Page 16 - Hitachi Benefits Booklet Final

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.

Dental Plan Delta Dental

Network Name Delta PPO Premier PPO Non-Network
(Non-Network)

Dental Benefits
Calendar Year Maximum $3,000 $3,000 $3,000
Delta Pays

Deductible
Individual $50 $50 $50
Family $150 $150 $150
Preventative Services 100% 100% 100%
Exams, X-Rays, Cleanings Deductible Waived Deductible Waived Deductible Waived

Basic Services
Fillings, Oral Surgery, 90% 80% 80% + balance billing
Endodontics, Periodontics

Major Services
Crowns, Prosthetics 70% 50% 50% + balance billing
Orthodontia
Covered Members Children & Adult
Benefit 50% to $3,000 lifetime benefit maximum
*Note: Non-Network charges are subject to balance billing

Note:
We strongly recommend you ask your
dentist for a predetermination if total Finding a Dental Provider
charges are expected to exceed $300. Go to www.deltadentalins.com.
Predetermination enables you and your • PPO: Refer to the Dental Dental PPO or Delta Dental
dentist to know in advance what the Premier network when prompted.
payment will be for any service that may
be in question.

Non-Network Charges
Providers who are not contracted with Delta Dental of California may charge you any amount. Amounts in excess of
Delta’s allowable charges will be the responsibility of covered members.