Page 13 - Work Life and Benefits Booklet 2018 - SW

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
PLAN NAME PPO

NETWORK NAME DELTA DENTAL DELTA DENTAL NON-NETWORK
PREMIER
PPO
Deductible (per calendar year)
Individual / Family $50 / $150 FINDING A DENTAL
PROVIDER
Benefit Maximum (per calendar year; Preventive, Basic and Major Services Go to
combined) www.deltadentalins.com.
Per Individual $1,500 PPO members refer to the
Delta Dental PPO or Delta
Covered Services Dental Premier network
when prompted.
100%
Preventive Services Deductible Waived 80% 80%

Basic Services 80% 80% 80%
Major Services 50% 50% 50%
Orthodontia 50%
(Child/Adult) $1,500