Delta Dental of California—Small Group

Delta Dental of California offers “Choice,” an exclusive plan to CoPower, for groups with 5 to 99 lives. “Choice” offers plans with a $25 employee deductible and a cap of $75 for families, as well as $1000, $1500 or $2000 calendar year maximums. Delta Dental also offers “Classic,” another portfolio of dental programs for small businesses with 5 to 99 employees. “Classic” offers plans with a $50 deductible and $1,000, $ 1,500 or $2,000 calendar year maximum. “Options” is also available for larger businesses with 50 to 99 employees. “Options” offers plans with a $50 deductible and $1,000, $1,500 or $2,000 calendar year maximums.

DeltaCare USA Plans.

Plan Summaries:

Plan Name	Plan Summary	Plan Summary (Spanish)
DeltaCare USA Choice Plan 10B (“Choice” only)
DeltaCare USA Plan 10A (“Classic” or “Options”)
DeltaCare USA Plan 11A (“Classic” or “Options”)
DeltaCare USA Plan 12A (“Classic” or “Options”)

Enrollment Forms:

• Delta Dental Enrollment/Change Form
• Delta Dental Declination/Waiver Form
• Delta Dental Claim Form

Enrollment Applications:

• Employer Application for Dental and Vision
• Delta Dental Voluntary Spanish Application
• Delta Dental & VSP Enrollment/List Form

Contracts:

• 5-99 Premier Contract—Orthodontics
• 5-99 Premier Contract—No Orthodontics
• 5-99 PPO Contract—Orthodontics
• 5-99 PPO Contract—No Orthodontics