Dental Plan Monthly Premium
PLAN YEAR 2019-2020
|PLAN||EMPLOYEE||EMPLOYEE & SPOUSE||EMPLOYEE & CHILD(REN)||EMPLOYEE & FAMILY|
UT Benefits and Delta Dental Insurance Company provide three plan options for employees and their families, two PPO Plans and one dental HMO plan.
Dental PPO Plans
UT Benefits offers two dental PPO plans for you to choose from based on the level of benefits your family needs. Both dental PPO plans allow you the freedom to choose from any licensed dentist although you will maximize your benefits when you use a Delta Dental DPO or Delta Premier network provider.
- UT SELECT Dental Plan (Standard Dental PPO Plan) - good for standard dental insurance needs
- UT SELECT Dental Plus Plan (Enhanced Dental PPO Plan) - greater benefits than the standard UT SELECT Dental Plan
Dental Plan Comparison Chart
|DENTAL SERVICE||UT SELECT
|Service Area**||Use any licensed dentist, but save with the Delta Dental DPO or Delta Premier networks|
|Deductible||$25||Plan pays deductible|
|Maximum Annual Benefit
(per enrollee per plan year)
|Orthodontic Maximum Benefits (Lifetime)||$1,250||$3,000|
|Diagnostic & Preventive Services (D&P)
Exams, cleanings, x-rays, sealants
Fillings, stainless steel crowns
(root canals) Covered Under Basic Services
(periodontal scaling, root planing, and treatment of gum disease. Covered Under Basic Services
Covered Under Basic Services
Crowns, inlays, onlays and cast restorations, bridges and dentures
Adults and dependent children
* Limitations may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist’s actual fees. Fees are based on DPO contracted fees for DPO dentists, Premier contracted fees for Premier dentists, and Premier contracted fees for non-Delta Dental dentists.
** Visit www.deltadentalins.com/universityoftexas to locate a network provider.
DeltaCare USA Dental HMO Plan (Fully-Insured Dental HMO Plan)
Available in Austin, Dallas/Ft. Worth, El Paso, Galveston, Houston, San Antonio, Tyler, and part of the Valley. Plan eligibility is based on your zip code. Ask your benefits office if you are eligible to enroll in the DeltaCare Dental HMO. You must select and receive services from a DeltaCare plan dentist to use the benefits under this plan.
DeltaCare USA plans feature:
- Set copayments.
- No annual deductibles and no maximums for covered benefits.
- Low out-of-pocket costs for many diagnostic and preventive services (such as professional cleanings and regular dental exams).
- UT SELECT Dental Plan Guide
- UT SELECT Dental Plus Plan Guide
- UT SELECT Dental & Dental Plus Video
- DeltaCare USA Dental HMO Video
- Your Dental Plan Options
- Find a Dentist (Directory)
- Delta Dental Website
CUSTOMER SERVICE (800) 893-3582