Page 9 - Galassos EE Guide 10-18_ENG_FINAL

BENEFITS

DENTAL INSURANCE

Delta Dental | PPO Dental Plans
With the Delta Dental Preferred Provider Organization (DPPO) dental plans, you may visit a DPPO dentist and benefit from the
negotiated rate or visit a non‐network dentist. When you utilize a DPPO dentist, your out-of-pocket expenses will be less. You may
also obtain services using a non-network dentist; however, you will be responsible for the difference between the covered amount
and the actual charges and you may be responsible for filing claims.

Delta Dental Delta Dental
Plan Name Low DPPO Plan High DPPO Plan
Network Name Delta Dental PPO Non-Network Delta Dental PPO Non-Network
Dental Benefits
Calendar Year Maximum $1,000 $2,000

Deductible (Annual)
- Individual $75 $50
- Family $225 $150
Preventive No Charge No Charge No Charge No Charge
Exams, X-Rays, Cleanings
Basic Services Deductible, 20% Deductible, 30% Deductible, 20% Deductible, 20%
Fillings, Oral Surgery,
Endodontics, Periodontics
Major Services Deductible, 50% Deductible, 60% Deductible, 50% Deductible, 50%
Crowns, Prosthetics
Orthodontia
- Covered Members Not Covered Children & Adults
- Coinsurance Not Covered 50%
- Lifetime Benefit Maximum Not Covered $1,750

Finding a Dental Provider
Go to www.deltadentalins.com or call (800) 765-6003. Refer to the “Delta Dental PPO” network when
prompted.

Note
We strongly recommend you ask your dentist for a predetermination 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.

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