Page 18 - Work Life and Benefits Booklet 2020 - Global Post

DPPO Plan
This plan offers you the freedom and flexibility to use the dentist of your choice. However, you will maximize your benefits and reduce your out-of-pocket costs if
you choose a dentist who participates in the Delta Dental PPO or Premier network. When you utilize a PPO or Premier dentist, your out-of-pocket expenses will be
less, however, you will usually pay the lowest amount for services when you visit a Delta Dental PPO dentist. If you obtain services using a non-network dentist, you
will be responsible for the difference between the covered amount and the actual charges and you may be responsible for filing claims. The chart below provides a
high-level overview of your dental plan.

DELTA DENTAL OF CALIFORNIA
PLAN NAME PPO

NETWORK NAME DELTA DENTAL DELTA DENTAL NON-NETWORK FINDING A DENTAL
PREMIER
PPO
PROVIDER
Deductible (per calendar year) Go to
Individual / Family $50 / $150 www.deltadentalins.com.
Benefit Maximum (per calendar year; Preventive, Basic and Major Services DHMO members refer to the
DeltaCare USA network and
combined) PPO members refer to the
Per Individual $1,500 Delta Dental PPO or Delta
Dental Premier network when
Covered Services prompted.

Preventive Services 100% 80% 80% + balance billing
Deductible Waived
Basic Services 80% 80% 80% + balance billing This is a California contract.
Major Services 50% 50% 50% + balance billing
Orthodontia 50% to $1,500 Lifetime Maximum
(Child/Adult) Non-Network dentists may also balance bill

Important
We strongly recommend you ask your dentist for a predetermination of benefits if total charges are expected to exceed $300. Predetermination enables you and
your dentist to know in advance what the payment will be for any service that may be in question.