Page 6 - BB Dakota Benefit Summary 12-2017.pub

Benefits

Dental Insurance

Delta Dental | DHMO Dental Plan
With the Dental Health Maintenance Organiza on (DHMO) plan through Delta Dental, 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.

Delta Dental| PPO Dental Plan
With the Delta Dental Preferred Provider Organiza on (PPO) dental plan, you may visit a PPO den st and benefit from the
nego ated rate or visit a non‐network den st. When you u lize a 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.

Delta Dental Delta Dental
DHMO Plan PPO Plan

Network Name DeltaCare USA DeltaDental PPO Non‐Network*
Dental Benefits
Calendar Year Maximum Unlimited $1,000 Per Person

Deduc ble (Annual) Waived for Preven ve Services
‐ Individual None $50
‐ Family None $50 Per Family Member
Preven ve (Plan Pays) 100% 100% 100%
Exams, X‐Rays, Cleanings

Basic Services (Plan Pays) See Copay Schedule Deduc ble, 80% Deduc ble, 80%
Fillings, Oral Surgery, Endodon cs, Periodon cs

Major Services (Plan Pays) See Copay Schedule Deduc ble, 50% Deduc ble, 50%
Crowns, Prosthe cs
Orthodon a
‐ Covered Members Children & Adults Children Only
‐ Copay $1,700 Child / $1,900 Adult N/A
‐ Coinsurance N/A 50%
‐ Life me Benefit Maximum N/A $1,000

*Based on a fee schedule

Finding a Dental Provider

Go to www.deltadentalins.com or call (800) 422‐4234 for DHMO or (800) 765‐6003 for PPO.
 DHMO: Refer to the ”DeltaCare USA” network
 PPO: Refer to the ”Delta Dental PPO” network

We strongly recommend you ask your den st for a predetermina on if total charges are expected to exceed $300.
Predetermina on enables you and your den st to know in advance what the payment will be for any service that may be in
ques on.

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