*Some services are subject to frequency and age limitations. See SPD or Handbook for details.
**2021 coverage: White (composite) fillings are covered at 100% on front teeth only. The plan will pay for white (composite) fillings on back teeth only up to the amount covered for amalgam (silver) fillings.
2022
2021
What is covered
In-network providers
(No out-of-network coverage)
Annual deductible
Annual maximum
Routine evaluations. dental cleanings, sealants*, bitwing and panoramic X-rays, fluoride treatments*, pulp vitality tests
Fillings**
Periodontal maintenance
Crowns, bridges, dentures, implants
Surgical extraction, root canal (endodontics), periodontics (except maintenance), oral surgery
Non-surgical extractions
(above gumline)
Orthodontics coverage
Orthodontics lifetime maximum
Delta Dental PPO and
Delta Dental Premier
100%
None
100%
100%
No coverage
$1,000 / person
90%
50%
$1,500
UDB or Preventive Plan Coverage
No coverage
In-network providers
Routine evaluations, dental cleanings, sealants*, bitwing and panoramic X-rays, fluoride treatments*, pulp vitality tests
Annual deductible
White (composite) fillings
Periodontal maintenance
Crowns, bridges, dentures, implants
Annual maximum
Non-surgical extractions
Orthodontics coverage
Orthodontics lifetime maximum
What is covered
*Some services are subject to frequency and age limitations. See SPD or Handbook for details.
2022
2021
Coverage Type
Uniform Dental Benefit
Preventive Plan
State Active Employee
Local Active Employee
Retiree
Retiree
Active Employee
Self
Self + spouse,
Self + Child(ren)
Family
$4
$30.20
$30.20
$30.20
$30.20
$9
$75.50
$75.50*
$75.50
$75.50
*Medicare 1 and Medicare 2 recipients pay a family rate of $60.40 for UDB.
(No out-of-network coverage)
Delta Dental PPO and
Delta Dental Premier
100%
None
100%
100%
No coverage
No coverage
$1,000 / person
90%
50% (under age 19)
$1,500
UDB or Preventive Plan Coverage
(front and back teeth)
Surgical extraction,
root canal
periodontics
oral surgery
(endodontics),
(except maintenance,
(above gumline)