Proper dental care plays an important role in your overall health. That’s why UC provides dental coverage for you and your family, including routine preventive care and fillings, oral surgery, dentures, bridges and braces. You have a choice of two plans, a PPO and an HMO.
Proper dental care plays an important role in your overall health. That’s why UC provides dental coverage for you and your family, including routine preventive care and fillings, oral surgery, dentures, bridges and braces. You have a choice of two plans, a PPO and an HMO.
Note: The charts below show what the plan pays for care. UC pays 100% of the monthly dental plan premium for employees and for retirees eligible for the full UC contribution.
This is a summary only. Important details — such as limitations, exclusions, exceptions, and other qualifiers — may not be included. For detailed information, call the plan or visit their website for specific benefits, benefits when traveling overseas, provider information, and plan booklets. If any information on the website conflicts with plan documents, plan documents prevail.
Total benefit (preventive, basic, major and prosthetic)
Service area and provider network
Delta Dental PPO Plan
$50 combined for basic and major dentistry, TMJ disorder benefits and prosthetic dentistry; does not apply to preventive dentistry or orthodontics
$1,700 if a Delta Dental PPO dentist is used; otherwise $1,500 per person per calendar year
Nationwide — Delta Dental PPO, Delta Dental Premier and non-Delta Dental dentists (licensed); Worldwide — Coverage available only from non-Delta Dental dentists (licensed)
DeltaCare USA HMO Plan
No deductible
No maximum
California DeltaCare USA network providers only; coverage of up to $100 in 12-month period for pain relief when you are more than 25 miles from your dentist’s office
Plan
Cleaning — prophylaxis
Oral exam
Emergency office visit for pain relief
Topical fluoride
X-rays
Delta Dental PPO Plan
You are covered at 100% (up to 2 times in a calendar year; additional cleanings by report)
100% (limited to 2 per calendar year — routine, non-routine or a combination of both; additional routine exam is covered for members with identified risk factors)
100%
100% (includes cleaning; up to 2 times in a calendar year)
100% (full mouth x-rays limited to 1 set in 5 years unless necessary)
DeltaCare USA HMO Plan
100% up to 2 times in any 12-month period; additional cleanings when necessary: $45 copayment for adults, $35 copayment forchildren
100%
100%
100% (up to 2 times in any 12-month period through age 18)
100% (full mouth x-rays limited to 1 set in any12-month period)
80% PPO/80% Premier (general anesthesia for covered oral surgery)
80% PPO/80% Premier
80% PPO/80% Premier
80% PPO/80% Premier
DeltaCare USA HMO Plan
100% for standard benefit
Local — 100%. General and intravenous sedation — 100%; limited to medically necessary extractions
Extractions: 100% if uncomplicated (not covered if done only for orthodontics)
Oral surgery: $15 copayment for impactions; other covered services at 100%
$20–$60 copayment for each canal; other covered services at 100%
$100 copayment per quadrant for surgery (mucogingival and osseous gingival); $150 copayment for soft tissue graft procedures; periodontal maintenance: 100% for 1 in each 6-month period; additional maintenance when necessary: $55 copayment
50% up to $500 for all benefits in a lifetime (not applied to calendar year maximum). Deductible applies.
DeltaCare USA HMO Plan
$50 per unit copayment ($150 extra charge for precious metals)
100% for standard benefit
100%
Plan
Standard, full or partial dentures
Bridges
Implants
Delta Dental PPO Plan
50%
50%
50%
DeltaCare USA HMO Plan
Upper — $65 copayment per denture Lower — $65 copayment per denture (extra charge for precious metals) Removable partial denture with flexible base — $115
$50 per unit copayment (extra charge for precious metals)
Not covered
Plan
Who is eligible for service
Benefit
Delta Dental PPO Plan
All covered family members
50% copayment; maximum of $1,500 for each eligible patient under age 26 and $500 for each eligible patient age 26 and older
DeltaCare USA HMO Plan
All covered family members
$1,000 copayment (plan covers 36 months of usual and customary treatment — a monthly office visit fee of $75 applies after the 36 months)
Footnotes
1 Disabled members may receive anesthesia for any covered dental service if needed to receive treatment. Preauthorization is required.
