Page 18 - Work Life and Benefits Booklet 2020 SE

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

Basic Services 80% 80% 80% + balance billing This is a California contract.
Major Services 50% 50% 50% + balance billing
Orthodontia 50% to $1,500 Lifetime Maximum
(Child/Adult) Non-Network dentist may also balance bill

Important
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.