Delta Dental of California—Small Group

Delta Dental of California offers “Choice,” an exclusive plan to CoPower, for groups with 5 to 99 lives. Delta Dental also offers “Classic,” another portfolio of dental programs for small businesses with 5 to 99 employees. “Options” is also available for larger businesses with 50 to 99 employees.

Plan Details:

Delta Dental Premier Plans:

Plan Name	Evidence of Coverage	Plan Highlights	Plan Highlights (Spanish)
Choice Premier 1,000 w/out Ortho			n/a
Choice Premier 1,500 w/out Ortho			n/a
Choice Premier 2,000 w/out Ortho			n/a
Choice Premier 1,000 w/ Ortho			n/a
Choice Premier 1,500 w/ Ortho			n/a
Choice Premier 2,000 w/ Ortho			n/a
Classic Premier 100 1,000 w/out Ortho
Classic Premier 100 1,500 w/out Ortho
Classic Premier 100 2,000 w/out Ortho			n/a
Classic Premier 100 1,000 w/ Ortho
Classic Premier 100 1,500 w/ Ortho
Classic Premier 100 2,000 w/ Ortho			n/a
Classic Premier 50 1,000 w/out Ortho			n/a
Classic Premier 50 1,500 w/out Ortho			n/a
Classic Premier 50 2,000 w/out Ortho			n/a
Classic Premier 50 1,000 w/ Ortho			n/a
Classic Premier 50 1,500 w/ Ortho			n/a
Classic Premier 50 2,000 w/ Ortho		n/a	n/a

Delta Dental PPO Plans:

Plan Name	Evidence of Coverage	Plan Highlights	Plan Highlights (Spanish)
Choice PPO 1,000 w/out Ortho			n/a
Choice PPO 1,500 w/out Ortho			n/a
Choice PPO 2,000 w/out Ortho			n/a
Choice PPO 1,000 w/ Ortho			n/a
Choice PPO 1,500 w/ Ortho			n/a
Choice PPO 2,000 w/ Ortho			n/a
Classic PPO 1000 w/out Ortho
Classic PPO 1500 w/out Ortho
Classic PPO 2,000 w/out Ortho			n/a
Classic PPO 1000 w/ Ortho
Classic PPO 1500 w/ Ortho
Classic PPO 2,000 w/ Ortho			n/a

DeltaCare USA Plans:

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”)

Delta Dental “Options” Plans.

To obtain an Evidence of Coverge or Plan Summary for a Delta Dental “Options” 50–99 plan, please contact your CoPower Group Service Representative.

Enrollment Forms:

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

Directories:

• Quarterly DeltaCare USA Northern California Directory of Dentists
• Quarterly DeltaCare USA Southern California Directory of Dentists

Brochures:

• How to Find a Dentist and Save Money
• How to Find a Delta Dental PPO Dentist and Save Money
• Getting the Most from your Delta Dental Premier Program
• Getting the Most from your Delta Dental PPO Program
• A Free Estimate of your Dental Costs
• What Enrollees Want to Know About Dental Insurance
• Dual Coverage Brochure
• Contractual Limitations and Exclusions
• CalCOBRA Disclosure to Employees

General Information:

• Delta Dental Grievance Procedure & Claims Appeal

CoPower Manuals:

• Delta Dental Manual
• DeltaCare USA Manual