Xerox Plan Information
Benefit Summaries & Plan Comparison
PPO Network
Using a PPO dentist is considered in-network and will offer you the greatest savings on dental services and will maximize your benefits.
Premier Network
Using a Premier dentist is considered in-network and will offer you great savings on dental services. It is the largest network.
Out of Network
You have the freedom to choose any dentist that does not participate in either the PPO or Premier networks.
DCUSA (DHMO)
Using your assigned DeltaCare USA Contract Dentist means fixed copays per procedure—no deductible, no annual maximum, and no percentage coinsurance.
Plan Comparison
| Basic Plan | Enhanced Plan | 18PRO (DCUSA) Plan | |||||
|---|---|---|---|---|---|---|---|
| Service | In-Network (PPO/Premier) | Out-of-Network | In-Network (PPO/Premier) | Out-of-Network | Contract Dentist (Copay) | ||
| Preventive & Diagnostic Exams, cleanings, bitewing x-rays, sealants, space maintainers, fluoride treatments (frequency limitations apply) |
100% | 80% | 80% | 100% | 100% | No Cost | |
| Basic Fillings, simple extractions, root canals (endodontics), periodontics, oral surgery, cone beam radiographs |
50% | 40% | 40% | 80% | 80% | Copay per procedure (e.g., filling $23–$40; scaling/root planing $75–$125) |
|
| Major Crowns & gold restorations, bridgework, full & partial dentures, repair of dentures, implants |
30% | 60% |
Copay per procedure (e.g., crown $415–$530; denture $675–$780; implant crown $750–$780) |
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| Annual Maximum (per person – waived for Preventive & Diagnostic) |
$1,000 |
$1,500 | - | ||||
|
Annual Deductible (waived for preventive and diagnostic) Per person Family maximum Waived for Preventive & Diagnostic |
$50 $150 |
$50 $100 |
- | ||||
| Orthodontics Adult and child to age 19 Lifetime maximum (per person) |
- | 50% $1,800 |
Comprehensive (adult): $2,000 copay (up to 24 months treatment) |
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| Benefit Summaries |
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| Plan information resources | - | - | |||||
