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SECTION 10.0 - DENTAL PROGRAM (Administered by Delta Dental of Pennsylvania)

  1. Benefit: If an Eligible Active Participant or dependent receives one or more of the covered dental services outlined below from a participating dentist, the following co-payments shall apply, subject to a maximum annual allowance of $1,000.00 per eligible person.

  2. Covered Dental Services:

    % Paid by Delta1 % Paid by Patient1
    Diagnostic (exam & x-rays) 80% 20%
    Preventive (flouride treatments to age 19, teeth Cleaning – children, adults & sealants to age 14) 80% 20%
    Basic Restorative (fillings) 80% 20%
    Uncomplicated Extractions (routine removal of teeth) 80% 20%
    Endodontics (root canal therapy) 80% 20%
    Periodontics (treatment of gum disorders) 80% 20%
    Major Restorative (crowns) 80% 20%
    Prosthodontics (dentures) 80%2 20%
    Orthodontics (straightening teeth) 50%3 50%
    1. Payment percentages refer to (1) participating dentist’s charges or (2) non-participating dentist’s charges that are within “usual customary and reasonable” (UCR) maximum levels as calculated by Delta.
    2. Benefit available once every five years.
    3. $1,500 lifetime maximum per patient up to age 19.
  3. Predetermination: If the amount of care to be rendered to any one patient will exceed $300, the dentist must submit the claim form to Delta Dental for predetermination before completing the treatment. Delta’s dental consultants will examine the treatment plan and x-rays, which should accompany the form, and future benefits will be detailed. This is generally a very simple procedure that takes only a few days, but it is very important because it assures you and the dentist that you are eligible for dental benefits, and it tells both you and the dentist if the proposed services are covered by the contract.

  4. Dentists: A number of licensed dentists in Pennsylvania have entered into agreements with Delta to abide by Delta’s policies regarding services, your portion of the charged fees and other matters pertinent to Delta’s obligations to its subscribers. These dentists, known as participating dentists, will send claim forms to Delta and will be paid directly by Delta. You pay only for services not covered or co-payment amounts as stated in the notification of payment form, which Delta will send you with each claim. Other dentists not participating in Delta also regularly perform services for Delta subscribers; in such cases, payment is made directly to you. Payout by Delta is the same in either case. While Delta can guarantee your personal co-payment with participating dentists, you have complete freedom of choice in selection of your dentist. A list of participating dentists in your area may be obtained by contacting Delta Dental at 1-800-932-0783

  5. Limitations and Exclusions: The following limitations and exclusions apply to your dental plan. No benefits will be paid for dentistry that is performed for appearance only, preventative plaque control programs, periodontal splinting, and services rendered or devices started prior to the effective date of coverage.

  6. Claim Forms: Claim forms may be obtained from the Fund Office or by contacting Delta Dental.


    Fill in Sections 1 through 15. Sections 1 through 8 are self-explanatory; Section 9 may be skipped. Section 10 should be “1020”. Sections 11 through 15 are to be completed since they are used to assist Delta in determining whether you are entitled to dual coverage and/or coordination of benefits with another carrier. The form should be given to the dentist of your choice at your next appointment.


    If you or your dentists have any questions about claim filing procedures or the status of your claim, please feel free to contact Delta’s Benefit Service Department at:


    Delta Dental
    One Delta Drive
    Mechanicsburg, Pennsylvania 17055

    Phone Number: 717-766-8500
    Toll-Free Number: 1-800-932-0783