Cotati-Rohnert Park USD SEIU - Delta Dental PPO Incentive Plan Summary of Benefits - Effective Oct 1, 2022 to Sep 30, 2023

Sep 12, 2026

Upload by Jasmine

Delta Dental PPO Incentive Plan Summary of Benefits for Cotati-Rohnert Park USD and SEIU outlines key cost-sharing and coverage levels for covered dental services from October 1, 2022 through September 30, 2023. The document compares PPO network benefits with Premier and out-of-network benefits across diagnostic, basic, periodontics, endodontics, oral surgery, major services, prosthodontics, orthodontics, and dental accident benefits. It also explains network choices, how to find a Delta Dental dentist, and how the incentive plan encourages regular visits, plus online and mobile resources.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Benefits and Covered Services

Network comparison (PPO vs Premier/Out of Network)

Delta Dental Network options

Finding a dentist

How the incentive plan works

Online and mobile resources

Cotati-Rohnert Park USD SEIU Delta Dental PPO Incentive Plan Summary of Benefits Effective October 1, 2022 to September 30, 2023 | | Benefits and Covered Services* | PPO Network ** | Premier Network and Out of Network ** | | --- | --- | --- | --- | | Calendar Year Deductible | | None | None | | Calendar Year Maximum Benefit | | Unlimited | Unlimited | | Diagnostic & Preventive Services
Oral Examinations: 2
Annual Cleanings: 4 X-rays | | Paid at: 70% -100% * | Paid at: 70% -100% * | | Basic Services
Fillings
Posterior Composite Restorations Sealants
Nitrous Oxide | | Paid at: 70% -100% * | Paid at: 70% -100% * | | Periodontics (gum treatment) Covered Under Basic Services | | Paid at: 70% -100% * | Paid at: 70% -100% * | | Endodontics (root canals) | | Paid at: 70% -100% * | Paid at: 70% -100% * | | Oral Surgery (extraction)
Covered Under Basic Services | | Paid at: 70% -100% * | Paid at: 70% -100% * | | Major Services
Crowns, Inlays, Onlays & Cast Restorations | | Paid at: 70% -100% * | Paid at: 70% -100% * | | Prosthodontics
Bridges
Dentures
Implants : $2000 Annual Max | | Paid at: 60% * | Paid at: 50% * | | Orthodontic Benefits
Adults & Dependent Children Lifetime Maximum: $2,000
12 Month Wait: No | | Paid at: 50% * | Paid at: 50% * | | Dental Accident Benefits | | Paid at: 100% *
($1,000 maximum per enrollee each calendar year) | Paid at: 100% *
($1,000 maximum per enrollee each calendar year) | * This summary is for comparison purposes only. The Evidence of Coverage should be consulted for a detailed description of the covered benefits and is [available at www.cvtrust.org/plandocuments](available at www.cvtrust.org/plandocuments). ** See back for additional details 520 E. Herndon Avenue-Fresno, [CA 93720-P 559-437-2960-F 559-437-2965-800-CVT-9870-cvtrust.org](CA 93720-P 559-437-2960-F 559-437-2965-800-CVT-9870-cvtrust.org) What are my Delta Dental Network options? The Delta Dental PPO plan allows you the option to visit any licensed dentist. You will usually save more on your out-of-pocket costs when you visit a Delta Dental PPO dentist. The Delta Dental Premier network also provides cost-saving features and is the next best option when you can’t find a PPO dentist. Non-Delta Dental (Out of Network) dentists have no fee agreements with Delta Dental, so you will usually have the highest out-of-pocket costs when you visit a non-Delta Dental dentist. You are responsible for the difference between what Delta Dental pays and the dentist’s fee. How do I find a Delta Dental dentist? To locate a Delta Dental dentist near you, check the dentist directory on the Delta Dental website ([deltadentalins.com](deltadentalins.com)), which also provides a map to the dental office. Or, to hear or receive a faxed listing of dentists in your area, call 866-499-3001. Follow the automated instructions to search for a dentist. How does my Delta Dental incentive plan work? Your dental benefit incentive plan is designed to encourage regular visits to the dentist to keep your teeth and gums healthy. Here is an example of how an incentive plan works. (This is the most common incentive plan. Check your benefits information for details of your particular incentive plan. ) What are my online resources? The full Delta Dental website is a one-stop-shop for plan and oral health information. Also available in Spanish: [es.deltadentalins.com](es.deltadentalins.com). Create a free Online Services account at [deltadentalins.com](deltadentalins.com) to: • Locate a Delta Dental dentist • Check benefits, eligibility, and claim status • Opt for paperless statements • View or print your ID card • Check average dental costs in your area Check out Your Dental Plan Support Guide for money-saving tips and treatment information. And, don’t miss [mysmileway.com](mysmileway.com) – a great resource for oral health-related tools and tips. Mobile? Get the information you need

FAQs

What is the effective date range for the Delta Dental PPO Incentive Plan summary?

Coverage in the summary is effective October 1, 2022 to September 30, 2023.

How do PPO, Premier, and out-of-network options differ for covered services?

The summary compares benefit payment levels across networks, generally showing different percentages for PPO versus Premier and out-of-network services, along with separate maximums for certain categories.

How does the Delta Dental incentive plan work and why is it offered?

The incentive plan is designed to encourage regular visits to the dentist to help keep teeth and gums healthy, with examples provided for how incentives are applied.

Sep 12, 2026

Upload by Jasmine