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.

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

Forms:

Please be advised that CoPower has discontinued the use of the Remittance Report and has replaced it with the following forms, effective immediately:

• Delta Dental Enrollment/Change Form
  (for adding new members or making changes to the coverage on any of CoPower’s policies)
• Termination Form
  (for employee terminations from any of CoPower’s policies)

For more information, please read our Notice to CoPower groups regarding these changes.

• 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

General Information:

• Delta Dental Grievance Procedure & Claims Appeal

CoPower Information:

Third Party Administration Details:

• Maintaining Your Delta Dental Plan
• Important Delta Dental Open Enrollment Information
• Important Notice to CoPower Groups
• Who Are Your Eligible Dependents on Your Delta Dental Plan?
• New Hires, Additions & Terminations and COBRA Employees
• When to Use Your CoPower ID & Group Claim Numbers

Manuals:

• Delta Dental Manual
• DeltaCare USA Manual