining and rebase	80% PPO/75% Out of PPO network.	Relining - no charge (limited to 1 in any 12-month period). Rebase - $20 copay (limited to 1 in any 12-month period.
	Delta Dental PPO	DeltaCare® USA
Major Dentistry
Coverage	Deductible applies.	Copayments apply as noted.
Crowns	50%	$50 per unit copayment ($100 extra charge for precious metals).
Inlays/onlays	50%	No charge for standard benefit.
TMJ disorder benefits Temporomandibular joint (TMJ) dysfunction: limited to occlusal devices/occlusal guards (night guards)	50% up to $500 for all benefits in a lifetime. Deductible applies. (not applied to calendar year maximum).	No charge.
	Delta Dental PPO	DeltaCare® USA
Prosthetic dentistry
Coverage	Deductible applies.	Copayments apply as noted.
Standard, full, or partial dentures	50%	Upper or lower - $65 copayment per denture. Removable upper or lower partial denture with flexible base - $115.
Bridges	50%	$50 per unit copayment ($100 extra charge for precious metals).
Dental Implants	50%	Not a covered Service.
	Delta Dental PPO	DeltaCare® USA
Orthodontics
Coverage	No deductible.	Copayments apply as noted.
Who is eligible for service	All covered family members.	All covered family members.
Benefit	50% up to $1,500 in a lifetime for covered individuals under age 26; up to $500 in a lifetime for covered individuals age 26 and over (not applied to calendar year maximum).	$1,000 copayment (plan covers 36 months of usual and customary treatment - a monthly office visit fee of $75 applies after the 36 months).
	Delta Dental PPO	DeltaCare® USA
Special provisions, limitations, exclusions
Work in progress when you join	Only services that started on or after your effective date of coverage are covered (except for ongoing orthodontic treatment).	Only services received from a DeltaCare® USA provider on or after your effective date of coverage are covered.
Predetermination of benefits	If services are expected to be $350 or more, your dentist files a treatment plan first; Delta Dental reviews it and notifies you and your dentist of the benefits payable.	Before any work is done, ask your DeltaCare® USA dentist what the charges will be. If you have any questions about what will be covered, call DeltaCare® USA.
Alternate treatment provision	If more than one professionally acceptable and appropriate treatment can be used, Delta Dental benefits will be based on the least expensive method.	If you select a treatment plan different from that customarily provided by DeltaCare® USA, you will pay the applicable copayment, plus the additional cost of the alternate treatment.
Replacement of crowns, dentures, partial dentures, and bridges	Not covered if crown or prosthetic appliance is less than 5 years old.	Not covered if crown or prosthetic appliance is less than 3 years old.
Out-of-area emergencies	Coverage applies worldwide.	Plan pays up to $100 per emergency in any 12-month period for pain relief when you are more than 25 miles from your dentist's office.
Teeth bleaching	Not covered.	$125 copayment per arch. External bleaching is limited to one bleaching tray per arch per 36-month period; bleaching gel for two weeks of patient self treatment.

Dental Plans