Page 8 - 2021 HN Benefits Booklet

DENTAL INSURANCE

Health Net
Group Number: 1234567

Plan: DPPO Essential 6 1500

Benefits PPO Non PPO

Individual/Family Deductible $50/$150
Waived for Preventive? Yes

Annual Max (per person): $1,500 per member
Benefit payments are based
th
Plan Pays on a 95 Precentile Usual &
Customary. Members are

responsible for all charges in
excess of covered expense
for Non Network providers.
Preventive Services:
Routine Exams/cleanings 100% 100%
Fluoride application
Diagnostic Services:

Oral exams 100% 100%
X-rays
Restorative Services:
Fillings 80% 80%
Oral Surgery: tooth extraction
Endodontics: root canal therapy
Periodontics: non-surgical treatment of gum disease
Major Services:
Prosthodontics: removable and fixed 50% 50%

Orthodontia (Adult & Child): 50% 50%
Lifetime Ortho annual Maximum: N/A

Questions?

Member Services: 888-926-4988
Website: www.healthnet.com

8