$22
.93 per month
per month
Individual + 1
$42.99
Individual + 2 or More
$79.31
Annual Max Year 1
$500
Annual Max Year 2
$750
Annual Max Year 3+
$1000
Teeth Whitening
COVERED
Veneers
COVERED
Now offering DeltaVision® in partnership with VSP®
$34
.13 per month
per month
Individual + 1
$64.32
Family
$100.92
Annual Max Year 1
$500
Annual Max Year 2
$1,000
Annual Max Year 3
$1250
Annual Max Year 4+
$1,500
Now offering DeltaVision® in partnership with VSP®
$37
.47 per month
per month
Individual +1
$71.35
Family
$122.40
Annual Max Year 1
$750
Annual Max Year 2
$1,000
Annual Max Year 3
$1,250
Annual Max Year 4+
$1,500
Teeth Whitening
COVERED
Veneers
COVERED
Braces - All Ages
COVERED
Now offering DeltaVision® in partnership with VSP®
Essential Advantage®
Covered Dental Services
Delta Dental PPO℠ Network
Year One
Years Two & Three
Year Four or more
Annual Maximum Benefits
Contract Year
$500
$750
$1,000
Deductible
Per person / Per family max (contract year; applies to all services except Delta Dental PPO Diagnostic & Preventive services.)
$50 / $150
$50 / $150
$50 / $150
Diagnostic & Preventive Services
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
100%
100%
100%
Basic Services
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments, Repairs, Bleaching & Whitening
25%
50%
80%
Bleaching & Whitening
25%
50%
50%
Major Services
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services, and Veneers
10%
25%
25%
Orthodontia
Braces
Not Included
Not Included
Not Included
Covered Dental Services
Out of Network
Diagnostic & Preventive Services
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
80%
80%
80%
Basic Services
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments, Repairs, Bleaching & Whitening
10%
25%
40%
Bleaching & Whitening
10%
25%
25%
Major Services
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services, and Veneers
10%
10%
10%
Orthodontia
Braces
Not Included
Not Included
Not Included
DeltaVision® I-150 in partnership with VSP®
Monthly Premiums
Individual - $8.14
Individual + 1 - $16.28
Individual + 2 or More - $26.21
WellVision Exam
• Comprehensive eye exam to ensure overall visual wellness
Once every 12 months
$10 Copay
Prescription Glasses
• Includes frames and lenses
$20 Copay
Frames
• $150 allowance for wide selection of frames • 20% savings on amount over allowance • $80 Costco frame allowance
Once every 12 months
Included in Prescription Glasses Copay
Lenses
• Single vision, lined bifocal and lined trifocal lenses
Once every 12 months
Included in Prescription Glasses Copay
Contact Lenses - Instead of Glasses
• $150 allowance for contacts; copay does not apply • Contact lens exam (fitting and evaluation)
Once every 12 months
up to $60 Copay
Featured Frames
$170 allowance on featured frame brands. Check vsp.com for current offers.
Contract Year
| Year One | $500 |
| Years Two & Three | $750 |
| Year Four or more | $1,000 |
Per person / Per family max (contract year; applies to all services except Delta Dental PPO Diagnostic & Preventive services.)
| Year One | $50 / $150 |
| Years Two & Three | $50 / $150 |
| Year Four or more | $50 / $150 |
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
| Year One | 100% |
| Years Two & Three | 100% |
| Year Four or more | 100% |
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments, Repairs, Bleaching & Whitening
| Year One | 25% |
| Years Two & Three | 50% |
| Year Four or more | 80% |
| Year One | 25% |
| Years Two & Three | 50% |
| Year Four or more | 50% |
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services, and Veneers
| Year One | 10% |
| Years Two & Three | 25% |
| Year Four or more | 25% |
Braces
| Year One | Not Included |
| Years Two & Three | Not Included |
| Year Four or more | Not Included |
Out of Network
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
| Year One | 80% |
| Years Two & Three | 80% |
| Year Four or more | 80% |
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments, Repairs, Bleaching & Whitening
| Year One | 10% |
| Years Two & Three | 25% |
| Year Four or more | 40% |
| Year One | 10% |
| Years Two & Three | 25% |
| Year Four or more | 25% |
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services, and Veneers
| Year One | 10% |
| Years Two & Three | 10% |
| Year Four or more | 10% |
Braces
| Year One | Not Included |
| Years Two & Three | Not Included |
| Year Four or more | Not Included |
| Year One | Individual - $8.14 |
| Years Two & Three | Individual + 1 - $16.28 |
| Year Four or more | Individual + 2 or More - $26.21 |
• Comprehensive eye exam to ensure overall visual wellness
| Year One | Once every 12 months |
| Years Two & Three | $10 Copay |
| Year Four or more |
• Includes frames and lenses
| Year One | |
| Years Two & Three | $20 Copay |
| Year Four or more |
• $150 allowance for wide selection of frames • 20% savings on amount over allowance • $80 Costco frame allowance
| Year One | Once every 12 months |
| Years Two & Three | Included in Prescription Glasses Copay |
| Year Four or more |
• Single vision, lined bifocal and lined trifocal lenses
| Year One | Once every 12 months |
| Years Two & Three | Included in Prescription Glasses Copay |
| Year Four or more |
• $150 allowance for contacts; copay does not apply • Contact lens exam (fitting and evaluation)
| Year One | Once every 12 months |
| Years Two & Three | up to $60 Copay |
| Year Four or more |
Superior Advantage®
Covered Dental Services
Delta Dental PPO℠ Network
Year One
Years Two, Three, Four or more
.
Annual Maximum Benefits
Contract Year
$500
$1,000 | $1,250 | $1,500
Deductible
Per person / Per family max (contract year; applies to all services except Delta Dental PPO Diagnostic & Preventive services.)
$50 / $150
$50 / $150
Diagnostic & Preventive Services
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
100%
100%
Basic Services
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs
50%
80%
Major Services
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services
25%
50%
Orthodontia
Braces
Not Included
Not Included
Covered Dental Services
Out of Network
Diagnostic & Preventive Services
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
80%
80%
Basic Services
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs
40%
60%
Major Services
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services
10%
40%
Orthodontia
Braces
Not Included
Not Included
DeltaVision® I-150 in partnership with VSP®
Monthly Premiums
Individual - $8.14
Individual + 1 - $16.28
Individual + 2 or More - $26.21
WellVision Exam
• Comprehensive eye exam to ensure overall visual wellness
Once every 12 months
$10 Copay
Prescription Glasses
• Includes frames and lenses
$20 Copay
Frames
• $150 allowance for wide selection of frames • 20% savings on amount over allowance • $80 Costco frame allowance
Once every 12 months
Included in Prescription Glasses Copay
Lenses
• Single vision, lined bifocal and lined trifocal lenses
Once every 12 months
Included in Prescription Glasses Copay
Contact Lenses - Instead of Glasses
• $150 allowance for contacts; copay does not apply • Contact lens exam (fitting and evaluation)
Once every 12 months
up to $60 Copay
Featured Frames
$170 allowance on featured frame brands. Check vsp.com for current offers.
Contract Year
| Year One | $500 |
| Years Two, Three, Four or more | $1,000 | $1,250 | $1,500 |
| . |
Per person / Per family max (contract year; applies to all services except Delta Dental PPO Diagnostic & Preventive services.)
| Year One | $50 / $150 |
| Years Two, Three, Four or more | $50 / $150 |
| . |
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
| Year One | 100% |
| Years Two, Three, Four or more | 100% |
| . |
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs
| Year One | 50% |
| Years Two, Three, Four or more | 80% |
| . |
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services
| Year One | 25% |
| Years Two, Three, Four or more | 50% |
| . |
Braces
| Year One | Not Included |
| Years Two, Three, Four or more | Not Included |
| . |
Out of Network
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
| Year One | 80% |
| Years Two, Three, Four or more | 80% |
| . |
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs
| Year One | 40% |
| Years Two, Three, Four or more | 60% |
| . |
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services
| Year One | 10% |
| Years Two, Three, Four or more | 40% |
| . |
Braces
| Year One | Not Included |
| Years Two, Three, Four or more | Not Included |
| . |
| Year One | Individual - $8.14 |
| Years Two, Three, Four or more | Individual + 1 - $16.28 |
| . | Individual + 2 or More - $26.21 |
• Comprehensive eye exam to ensure overall visual wellness
| Year One | Once every 12 months |
| Years Two, Three, Four or more | $10 Copay |
| . |
• Includes frames and lenses
| Year One | |
| Years Two, Three, Four or more | $20 Copay |
| . |
• $150 allowance for wide selection of frames • 20% savings on amount over allowance • $80 Costco frame allowance
| Year One | Once every 12 months |
| Years Two, Three, Four or more | Included in Prescription Glasses Copay |
| . |
• Single vision, lined bifocal and lined trifocal lenses
| Year One | Once every 12 months |
| Years Two, Three, Four or more | Included in Prescription Glasses Copay |
| . |
• $150 allowance for contacts; copay does not apply • Contact lens exam (fitting and evaluation)
| Year One | Once every 12 months |
| Years Two, Three, Four or more | up to $60 Copay |
| . |
Brighter Advantage®
Covered Dental Services
Delta Dental PPO℠ Network
Year One
Years Two, Three, Four or more
.
Annual Maximum Benefits
Contract Year
$750
$1,000 | $1,250 | $1,500
Deductible
Per person / Per family max (contract year; applies to all services except Delta Dental PPO Diagnostic & Preventive services.)
$50 / $150
$50 / $150
Diagnostic & Preventive Services
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
100%
100%
Basic Services
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs
50%
80%
Major Services
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services, Bleaching, Whitening, and Veneers
25%
50%
Orthodontia
Braces
Not Included
50%
Covered Dental Services
Out of Network
Diagnostic & Preventive Services
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
80%
80%
Basic Services
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs
40%
60%
Major Services
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services, Bleaching, Whitening, and Veneers
10%
40%
Orthodontia
Braces
Not Included
40%
DeltaVision® I-175 in partnership with VSP®
Monthly Premiums
Individual - $11.73
Individual + 1 - $23.46
Individual + 2 or More - $37.77
WellVision Exam
• Comprehensive eye exam to ensure overall visual wellness
Once every 12 months
$10 Copay
Prescription Glasses
• Includes frames and lenses
$10 Copay
Frames
• $175 allowance for wide selection of frames • 20% savings on amount over allowance • $95 Costco frame allowance
Once every 12 months
Included in Prescription Glasses Copay
Lenses
• Single vision, lined bifocal and lined trifocal lenses
Once every 12 months
Included in Prescription Glasses Copay
Contact Lenses - Instead of Glasses
• $195 allowance for contacts; copay does not apply • Contact lens exam (fitting and evaluation)
Once every 12 months
up to $60 Copay
Featured Frames
$170 allowance on featured frame brands. Check vsp.com for current offers.
Contract Year
| Year One | $750 |
| Years Two, Three, Four or more | $1,000 | $1,250 | $1,500 |
| . |
Per person / Per family max (contract year; applies to all services except Delta Dental PPO Diagnostic & Preventive services.)
| Year One | $50 / $150 |
| Years Two, Three, Four or more | $50 / $150 |
| . |
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
| Year One | 100% |
| Years Two, Three, Four or more | 100% |
| . |
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs
| Year One | 50% |
| Years Two, Three, Four or more | 80% |
| . |
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services, Bleaching, Whitening, and Veneers
| Year One | 25% |
| Years Two, Three, Four or more | 50% |
| . |
Braces
| Year One | Not Included |
| Years Two, Three, Four or more | 50% |
| . |
Out of Network
Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance
| Year One | 80% |
| Years Two, Three, Four or more | 80% |
| . |
Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs
| Year One | 40% |
| Years Two, Three, Four or more | 60% |
| . |
Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services, Bleaching, Whitening, and Veneers
| Year One | 10% |
| Years Two, Three, Four or more | 40% |
| . |
Braces
| Year One | Not Included |
| Years Two, Three, Four or more | 40% |
| . |
| Year One | Individual - $11.73 |
| Years Two, Three, Four or more | Individual + 1 - $23.46 |
| . | Individual + 2 or More - $37.77 |
• Comprehensive eye exam to ensure overall visual wellness
| Year One | Once every 12 months |
| Years Two, Three, Four or more | $10 Copay |
| . |
• Includes frames and lenses
| Year One | |
| Years Two, Three, Four or more | $10 Copay |
| . |
• $175 allowance for wide selection of frames • 20% savings on amount over allowance • $95 Costco frame allowance
| Year One | Once every 12 months |
| Years Two, Three, Four or more | Included in Prescription Glasses Copay |
| . |
• Single vision, lined bifocal and lined trifocal lenses
| Year One | Once every 12 months |
| Years Two, Three, Four or more | Included in Prescription Glasses Copay |
| . |
• $195 allowance for contacts; copay does not apply • Contact lens exam (fitting and evaluation)
| Year One | Once every 12 months |
| Years Two, Three, Four or more | up to $60 Copay |
| . |
Membership is open to all Tennessee adult residents and their dependents. If you have been covered by a Delta Dental of Tennessee individual policy and drop your coverage, you cannot re-enroll for 12 months.
Your benefits for either plan will become effective the first day of the month following receipt of application, $25 application fee, and initial premium if received on or before the 15th of the month. If received after the 15th, effective date will be the first day of the following month.
When it comes to choices, VSP has your eyes covered. With a large network of independent doctors and popular retailers, a VSP doctor is always near. All DeltaVision doctors a part of VSP's "Choice" network.
