The Dental Benefit Plan is administered by Delta Dental: 1-866-579-5717,

Who is Eligible?

Employees, legal spouse, and dependent children are eligible if you elect to have this coverage.

Because dental coverage is an annual required benefit choice, you can select from two options: Basic Plan and Select Plan. Review the chart below and pay close attention to the different benefits and the different monthly rates to help you make your selection.

Dental claims are reimbursed based on a fee schedule. Note: the Basic Plan provides coverage for a limited range of services including diagnostic and preventive services. The fee schedule dollar amount is the maximum reimbursement for the specified dental procedure code.

Covered individuals are responsible for the difference (if any) between the provider’s charge and the
fee schedule reimbursement amount. See the Summary Plan Description for fee schedule listing.

Basic Plan Coverage

Select Plan Coverage
Maximum Annual Benefit $750 per covered individual $2,000 per covered individual
Preventive and Diagnostic Services
  • Twice Per Benefit Year
  • Initial and Periodic oral exam
  • Cleaning
  • Complete series of intraoral X-rays
  • Twice Per Benefit Year
  • Initial and Periodic oral exam
  • Cleaning
  • Complete series of intraoral X-rays

**The Preventive & Diagnostic Services listed above do not apply to the $2,000 annual benefit maximum

Basic Restorative Services
  • Not covered
  • Amalgam filling
  • Endodontic treatment
  • Periodontic treatment
  • Oral surgery
Major Dental Services
  • Not covered
  • Crown
  • Root canal
  • Complete lower and upper denture
  • Dental implant
  • Occlusal guards
Removal of impacted teeth
  • Not covered
  • Covered benefit


Orthodontic Benefit
The Select Plan provides a $1,500 lifetime orthodontic benefit per covered individual. Benefits are paid at 50% of the allowed amount for authorized services. Treatment plans usually include an initial down payment and ongoing monthly fees. If an initial down payment is required, Choices will pay up to 50% of the initial payment, up to 1/3 of the total treatment charge. In addition, Delta Dental (our dental plan administrator) will establish a monthly reimbursement based on your provider’s monthly fee and your prescribed treatment plan.