Page 13 - Work Life and Benefits Booklet 2018 - SW.pub
P. 13

13

                                 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
                                                                 FINDING A DENTAL   PROVIDER   Go to  www.deltadentalins.com.   PPO members refer to the  Delta Dental PPO or Delta  Dental Premier network   when prompted.   Dental Plan choices
                            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
























                  Dental Plan Choices
                                                         NON-NETWORK                80%   80%   50%











                                                  DELTA DENTAL   PPO   DELTA DENTAL   PREMIER   $50 / $150    $1,500    80%   80%   50%   50%   $1,500
                                     claims. The chart below provides a high-level overview of your dental plan.










                                                        DELTA DENTAL    PPO  Benefit Maximum (per calendar year; Preventive, Basic and Major Services   100%    Deductible Waived   80%   50%









                                                               Deductible (per calendar year)










                          DPPO Plan                  PLAN NAME   NETWORK NAME   Individual / Family   combined)   Per Individual   Covered Services   Preventive Services   Basic Services   Major Services   Orthodontia    (Child/Adult)
   8   9   10   11   12   13   14   15   16   17   18