Page 13 - PriMed 2022 Benefits Guide

Dental Coverage

Dental coverage is provided by Delta Dental. You have the choice of
visiting a Delta Dental contracted PPO network provider, Premier Find a Dentist
Delta Dental provider or a non-network provider each time you or
To find an in-network provider, visit
your dependents need dental care.
http://www.deltadentalins.com
PPO Dental Plan – In-Network
PPO dentists offer the deepest discounts due to the contract
agreement with Delta Dental. They cannot balance bill any amounts above Delta Dental’s approved amount.
No claim submissions are needed when using the Premier Delta Dental providers.

Premier Delta Dental Network
Premier dentists are the 2nd tier providers who also have discounted cost based on the contract agreement
with Delta Dental. They cannot balance bill any amounts above Delta Dental’s approved amount. No claim
submissions are needed when using the Premier Delta Dental providers.
Out-of-PPO Network
You have the flexibility to use any dental provider, but you will be responsible for the difference between the
amount Delta Dental pays (what Delta considers allowable) and the amount your non-contracted dentist bills.
You will usually have the highest out-of-pocket costs when you visit a non-Delta Dental dentist. Non-Delta
Dental dentists may require you to pay the entire amount of the bill in advance and wait for reimbursement.
Therefore, you will have to complete and submit your own claim forms or pay your non-Delta Dental dentist a
service fee to submit for reimbursement for you.

Claim forms are available on the Delta Dental Website: http://www.deltadentalins.com

Plan Features Delta Dental PPO Plan
In-Network Out-of-Network*
Calendar Year Deductible $25/person $50/person
(waived for Preventive Services)
Calendar Year Benefit Maximum $1,500/person
Diagnostic and Preventive Services
100%, No deductible
(e.g., x-rays, cleanings, exams)
Basic and Restorative Services 90% 80%
(e.g., fillings, extractions, root canals) After deductible After deductible
Major Services 50% After deductible
(e.g., dentures, crowns, bridges)
Orthodontia
Children to age 19, or to age 26 if full- 60% 50%
time student
1
Orthodontia Lifetime Maximum $1,000/person
1 Available after 12 months of continuous enrollment in the dental plan
* For Out-of-Network services, members pay applicable coinsurance plus any amount that exceeds the usual, customary, and reasonable charge.

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