Page 13 - Work Life and Benefits Booklet 2018 - SDC.END.pub
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                                                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
                              will contact your general dentist for all of your dental needs, such as routine check-ups and emergency situations. If specialty care is needed, your general
                                            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
                                                   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.   DHMO members refer to  the DeltaCare USA network   and PPO members refer to   the Delta Dental PPO or   Delta Dental Premier  network when prompted.   Dental Plan choices
                                 dentist will provide the necessary referral. For covered procedures, you'll pay the pre-set copay or coinsurance fee described in your DHMO plan booklet.
                            With the DHMO plan through Delta Dental, you select a General Dentist who is a member of the DeltaCare USA network to provide your dental care. You
                                              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
                                   Please keep a copy of your booklet to refer to when utilizing your dental care. This will show the applicable copays that apply to all of the dental services













                                                                  NON-NETWORK                80%   80%   50%





                  Dental Plan Choices



                                                           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        100%    Deductible Waived   80%   50%










                                                                                Benefit Maximum (per calendar year; Preventive, Basic and Major Services combined)
                                                           DELTA DENTAL   DHMO    DELTACARE USA   NETWORK   $0   Unlimited   See Copay Schedule   See Copay Schedule   See Copay Schedule   $1,700 / $1,900
                          DHMO Plan (available in CA only)




                                     that are covered under this plan.      DPPO Plan         PLAN NAME     NETWORK NAME  Deductible (per calendar year)       Individual / Family     Per Individual   Covered Services     Preventive Services     Basic Services     Major Services     Orthodontia    (Child/Adult)
   8   9   10   11   12   13   14   15   16   17   18