Page 8 - C.J. Segerstrom 2022 Benefit Guide

DENTAL PLAN

It’s important to have regular dental exams and cleanings so problems are detected before they become
painful — and expensive. Keeping your teeth and gums clean and healthy will help prevent most tooth
decay and is an important part of maintaining your overall health. You have a choice of two dental plans:
the DeltaCare DHMO and the Delta Dental PPO.

Delta Dental PPO
DeltaCare DHMO
Plan Provisions In-Network Out-of-Network

Annual Deductible
None $25/$50 $50/$100
(Individual/Family)
Calendar Year Maximum None $1,500 per person

Orthodontia Lifetime Maximum See Copay Schedule $1,500 per individual
Diagnostic and Preventive Services
Covered at 100% Covered at 100% Covered at 100%
(e.g., X-rays, cleanings, exams)
Amount you pay after deductible
Basic and Restorative Services See Copay Schedule 80% 80%
(e.g., fillings)

Major Services
See Copay Schedule 50% 50%
(e.g., dentures, crowns, bridges, implants)
Orthodontia Copays and limits apply 50% for adults and children

Bi-weekly Cost

Employee Only $3.17 $9.05
Employee + Spouse $6.83 $21.33

Employee + Child(ren) $6.26 $17.88

Employee + Family $10.25 $35.28

To Find a Network Dentist:
1. Go to deltadentalins.com
Using in-network dental providers 2. Look for the Find a Dentist tool on the right
While you have the option of choosing 3. Enter your zip code
any provider, you will save money 4. Select the Delta Dental PPO or Delta Care USA network from the
when you use in-network dentists. drop-down menu
When using an out-of-network dental 5. Click Search
provider, you will pay more because
the provider has not agreed to charge
you a negotiated rate.

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