Page 10 - Oremor EE Benefits Guide 01-19.pub

Benefits

Dental Insurance

DHMO Dental Plan | California Dental Network
With the Dental Health Maintenance Organiza on (DHMO) plan through California Dental Network, you are required to select a
general den st to provide your dental care. You will contact your general den st for all of your dental needs, such as rou ne check‐
ups and emergency situa ons. If specialty care is needed, your general den st will provide the necessary referral. For covered
procedures, you'll pay the pre‐set copay or coinsurance fee described in your DHMO plan booklet. Please keep a copy of your
booklet to refer to when u lizing your dental care. This will show the applicable copays that apply to all of the dental services that
are covered under this plan.

DPOS Dental Plan | Principal Financial Group
With the Principal Financial Group Dental Preferred Provider Organiza on (DPOS) dental plan, you may visit an EPO or a PPO
den st and benefit from the nego ated rate or visit a non‐network den st. When you u lize an EPO or PPO den st, your out‐of‐
pocket expenses will be less. You may also obtain services using a non‐network den st; however, you will be responsible for the
difference between the covered amount and the actual charges and you may be responsible for filing claims.

CA Dental Network Principal Financial Group
Plan Name DHMO Plan DPOS Plan

Network Name Network EPO Network PPO Network Non‐Network
Dental Benefits
Calendar Year Maximum Unlimited $2,000 $1,500 $1,000

Deduc ble (Annual)
‐ Individual $0 $50
‐ Family Limit $0 $150
Preven ve No Charge No Charge No Charge No Charge
Exams, X‐Rays, Cleanings for Most Services

Basic Services See Copay Schedule Deduc ble, 20% Deduc ble, 20% Deduc ble, 30%
Fillings, Oral Surgery,
Endodon cs, Periodon cs
Major Services See Copay Schedule Deduc ble, 50% Deduc ble, 50% Deduc ble, 60%
Crowns, Prosthe cs
Orthodon a
‐ Covered Members Children & Adults Children & Adults Children & Adults Children & Adults
‐ Copay $1,775 Child / $1,975 Adult N/A N/A N/A
‐ Coinsurance N/A 50% 50% 50%
‐ Life me Benefit Maximum N/A $1,500 $1,500 $1,000

California Dental Network: Provider Finder Instructions
 Website: Go to www.caldental.net. Select “Find a Den st” and enter a zip code for the area you would like
to search.
 Telephone: Call (877) 433‐6825

Principal Financial Group: Provider Finder Instructions

Website: Go to hƩps://c3.go2dental.com/member/dental_search/searchprov.cgi. Click on “Search the directory”
 Enter a state and select the “Principal POS Plan”.
 Telephone: Call (800) 247‐4695

10