Page 13 - Sample Calendar Layout EE Guide

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.

Kaiser Members
The Kaiser plan offers pediatric dental only for children to age 19. In general, the Kaiser pediatric dental plan covers basic dental care and major dental
services only when medically necessary. Kaiser uses the Delta Dental network. Please review the Kaiser documents to learn more about the benefits and
exclusions.

KAISER HMO DELTA DENTAL
PLAN NAME MEDICAL PPO

NETWORK NAME DELTACARE USA DELTA DENTAL DELTA DENTAL NON-NETWORK FINDING A DENTAL
NETWORK
PREMIER
PPO
PROVIDER
Deductible (per calendar year) Go to
Individual / Family $0 $50 / $150 www.deltadentalins.com.
DHMO members refer to
Benefit Maximum (per calendar year; Preventive, Basic and Major Services combined)
the DeltaCare USA network
Per Individual N/A $1,500 and PPO members refer to
the Delta Dental PPO or
Covered Services
Delta Dental Premier
100%
Preventive Services Covered Deductible Waived 80% 80% network when prompted.

Basic Services Covered 80% 80% 80% For Kaiser pediatric
Major Services Covered 50% 50% 50% benefits: please go to
kp.org
Orthodontia Medical necessity 50%
(Child/Adult) only* $1,500

*Orthodontic treatment for Kaiser members are covered when there is severe handicapping malocclusion and is not
a cosmetic condition. Prior authorization is required. Please review the Kaiser documents for full details on all dental
plan provisions.