Page 10 - Inglewood USD Benefits Guide 2019 - Retiree_FINAL

BENEFITS

Dental Insurance

Delta Dental | PPO
With the Delta Dental Preferred Provider Organization (PPO) dental plan, you may visit a PPO dentist and benefit from the
negotiated rate or visit a non‐network dentist. When you utilize a Delta Dental 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
Plan Name PPO

Network Name Delta Dental Non-Network
Dental Benefits
Calendar Year Maximum $1,700 per member $1,700 per member
Calendar Year Deductible:

- Individual
N/A N/A
- Family
Diagnostic & Preventive: No Charge No Charge*
Exams, X-Rays, Cleanings

Basic Services:
Fillings, Oral Surgery, No Charge No Charge*
Endodontics, Periodontics
Major Services:
Crowns, inlays, onlays and cast No Charge No Charge*
restorations
Prosthodontics 30% 50%*
Bridges, dentures and Sealants
Orthodontia Not covered

*Dentists who are out-of-network have not agreed to pricing, and may bill you for the difference between what Delta Dental pays
them and what the dentist usually charges.

Finding a Dental Provider
Go to www.deltadentalins.com/welcome or call (800) 765-6003

Dental Billing Tip!
We 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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