Fresno Unified School District
2024 Delta Dental PPO Incentive
Using the Plan
The Delta Dental PPO Incentive plan is designed to incentivize dental health maintenance while giving you the freedom to receive dental care from any licensed dentist of your choice. Keep in mind, you’ll receive the highest level of benefit from the plan if you select an in-network PPO dentist versus an out-of-network dentist who has not agreed to provide services at the negotiated rate. Additionally, no claim forms are required when using in-network PPO dentists.
To find an in-network Delta Dental Incentive Plan PPO dentist, go to www.deltadentalins.com and search the Provider Network, or call 866.499.3001.
Note:
- Part-time employees are eligible to enroll in the UnitedHealthcare Dental HMO plan only.
- Dual Coverage Not Allowed for the Same Dental Plan
- If both you and your spouse are an employee of Fresno Unified School District and qualify for coverage as a Primary Enrollee, neither of you may enroll as a Dependent of the other for the same dental plan. In addition, only one of you may enroll your dependent child(ren) for the same dental plan. However, if you and your spouse enroll in separate dental plans (i.e., one enrolls in Delta Dental and the other enrolls in UHC), you may cover your spouse and dependent child(ren) in each plan.
(1) 100% Benefits Coverage for participants covered by the plan as of December 31, 2023. Otherwise, benefits increase 10% each year enrollee receives dental care: 70% first year, 80% second year, 90% third year, 100% fourth year.
Plan Highlights Delta Dental PPO Incentive
| Annual Calendar Year Deductible | In-Network | Out-of-Network |
|---|---|---|
| Per Person | N/A | N/A |
| Family Maximum | N/A | N/A |
| Calendar Year Maximum | $2,500 | $1,500 |
| Preventive Services | In-Network | Out-of-Network |
|---|---|---|
| Office Visits | 100% (1) | 100% (1) |
| X-rays | 100% (1) | 100% (1) |
| Cleanings | 100% (1) | 100% (1) |
| Sealants (per tooth) | 100% (1) | 100% (1) |
| Restorative Services | In-Network | Out-of-Network |
|---|---|---|
| Amalgam Fillings | 100% (1) | 100% (1) |
| Composite Fillings | 100% (1) | 100% (1) |
|
Periodontics (gum treatment) |
In-Network | Out-of-Network |
|---|---|---|
| Scaling & Root Planning | 100% (1) | 100% (1) |
| Gingivectomy (4+ teeth) | 100% (1) | 100% (1) |
| Endodontics (root canal therapy) | In-Network | Out-of-Network |
|---|---|---|
| Pulpotomy | 100% (1) | 100% (1) |
| Root Canal | 100% (1) | 100% (1) |
| Oral Surgery | In-Network | Out-of-Network |
|---|---|---|
| General Anesthesia | 100% (1) | 100% (1) |
| Simple Extraction | 100% (1) | 100% (1) |
| Soft Tissue Impaction | 100% (1) | 100% (1) |
| Complete or Partial Bony Impaction | 100% (1) | 100% (1) |
| Crowns & Inlays | In-Network | Out-of-Network |
|---|---|---|
| Inlay / Only (2 surfaces) | 100% (1) | 100% (1) |
| Crowns | 100% (1) | 100% (1) |
| Prosthetics & Bridges | In-Network | Out-of-Network |
|---|---|---|
| Bridges | 50% | 50% of UCR |
| Denture Adjustment | 50% | 50% of UCR |
| Complete or Partial Denture | 50% | 50% of UCR |
| Other Services | In-Network | Out-of-Network |
|---|---|---|
| Implants | 50% up to $1,000 | 50% up to $1,000 |
| Orthodontia Services | In-Network | Out-of-Network |
|---|---|---|
| Child / Adult Orthodontia Phase 1 & 2 | 50% to $2,000 per Lifetime for Adults and Children | 50% to $2,000 per Lifetime for Adults and Children |
(2) Resin, porcelain and any resin to metal or porcelain to metal crowns and pontics are excluded on molar teeth. If titanium, noble or high noble metals are requested for filings, crowns, pontics, bridges or prosthetic devices, there will be an additional charge, based on the amount of the metal used. Flexible base partial dentures are subject to an additional charge based on additional laboratory cost.
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions down below.