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Dental Insurance

Delta Dental | DHMO Dental Plan

With the Dental Health Maintenance Organization (DHMO) plan through Delta Dental, you are required to select a general
dentist who is a member of the network to provide your dental care. You 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 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. 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 that are covered under this plan.

Delta Dental | PPO Dental Plan
With the Delta Dental Preferred Provider Organization (PPO) dental plan, you may visit a PPO dentist, a Premier dentist,
or a non-network dentist. 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 PPO dentist. If you obtain services using a non-network
dentist, you will incur much higher out-of-pocket expenses and you may be responsible for filing claims.

Delta Dental Delta Dental
DHMO PPO
Network Name DHMO PPO Premier Non-Network
DENTAL BENEFITS

Office Visit Copay $5 Copay N/A
Calendar Year Maximum Benefit Unlimited $1,500
Annual Deductible
• Individual None $50
• Family None $150
Preventive Services (Plan Pays) 100% for Most Services 100% 100% 100%
• Deductible Waived N/A Yes Yes Yes
Basic Services (Plan Pays) See Copay Schedule 80% 80% 80%
Major Services (Plan Pays) See Copay Schedule 50% 50% 50%
ORTHODONTIA BENEFITS
Covered Family Members Child & Adult Child & Adult
Copay $1,900 / $2,100 N/A
Coinsurance N/A 50%
Lifetime Benefit Maximum N/A $1,500

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.

Finding a Dental Provider:
Go to www.deltadentalins.com or call (800) 422-4234 for DHMO or (800) 765-6003 for PPO. DHMO
participants should refer to the “DeltaCare USA” network and PPO participants should refer to
the “PPO” or “Premier” network when prompted.

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