Notice
Change Healthcare announced a breach of HIPAA privacy and is reaching out to individuals whose personal information may have been compromised. Although this incident does not involve Delta Dental of New Jersey or Connecticut, Change Healthcare is a vendor we used and we are providing this information to help our members who might be affected.
SHU Benefits Overview
Group #07742
| Service | Delta Dental PPO Plus Premier™ Plan | Delta Dental PPO Plus Premier™ Buy-up Plan | DeltaCare® USA DHMO Plan |
|---|---|---|---|
| Calendar year maximum (per person) | $1,500 | $2,000 | N/A |
| Calendar year deductible (waived on Preventive & Diagnostic) | |||
| Per person | $50 | $50 | N/A |
| Family aggregate | $100 | $100 | N/A |
| Preventive & diagnostic | |||
| Exams (twice per calendar year) | 100% | 100% | No cost (no frequency) |
| Cleanings (twice per calendar year) | 100% | 100% | No cost (once per 6 months) |
| Bitewing x‐rays (twice per calendar year for persons 18 and younger, once per calendar year for persons age 19 and over) |
100% | 100% | No cost (once per 6 months) |
| Full Mouth X-Rays (once per every 3 years) | 100% | 100% | No cost (once per 24 months) |
| Fluoride treatment (twice in a calendar year, children to age 19) | 100% | 100% | No cost (once per 6 months, to age 19) |
| Sealants (once per 3 years, permanent molars, children to age 15) | 100% | 100% | $10 per tooth (to age 16) |
| Space maintainers (1 per arch, per lifetime, to age 14) | 100% | 100% | $12 - $70 |
| Periodontal maintenance (2 per calendar year ‐ with history of periodontal disease) | 100% | 100% | $12 - $70 |
| Basic services | |||
| Simple restorations (including composite restorations on back teeth) | 80% | 80% | No cost - $85 |
| Simple extractions | 80% | 80% | $5 - $130 |
| Endodontics (root canal) | 80% | 80% | $110 - $350 |
| General periodontics | 80% | 80% | No cost - $130 |
| Oral surgery | 80% | 80% | TBD |
| Repair of Dentures | 80% | 80% | No cost - $345 |
| Major services | |||
| Crowns, gold restorations (over natural teeth – once per tooth per five years) | 50% | 80% | $160 - $380 |
| Implants, implant related services | 50% | 80% | $1,025+ |
| Bridgework | 50% | 80% | $170 - $380 |
| Full and partial dentures | 50% | 80% | $335 - $415 |
| Orthodontics | |||
| Full comprehensive treatment | 50% | 50% | $1,900 /$2,100 |
| Lifetime maximum | $1,000 per patient; child, to age 26 |
$2,000 per patient; adult & child, to age 26 |
N/A per patient; adult & child, to age 26 |
| Download | Download | Download |
*** DeltaCare® USA DHMO members must choose and visit their selected DeltaCare® USA dentist to receive benefits. Implant copays vary by service.
Your dentist's network will impact how much you pay. Dentists that help participate in the Delta Dental PPO will have the lowest costs and will save you the most out of pocket expense. Dentists that participate in Delta Dental Premier, are participating Delta Dental dentists, but you will pay a greater portion of the cost if utilized. If you receive services from a non-participating, out of network dentists, you will pay the most out of pocket and are responsible for your coinsurance amount plus the difference between Delta Dental's approved fee and the dentist submitted fee for the claim.
Delta Dental of New Jersey is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.
