Page 9 - The Polyclinic New Hire Guide
P. 9
Dental Benefits Overview
Dental Benefits Overview
Taking care of your teeth is important to your overall health. The
Polyclinic dental plan by Delta Dental provides 100 percent coverage You may elect dental coverage for
for diagnostic and preventive care services when you use providers who eligible dependent children and a
participate in their Preferred Provider Plan (PPO). lawful spouse. The Polyclinic does not
offer medical or dental coverage for a
What is a Dental PPO Plan? spouse who is eligible for other medical
or dental coverage through another
A Dental PPO (Preferred Provider Organization) plan works in the creditable coverage plan. To enroll an
same way as a medical PPO in that you will receive the maximum eligible spouse, you must submit the
beneit if you receive care from a PPO in-network dentist. While you Spousal Afidavit found on page 23.
may still be covered if you choose an out-of-network dentist, those
beneits may be reduced.
Payment Levels
Delta Dental
Plan Summary Delta Dental Premier Dentist Non-Participating
Dentist
PPO Dentist
Deductible (waived on Class I)
per person/per beneit period $50 $50 $50
Annual family maximum $150 $150 $150
Class I diagnostic and preventive
(exams, prophys, luoride, x-rays, 100% 80% 80%
sealants)
Class II restorative
(restorations, endodontics, 80% 70% 70%
periodontics, oral surgery)
Class III major
(crowns, dentures, partials, bridges, 50% 40% 40%
and implants)
Annual maximum per person $1,500 $1,500 $1,500
How to Locate a Provider
Visit www.DeltaDentalWA.com and select “Looking for a Dentist.” Click “Read
More”.
X Delta Dental PPO Dentist—select the “Delta Dental PPO plan” and follow the
prompts
X Delta Dental Premier Dentist—select the “Delta Dental Premier plan” and
follow the prompts
9
Dental Benefits Overview
Taking care of your teeth is important to your overall health. The
Polyclinic dental plan by Delta Dental provides 100 percent coverage You may elect dental coverage for
for diagnostic and preventive care services when you use providers who eligible dependent children and a
participate in their Preferred Provider Plan (PPO). lawful spouse. The Polyclinic does not
offer medical or dental coverage for a
What is a Dental PPO Plan? spouse who is eligible for other medical
or dental coverage through another
A Dental PPO (Preferred Provider Organization) plan works in the creditable coverage plan. To enroll an
same way as a medical PPO in that you will receive the maximum eligible spouse, you must submit the
beneit if you receive care from a PPO in-network dentist. While you Spousal Afidavit found on page 23.
may still be covered if you choose an out-of-network dentist, those
beneits may be reduced.
Payment Levels
Delta Dental
Plan Summary Delta Dental Premier Dentist Non-Participating
Dentist
PPO Dentist
Deductible (waived on Class I)
per person/per beneit period $50 $50 $50
Annual family maximum $150 $150 $150
Class I diagnostic and preventive
(exams, prophys, luoride, x-rays, 100% 80% 80%
sealants)
Class II restorative
(restorations, endodontics, 80% 70% 70%
periodontics, oral surgery)
Class III major
(crowns, dentures, partials, bridges, 50% 40% 40%
and implants)
Annual maximum per person $1,500 $1,500 $1,500
How to Locate a Provider
Visit www.DeltaDentalWA.com and select “Looking for a Dentist.” Click “Read
More”.
X Delta Dental PPO Dentist—select the “Delta Dental PPO plan” and follow the
prompts
X Delta Dental Premier Dentist—select the “Delta Dental Premier plan” and
follow the prompts
9
