Contact us for lower rates on groups of 50 or more eligible employees. (888) 492-7245
Monthly Administration Fee - $10
| Plan Name | EE | EE + 1 | EE + 2 | |
|---|---|---|---|---|
| Plan 1500 | $69.40 | $132.80 | $197.30 | $50 deductible, 100, 80, 50 plan with $1500 maximum benefit. |
The Delta Dental programs do not cover: Orthodontia, unless the option is selected; Service for injuries or conditions which are compensable under Workers' Compensation or Employer's Liability Laws; services which are provided to the Eligible Person by any Federal or State Government Agency or are provided without cost to the Eligible Person by any municipality, county or other political subdivision, except as provided in Section 1373(a) of the California Health and Safety Code; Services with respect to congenital (heredity) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to: cleft palate, maxillary and mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth), and anodontia (congenitally missing teeth); Services for restoring tooth structure lost from wear, for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusions, or for stabilizing the teeth. Such services including but are not limited to: equilibration and periodontal splinting; Prosthodontic services or any Single Procedure started prior to the date the person became eligible for such services under this contract; Prescribed or applied therapeutic drugs, premedication or analgesia; Experimental procedures; Prophylaxis, if the eligible patient has received two prophylaxes covered by the Program in the immediately preceding eleven months; All hospital costs and any additional fees charged by the Dentist for hospital treatment; Charges for anesthesia other than general anesthesia administered by a licensed Dentist in connection with covered Oral Surgery Services; Extra-oral grafts (grafting of tissues from outside the mouth to oral tissues) or implants (materials implanted into or on bone or soft tissue or the removal of implants, except as provided under Limitations on Prosthodontics Benefits; Services with respect to any disturbance of the temporomandibular joint (jaw joint); Replacement of existing restorations for any purpose other than restoring active tooth decay; Charges for cost of replacement and/or repairs of an orthodontic appliance furnished in whole or in part under this program; Surgical procedures for correction of misalignment of teeth and/or jaws. Only the first two oral examinations, including office visits for observation and specialist consultations, or combination thereof, provided to a patient in a calendar year while he or she is an Enrollee under any Delta Program are Benefits under this program. Direct composite (resin) restorations are Benefits on anterior teeth and the facial surface of bicuspids. Any other posterior direct composite (resin) restorations are optional services and Delta's payment is limited to the cost of equivalent amalgam restorations.
This brochure constitutes only a summary of the Plans. The Plan Contract must be consulted to determine the exact terms and conditions of coverage.
Delta Preferred Provider Option (PPO) is Delta's preferred provider program. The program provides the maximum benefit when you visit a PPO Dentist. PPO dentists are Delta dentists who have agreed to charge PPO patients reduced fees. Under the PPO program, you may visit any licensed dentist you wish. However, you receive the maximum benefits available under the program when you choose one of the more than 11,000 in-network dental offices throughout California. 44% of California Dentists are Delta Preferred Providers.
Delta Dental PPO Dentist Search For a printed list please call Delta at: (800) 4-AREA-DR (800-427-3237)
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Plan 1500 Use Any Dentist |
PPO Option II |
PPO Option III Use Any Dentist |
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Calendar Year Deductible $50.00* |
In Network |
Out of Network |
In Network |
Out of Network |
In Network |
Out of Network |
|
Preventive and Diagnostic
|
100% |
100% |
100% |
50% |
100% |
50% |
|
Basic Dental Services
|
80% |
80% |
80% |
50% |
80% |
50% |
|
Major Dental Services Effective March 1, 2002, All new groups with 20 or more employees enrolling in any Wolfpack Insurance Services Delta Dental plan will automatically have the waiting period for Major and Orthodontic services waived. For groups of 5 employees or more, the 12 month waiting period for Major Dental Services will be waived on all employees who had continuous dental coverage during the preceding 12 months. The 12 month Orthodontic waiting period will also be waived if the group had continuous orthodontic coverage during the preceding 12 months. Restorative - Inlays and CrownsProsthodontics - Dentures and Partials |
50% |
50% |
50% |
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Calendar Year Maximum, Benefit per Individual |
$1500 |
$1500 |
$1000 |
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Optional Orthodontic Benefit |
50% |
50% |
50% |
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As an option on a group Health Plan, eligible firms must have two or more full-time unrelated employees. (Husband and wife employees count as one. Please provide proof of any carriers group health coverage at enrollment.) This plan is offered on a stand alone basis to groups of five or more unrelated employees.
Benefit SelectionsBenefits are selected by the group and not the employee. For Example: Orthodontia benefits are available to all employees of the group and cannot be individually selected.
Contribution/ParticipationMinimum employer contribution is 50% of the employee premium. Minimum participation is 75% of the eligible employees, 100% if the employer contribution is 100% of the employee premium.
EmployeesAll employees of the employer who are performing active work on a full time basis (20 hours a week or over) are eligible for benefits including corporate officers, owners, or partners.
DependentsAll eligible dependents must enroll on the original effective date. Dependents will not be added for a later effective date unless newly eligible. Eligible dependents include legal spouse or domestic partner and unmarried children to age 19 or 25 if enrolled in an accredited school, college or university. You are responsible to report any changes to a dependents eligibility to Wolfpack Insurance Services, Inc.
Effective dateWhen a firm joins the Plan, the coverage of its current employees will be effective on the first day of the month following approval of the firms application to participate. Additions to your plan will be effective the first of the month after the elected probationary period from their date of hire. You make the probationary period election on the EZ Enrollment form.
How to EnrollTo participate in the plan;
Upon approval of the application, the agent and client will each receive a letter confirming coverage, giving the account identification and supplying the client with forms for new additions. Shortly thereafter the following material will be sent to the Agent for delivery to the Employer:
Billings will be sent directly to the employer. Each months remittance is due on the 25th day of the prior month and will become delinquent if not received by the 1st of the coverage month. Make checks payable to Wolfpack Insurance Services Inc.
Can the waiting period be waived?All groups with 20 or more employees enrolling in any Wolfpack Insurance Services Delta Dental plan will automatically have the waiting period for Major and Orthodontic services waived.
For groups of 5 employees or more, the 12 month waiting period for Major Dental Services will be waived on all employees who had continuous dental coverage during the preceding 12 months. The 12 month Orthodontic waiting period will also be waived if the group had continuous orthodontic coverage during the preceding 12 months.
Click here to Download the EZ Enrollment Form
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Please send the completed application and your check to:
