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Coverage and Costs for Certain Procedures: Prepaid Plans

​​The following compares retiree costs for certain types of procedures under each dental plan.  Please consult each dental plan's evidence of coverage for detailed information and plan limitations.
Coverage and Costs for Certain Procedures
Type of Plan  DeltaCare USA, Premier Access, and Western Dental (Standard)  
Who is Covered?Retirees and DependentsRetirees and Dependents

Diagnostic and Preventive Benefits (two cleanings annually)

No chargeNo charge*
Basic BenefitsNo chargeNo charge
Crowns​$50​No charge
Bridges, Full and Partial Dentures$65 and upNo charge
Implants Premier Access and Western Dental onlyNot covered
Orthodontia​$1,000,  plus up to $250 for start-up costs​$1,000,  plus up to $250 for start-up costs
 *Benefits provided by SafeGuard Health Plans, Inc. a MetLife company. SafeGuard provides the availability for a third cleaning to the retiree and all enrolled dependents.
  Updated: 9/20/2020
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