|PLAN||Employee||Employee & Spouse||Employee & Child(ren)||Employee & Family|
|UT SELECT Dental||$32.40||$61.51||$67.80||$96.40|
| DELTA CARE
UT Benefits and Delta Dental Insurance Company provide three plan options for employees and their families, two PPO Plans and one dental HMO plan.
UT Benefits offers two dental PPO plans for you to choose from based on the level of benefits your family needs. Both dental PPO plans allow you the freedom to choose from any licensed dentist although you will maximize your benefits when you use a Delta Dental DPO or Delta Premier network provider.
|Dental Service|| UT SELECT
| UT SELECT
|Service Area**||Use any licensed dentist, but save with the Delta Dental DPO or Delta Premier networks|
|Deductible||$25||Plan pays deductible|
| Maximum Annual Benefit
(per enrollee per plan year)
|Orthodontic Maximum Benefits (Lifetime)||$1,250||$3000|
| Diagnostic & Preventive Services (D&P)
Exams, cleanings, x-rays, sealants
| Basic Services
Fillings, stainless steel crowns
(root canals) Covered Under Basic Services
(periodontal scaling, Root planning, and treatment of gum disease. Covered Under Basic Services
| Oral Surgery
Covered Under Basic Services
| Major Services
Crowns, inlays, onlays and cast restorations, bridges and dentures
| Orthodontic Benefits
Adults and dependent children
* Limitations may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist’s actual fees. Fees are based on DPO contracted fees for DPO dentists, Premier contracted fees for Premier dentists, and Premier contracted fees for non-Delta Dental dentists.
** Visit www.deltadentalins.com/universityoftexas to locate a network provider.
Available in Austin, Dallas/Ft. Worth, El Paso, Galveston, Houston, San Antonio, Tyler, and part of the Valley. Plan eligibility is based on your zip code. Ask your benefits office if you are eligible to enroll in the DeltaCare Dental HMO. You must select and receive services from a DeltaCare plan dentist to use the benefits under this plan.
DeltaCare USA plans feature: