Dental

Dental 

Introduction
This summary is not designed to serve as Evidence of Coverage. If you have specific questions regarding benefit structure, limitations or exclusions, contact Delta Dental's Customer Service (see contact information above). Under this program you may use any dentist you wish. It is to your advantage to select a dentist who is a Delta dentist, since his/her fees will have been accepted in advance by Delta.

Using Your Delta Program - Delta Dental Plan 10
To use the program, call the dental office of your choice and make an appointment. If you go to a Delta dentist, he or she will have Delta treatment forms in the office and will complete and submit the form to Delta. The Delta program allows you to:

• Change dentist at any time without preapproval
• Go to a specialist of your choice without preapproval
• Have each member of our family go to a different dentist
• Receive dental care anywhere in the world

 During your first appointment, give your dentist the following information:

• The Delta group number: 07018
• The employee's (primary insured) social security number

Delta pays Delta dentists directly. You are responsible only for your share of the bill. A Delta dentist may not charge you for amounts payable by Delta. If you go to a non-Delta dentist, you are responsible for the dentist's entire bill. Delta will reimburse you directly. 

Dental Expense Benefits

Calendar year (January-December)

BSSP Plans subscribe to Delta's PPO Network.  Annual benefits under the PPO Network are $2200/$2000.

Diagnostic and Preventative Benefits
70%/80%/90%/100% (after 4th year) of Delta dentist's fees up to the annual maximum

• Oral examination
• X-rays
• Study models
• Biopsy/tissue examination
• Prophylaxis (cleaning) - two per year; 3rd for pregnant mothers
• Fluoride treatment
• Space maintainers
• Specialist consultation

Basic Benefit
70%/80%/90%/100% (after 4th year) of Delta dentist's fees up to the annual maximum

• Oral surgery (extractions including surgical removal of teeth)
• Restorative (fillings) for treatment of carious lesions (visible destruction of hard tooth structure resulting from dental decay)
• Endodontics (root canal therapy)
• Periodontics (treatment of gums and bone supporting them)
• Sealants (covered only on carious-free permanent posterior teeth for children to age 14) 

Crowns, Jackets, and Cast Restorations
70%/80%/90%/100% (after 4th year) of Delta dentist's fees up to the annual maximum.  Treatment of carious lesions (visible destruction of hard tooth structure resulting from dental decay which cannot be restored with amalgam, synthetic porcelain or plastic restorations.

Prosthodontic Benefits
50% of Delta dentist's fee up to annual maximum

• Bridges (fixed and removable)
• Dental implants
• Partial dentures
• Full dentures

Orthodontic Benefits for Eligible adults and dependent children
50% of Delta dentist's fee; $2,000 lifetime maximum per person.

Dental Accident Benefits
100% of Delta dentist's fee. Separate $1,000 maximum per person. Cracked teeth due to chewing or biting on something are not covered.

Contact Information
Butte Schools Self-Funded Programs (BSSP)
(530) 879-7438
www.bsspjpa.org

The Delta Dental Plan
P.O. Box 997330 Sacramento, CA 95899-7330
Customer Service: (866) 499-3001
www.deltadental.com