DentalandVisionIns.com


Administration Instructions for Groups
Employee Application/Deletion or Change Form

Plan Descriptions & Certificates

For descriptions in a language other than English, please have the member create a login at DeltaDentalins.com
 Plan Description
 With Waiting Periods		 Plan Description
No Waiting Periods (NW)*
* Please see Plan Rules for
information on waiting periods.		 Certificate of Coverage
High Option A  High Option A_NW High Option A
High Option A with Ortho High Option A with Ortho_NW  
High Option A D&P HIgh Option A D&P_NW
High Option A D&P w Ortho High Option A D&P w Ortho_NW  
     
High Option B  High Option B_NW High Option B
High Option B with Ortho High Option B with Ortho_NW  
High Option B D&P HIgh Option B D&P_NW  
High Option B D&P w Ortho High Option B D&P w Ortho_NW  
     
High Option C  High Option C_NW High Option C
High Option C with Ortho High Option C with Ortho_NW  
High Option C D&P HIgh Option C D&P_NW  
High Option C D&P w Ortho High Option C D&P w Ortho_NW  
     
Premier 2000 Plan  Premier 2000 Plan NW  Premier 2000 Plan
Premier 2000 with Ortho Premier 2000 with Ortho NW  
Premier 2000 Plan D&P Premier 2000 Plan D&P NW  
Premier 2000 D&P w Ortho Premier 2000 D&P w Ortho NW  
     
Premier 1500 Plan Premier 1500 Plan NW Premier 1500 Plan
Premier 1500 with Ortho Premier 1500 with Ortho NW  
Premier 1500 D&P Premier 1500 D&P NW  
Premier 1500 D&P w Ortho Premier 1500 D&P w Ortho NW  
     
Plan I Plan I NW Plan I
Plan I with Ortho Plan I with Ortho NW  
Plan I D&P Plan I D&P NW  
Plan I D&P w Ortho Plan I D&P w Ortho NW  
     
Plan II Plan II NW Plan II
Plan II with Ortho Plan II with Ortho NW  
     
Plan III Plan III NW Plan III
Plan III w Ortho Plan III w Ortho NW
     
Plan IV Plan IV NW Plan IV
     
Choice 2000 Choice 2000 NW Choice 2000
Choice 2000 w Ortho Choice 2000 w Ortho NW  
Choice 2000 D&P Choice 2000 D&P NW  
Choice 2000 D&P w Ortho Choice 2000 D&P w Ortho NW  
     
Choice 1500 Choice 1500 NW Choice 1500
Choice 1500 with Ortho Choice 1500 with Ortho NW  
Choice 1500 D&P Choice 1500 D&P NW  
Choice 1500 D&P w Ortho Choice 1500 D&P w Ortho NW  
     
PPO+ 2000 PPO+ 2000 NW PPO+ 2000
PPO+ 2000 with Ortho PPO+ 2000 with Ortho NW  
PPO+ 2000 D&P PPO+ 2000 D&P NW  
PPO+ 2000 D&P w Ortho PPO+ 2000 D&P w Ortho NW  
     
Option 1 Option 1 NW Option 1
Option 1 with Ortho Option 1 with Ortho NW  
Option 1 D&P Option 1 D&P NW  
Option 1 D&P w Ortho Option 1 D&P w Ortho NW  
     
Option 2 Option 2 NW Option 2
Option 2 with Ortho Option 2 with Ortho NW  
Option 2 D&P Option 2 D&P NW  
Option 2 D&P w Ortho Option 2 D&P w Ortho NW  
     
Option 3 Option 3 NW Option 3
Option 3 with Ortho Option 3 with Ortho NW  
Option 3 D&P Option 3 D&P NW  
Option 3 D&P w Ortho Option 3 D&P w Ortho NW  
     
Classic 1500 Classic 1500 NW Classic 1500
Classic 1500 with Ortho Classic 1500 with Ortho NW  
Classic 1500 D&P Classic 1500 D&P NW  
Classic 1500 D&P w Ortho Classic 1500 D&P w Ortho NW  
     
Classic 1000 Classic 1000 NW Classic 1000
Classic 1000 D&P Classic 1000 D&P NW  

 




 For descriptions in a language other than English, please have the member create a login at VSP.com.
Plan Descriptions Certificate of Coverage
VSP A $20/25 VSP A $20/25
VSP A $25 VSP A $25
VSP A $10 VSP A $10
VSP A No Co-pay VSP A No Co-pay
VSP B $10/$25 VSP B $10/$25
VSP B $25 VSP B $25
VSP B $10 VSP B $10
VSP B No Co-pay VSP B No Co-pay
   
VSP C $10/$25 VSP C $10/$25
VSP C $25 VSP C $25
VSP C $10 VSP C $10
VSP C $5 High Option VSP C $5 High Option
VSP C No Co-pay VSP C No Co-pay