Delta Dental Plan

2020 Plan Year Information

Delta Dental PPO Network

With Delta Dental, you have the option of seeing in-network providers, Premier Network providers and out-of-network providers:

  • Delta Dental PPO In-Network Providers: You may obtain services from any of Delta Dental’s 283,600 PPO network provider locations nationwide. With a PPO provider, the cost of services has been negotiated and is generally the lowest.
  • Delta Dental Premier Network Providers: You may obtain services from the Delta Dental Premier network, comprising approximately 359,000 providers. Those participating in the Premier network have contracted their service fees directly with Delta Dental and may be lower than out-of-network providers.
  • Out-of-Network: You may obtain services from any out-of-network provider of your choice, but the cost will generally be the highest.

Dental Services

  • Diagnostic and preventive services: X-rays and cleanings
  • Restorative services: fillings, oral surgery, root canals and gum treatments
  • Prosthodontics: crowns, bridges, dentures and implants
Delta Dental
Note

The figures in the chart below reflect what the Plan pays, with the exception of deductibles and out-of-pocket maximums.

Individual Deductible

In-Network:
No annual deductible

Out-of-Network:
$50

Family Annual Deductible

In-Network:
No annual deductible

Out-of-Network:
$150

Diagnostic and Preventive Care

In-Network:
100%

Out-of-Network:
80% of R&C; deductible waived

85% of allowed amount for Delta Premier; deductible waived

Restorative Services

In-Network:
80% of discounted fee

Out-of-Network:
75% of R&C, after annual deductible

Prosthodontics

In-Network:
50% of discounted fee

Out-of-Network:
50% of R&C, after annual deductible

Orthodontics

2019 & 2020
In-Network:
50% of discounted fee, up to a $3,000 lifetime benefit maximum per person (children to age 26 and adults)

Out-of-Network:
50% of R&C or Allowed Amount (Delta Premier), up to a $3,000 lifetime benefit maximum per person (children to age 26 and adults)

Annual Benefit Maximum per Person

In-Network:
$3,000

Out-of-Network:
$2,000

In-Network vs. Out-of-Network

Dental networks differ according to Dental Plan providers. Under the MetLife Options A and B, in-network includes any providers in the PDP network. Under Delta Dental, in-network includes any providers in the PPO network.

Out-of-network includes non-PDP or non-PPO services, depending on your administrator. Out-of-network reimbursements and maximums are based on reasonable and customary (R&C) charges as determined by each Dental Plan administrator. Please refer to the Health Benefits and Insurance SPD for details.

Under Delta Dental, your out-of-network costs may be less if you use a Delta Dental PPO Premier network provider.

Orthodontics Lifetime Maximum Benefit

The orthodontics lifetime benefit maximum is combined across plan options.

A Note About Annual Benefit Maximums

In no event can any one person receive more than the annual benefit maximum during a calendar year (excluding orthodontics), even if provided by an in-network or PDP dentist.

Dental Contributions

You and the Firm share the cost of your Dental Plan coverage. Your contributions are deducted from your pay on a before-tax basis.

Note: Your location and salary band are used to calculate only your medical contribution rates.

2019:

 Yourself OnlyYourself + Spouse/Domestic PartnerYourself + ChildrenYourself + Family
Delta Dental$13.25$26.50$26.50$39.75
MetLife Dental Plan — Option A$13.25$26.50$26.50$39.75
MetLife Dental Plan — Option B$7.50$15.00$15.00$22.75

2020:

 Yourself OnlyYourself + Spouse/Domestic PartnerYourself + ChildrenYourself + Family
Delta Dental$13.67$27.38$27.38$41.04
MetLife Dental Plan — Option A$13.67$27.38$27.38$41.04
MetLife Dental Plan — Option B$7.75$15.50$15.50$23.50

*The costs shown are per paycheck contributions. For the monthly cost, double the amounts shown.

If you are covering a domestic partner or the children of a domestic partner, the IRS determines the tax status of a dependent and may impose a tax on the value of coverage.