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Benefits Administration

HR Service Area

PMI DeltaCare Basic and Delta Dental Level I Enhanced Plans Benefits Comparison

For eligible employees in the following categories:

Unit 10 & Unit 11 (teaching Associates).
Unit 12 employees are Eligible for Delta Dental Level I Enhanced Only.

Procedure:

PMI DeltaCare Basic Plan Charges:

Delta Dental Plan of California
Enhanced Level I Plan Pays:

PREVENTATIVE & DIAGNOSTIC DENTISTRY

(No Deductible)*

(No Deductible)*

PROPHYLAXIS (Cleaning)

No Charge-limit 2 per 12 months

100% of UCR-limit 2 per 12 months

FlUORIDE APPLICATION

No Charge-only to age 19

100% of UCR

ORAL EXAMS

No Charge

100% of UCR-limit 2 per 12 months

SPACE MAINTAINERS

$ 10

100% of UCR (without deductible)

EMERGENCY OFFICE VISITS

No Charge

100% of UCR

X-RAYS

No Charge (Full mouth x-rays:
1 set per 24 consecutive months
Bitewings: 1 set (4 films) per every 6 month period.

100% of UCR (Full mouth x-rays:
1 set in a 3-year period.
Bitewings: 1 set per 12 months for age 18 and over.

BASIC DENTISTRY

(No Deductible)*

(Deductible)

FILLINGS

No charge for Amalgam

80% of UCR

ANESTHESIA

Local-no charge: General-not covered

80% of UCR-limited to required anesthesia applied by dentist during oral surgery.

INJECTION OF ANTIBIOTICS

Not covered

80% of UCR

EXTRACTIONS

Uncomplicated-no charge: $15-$25 for bony impactions (not covered for orthodontia)

80% of UCR

ORAL SURGERY

No charge

80% of UCR

ENDODONTICS

Root canal-$20 anterior, $40 bicuspid, $60 molars

80% of UCR

PERIODONTICS

$10 for curettage per quadrant
$20 for gingivectomy per quadrant
$80 for osseous surgery per quadrant

80% of UCR

DENTURE RELINING

Office-no charge; Lab-$15

80% of UCR

PROTHESTIC DENTISTRY 

(No Deductible)*

(Deductible)*

CROWNS

$35-$50 per crown + cost of precious metals

50% of UCR

PROSTHETIC APPLIANCE REPAIR

Up to $15

50% of UCR

DENTURES

Full-$60 each; Partials-$70 each

50% of UCR

BRIDGES

$50 per unit + cost of precious metals

50% of UCR

Maximum benefit for Preventative, Basic & Prosthetic Dentistry

No maximum*

$2,000 per calendar year per person

ORTHODONTICS

(No Deductible)*
$1,400 maximum co-payment plus $350 start-up costs for 24 month treatment plan (only for covered children up to age 23). Orthodontic extractions are not covered.

(No Deductible)*
50% of UCR. $1000 maximum per patient per case (for employees, spouse & dependant children).

SPECIAL PROVISIONS, LIMITATIONS, EXCLUSIONS

 

 

WORK IN PROGRESS WHEN YOU JOIN

Not covered. (Examples: in-progress orthodontics, root canals started, teeth prepped for crowns, etc).

Only covers charges for services the member receives on and after effective date of coverage.

PREDETERMINATION OF BENEFITS

Not required.

Not required; however, suggested for services proposed over $100.

ALTERNATIVE TO TREATMENT PROVISION

May be additional cost

If dentist determines that alternative treatment is necessary, approval is subject to Delta review.

REFERRAL TO A SPECIALIST

Approval is subject to review by a dental consultant.

N/A

MISSING TEETH

No exclusion against replacing missing teeth.

No exclusion against replacing missing teeth.

OUT-OF-AREA EMERGENCY

Maximum of $50

Out of California-submit dentist's billing statement to Delta Dental of California.

DEDUCTABLE

No deductible

$50 per person up to a maximum of $150 family deductible per calendar year for both basic and prosthetic dentistry. Any part of deductible satisfied during the last 3 months of calendar year is credited toward the next calendar year deductible.

PROSTHETIC REPLACEMENTS

Limited to one each 5 years.

Limited to one each 5 years.

* Refer to the Evidence of Coverage (EOC) booklet. **children under 18 are eligible for 2 sets of bitewing x-rays in a 12-month period. There is a $500 maximum, per year, per child for periodontal procedures only when performed by a specialist (applies to PMI DeltaCare only).

Under certain guidelines Delta Dental participants who are pregnant are eligible to receive an additional cleaning and/or periodontal examination in a calendar year.