Delta Dental ACTIVE/ARK

Summary of Benefits & Coverage 2016

Summary of Benefits & Coverage 2017

Summary of Benefits & Coverage 2018

Summary of Benefits & Coverage 2019

Summary of Benefits & Coverage 2020

Summary of Benefits & Coverage 2021

Summary Plan Description


2016 Arkansas Annual Claim Form

2017 Arkansas Annual Claim Form

2018 Arkansas Annual Claim Form

2019 Arkansas Annual Claim Form

2020 Arkansas Annual Claim Form

2021 Arkansas Annual Claim Form


2021 Mailings

6/9/21 COBRA rate change

3/24/21 Summary of Material Modification for Weight Loss Benefits

3/24/21 Temporary Changes to Claims, Appeals & COBRA revised

3/5/21 Temporary Changes to Claims, Appeals & COBRA

2/26/21 Change to New PBM AnWINS Rx

2/26/21 Summary of Materials Modification AnWINS Rx Changes

2020 Mailings

11/23/20 Notice of Children's Health Insurance Program (CHIP)

11/23/20 Notice of Prescription Drug Coverage and Medicare

11/23/20 Notice of the Plan's Use and Disclosure of PHI

11/23/20 Women's Health and Cancer Rights Act

11/23/20 Newborns' and Mothers' Health Protection Act

6/24/20 Network Changing to Aetna 

6/15/20 COBRA Rate Changes, 2020

2019 Mailings

2019 Summary of Material Modification re: Gene Therapy

2018 Mailings

11/27/18 Immunization Information

11/27/18 Summary of Materials Modification- OOP max and ER coverage

10/26/18 Summary of Materials Modification-Vision, Rx, A&S, ST & Hospital Room Changes

10/23/18 Summary Annual Report - Welfare Fund

2017 Mailings (newest to oldest)

11/29/17 Summary Annual Report - Welfare Fund

10/3/17 Summary of Materials Modification - Merger

7/10/17 COBRA Rate Change

2016 Mailings (newest to oldest)

12/2/16 Summary Annual Report for Arkansas

11/15/16 2017 Annual Claim Form




Delta Dental 


PAS (Personal Assistance Services)

PAS Flyer

Frequently Asked Questions

How much is my deductible?

Your deductible is $500

Has my deductible been met?

Login on the main  page to access your information

How much is my out of pocket?

Your maximum out of pocket is $3,750.

Do all providers have to be in-network.

Yes, all providers have to be in-network, otherwise there is no coverage.

What are considered wellness benefits and how are they paid?

Wellness benefits are paid at 100%. Examples of a Wellness benefit are annual visits to your primary care physician for a well visit, annual pediatrician visit for a well visit, colonoscopy, and mammogram.