The Delta Dental Dental PPO plan is designed to give 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 PPO dentist, go to www.deltadentalins.com and search the Provider Network, or call 866.499.3001.
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.
Plan Highlights
Delta Dental PPO
Annual Calendar Year Deductible
In-Network
Out-of-Network
Per Person
N/A
N/A
Family Maximum
N/A
N/A
Calendar Year Maximum
$2,000
$1,000
Preventive Services
In-Network
Out-of-Network
Office Visits
100%
50%
X-rays
100%
50%
Cleanings
100%
50%
Sealants (per tooth)
100%
50%
Restorative Services
In-Network
Out-of-Network
Amalgam Fillings
100%
50%
Composite Fillings
100%
50%
Periodontics (gum treatment)
In-Network
Out-of-Network
Scaling & Root Planning
100%
50%
Gingivectomy (4+ teeth)
100%
50%
Endodontics (root canal therapy)
In-Network
Out-of-Network
Pulpotomy
100%
50%
Root Canal
100%
50%
Oral Surgery
In-Network
Out-of-Network
General Anesthesia
100%
50%
Simple Extraction
100%
50%
Soft Tissue Impaction
100%
50%
Complete or Partial Bony Impaction
100%
50%
Crowns & Inlays
In-Network
Out-of-Network
Inlay / Only (2 surfaces)
100%
50%
Crowns
100%
50%
Prosthetics & Bridges
In-Network
Out-of-Network
Bridges
100%
50%
Denture Adjustment
100%
50%
Complete or Partial Denture
100%
50%
Other Services
In-Network
Out-of-Network
Implants
Not Covered
Not Covered
Orthodontia Services
In-Network
Out-of-Network
Child / Adult Orthodontia Phase 1 & 2
Not Covered
Not Covered
(1)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.
