Delta Dental of California—Large 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.

Plan Details:

Delta Dental Choice Premier Plans:

Plan Name	Evidence of Coverage	Plan Highlights	Plan Highlights (Spanish)
Choice Premier 1,000 w/out Ortho (5-99)			n/a
Choice Premier 1,500 w/out Ortho (5-99)			n/a
Choice Premier 2,000 w/out Ortho (5-99)			n/a
Choice Premier 1,000 w/ Ortho (10-99)			n/a
Choice Premier 1,500 w/ Ortho (10-99)			n/a
Choice Premier 2,000 w/ Ortho (10-99)			n/a

Delta Dental Choice PPO Plans:

Plan Name	Evidence of Coverage	Plan Highlights	Plan Highlights (Spanish)
Choice PPO 1,000 w/out Ortho (5-99)			n/a
Choice PPO 1,500 w/out Ortho (5-99)			n/a
Choice PPO 2,000 w/out Ortho (5-99)			n/a
Choice PPO 1,000 w/ Ortho (10-99)			n/a
Choice PPO 1,500 w/ Ortho (10-99)			n/a
Choice PPO 2,000 w/ Ortho (10-99)			n/a

Delta Dental Classic PPO Plans:

DeltaCare USA Plans:

Plan Name	Plan Summary	Plan Summary (Spanish)
DeltaCare USA Choice Plan 10B
DeltaCare USA Plan 10A
DeltaCare USA Plan 11A
DeltaCare USA Plan 12A
DeltaCare USA Plan 15B

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.

Forms, Applications and Contracts:

Enrollment Forms:

• Delta Dental Enrollment/Change Form
• Delta Dental Declination/Waiver Form
• DeltaCare USA New Group Submission Checklist
• Delta Dental Claim Form

Enrollment Applications:

• Employer Application for Dental and Vision

Contracts:

• 5-99 Premier Contract—Orthodontics
• 5-99 Premier Contract—No Orthodontics
• 5-99 PPO Contract—Orthodontics
• 5-99 PPO Contract—No Orthodontics
• 50-99 Premier Contract—Orthodontics
• 50-99 Premier Contract—No Orthodontics
• 50-99 PPO Contract—Orthodontics
• 50-99 PPO Contract—No Orthodontics