Page 12 - 2022 CPI Card Benefits Guide

Dental Plan

Coverage is provided through Delta Dental.

Regular dental exams can help you and your dentist detect problems
in the early stages when treatment is simpler and costs are lower.
Therefore, the plan pays benefits for covered preventive and diagnostic
services with no need for you to pay a deductible for in-network
services.

PPO Plus Premier PLAN

PPO PREMIER OUT-OF-
NETWORK NETWORK NETWORK*
IMPORTANT: Delta Dental Calendar Year Deductible

network is broad. You Individual $50 $50 $50
should check that your Family $150 $150 $150
dentist is in-network with
Delta Dental. If your dentist Calendar Year Out-of-Pocket Maximum
is not in-network you may Per Individual $1,500 per individual
want to consider finding (Basic and Major Services combined)
a new provider. Your plan You pay
will always provide better Services No Deductible
benefits when you use an Exams $0
in-network provider. Delta Preventive Care No Deductible
Dental offers two networks,
Premier and PPO. While Cleanings, X-rays, Fluoride $0 $0 $0
Treatments, Sealants
there is no difference in the
quality of these networks, Basic Services After Deductible
you will achieve maximum Fillings, Extractions, Oral Surgery, 20% 20% 20%
savings by seeing a PPO Endodontics, Periodontics
provider. You can contact Major Procedures After Deductible
your provider, go online to Crowns, Inlays/Onlays, Dentures
www.deltadentalco.com, or and Bridgework, Repairs 50% 50% 50%
call Delta Dental Customer Implants 50% 50% 50%
Service: 800-610-0201 Orthodontia No Deductible
to inquire if your provider
is in-network. Children 50% up to a lifetime maximum benefit
(end of 19th birthday month) of $1,500 per individual
* Using Out-of-Network Dentists, you will be responsible for the difference between the
non-participating Maximum Plan Allowance and the full fee charged by the Dentist.

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