Benefits Summary - SDRMA - 2015-01-01LEGAL NOTICES: Access federal and state legal notices related to your plan: deltadentalins.com/about/legal/index-enrollee.html 1 In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan.2 Enrollees are responsible for any coinsurance, deductible, amount over the plan maximum and charges for non-covered services.3 Verify that your dentist is a contracted Delta Dental PPO network dentist before each appointment.4 Applies only to procedures covered under your plan. If you began treatment prior to your effective date of coverage, you or your prior carrier will be responsible for any costs. Group- and state-specific exceptions may apply. Enrollees currently undergoing active orthodontic treatment may be eligible to continue treatment under Delta Dental PPO. Review your Evidence of Coverage, Summary Plan Description or Group Dental Service Contract for specific details about your plan. GO PPO! You can visit any licensed dentist under this plan, but you’ll maximize plan value by selecting a Delta Dental PPO 1 dentist.PPO network dentists have agreed to reduced contracted rates and can’t “balance bill” you for additional fees.2 Find a dentist at deltadentalins.com .3 CONVENIENT ONLINE SERVICES: DELTADENTALINS.COM > Create a free Online Services account from your PC or smartphone to view benefits, eligibility and claims status or check average dental costs in your area.> Update your dental benefit statement delivery preference: Go paperless! > Find a Delta Dental PPO dentist near you. NO ID CARD NECESSARY Just provide your dental office with your name, birth date and enrollee ID or social security number. Register for Online Services to print an ID card or pull it up on your smartphone at the dentist’s office. HASSLE-FREE TRANSITION & EASY BENEFITS COORDINATION New to Delta Dental PPO? This plan covers treatment started and completed after your plan’s effective date of coverage.4 If you’re covered under two plans, ask your dentist to include information about both plans with your claim, and we’ll handle the rest.HL_PPO_2 col #78011 NON-DELTA DENTAL DENTISTS DELTA DENTAL PPO DELTA DENTAL PPO : YOUR SMILE IS COVERED SAVE WITH A PPO DENTIST
Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent children to the end of the month dependent turns age 26 Deductibles Deductible waived for Diagnost ic, Preventive and Orthodontics? $50 per person / $150 per family each calendar year Yes Maximums PPO -D entists: $1 ,500 p er per s on each calendar year Non -P PO D entis t: $1 ,250 per per son eac h calendar year Waiting Period(s) Basic Benefits None Major Benefits None Prosthodontics None Orthodontics None *Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees.** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non -Delta Dental dentists.Delta Dental of California 100 First St. San Francisco, CA 94105 Customer Service 800 -765 -6003 Claims Address P.O. Box 997330 Sacramento, CA 95899 -7330 deltadentalins.com This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description . If you have specific questions regarding the benefit s , limitations or exclusions for your plan , p lease consult your company’s benefits representative. HLT_PPO_2COL_DDC (Rev. 08/06/2014 ) Pl an Benefit Highlights for: EIA D ental S mall G roup Group N o: 04 210 E ffective Date: 01/01/2015 Benefits and Covered Services* D elta Dental PPO dentists** In -PPO Network Non -PPO dentists** Out -of -PPO Network Diagnostic & Preventive Services (D & P) Exams, cleanings and x -rays 100 % 100 % Basic Services F illings, simple tooth extractions and sealants 80 % 80 % Endodontics (root canals)Covered Under Basic Services 80 % 80 % Periodontics (gum treatment)Covered Under Basic Services 80 % 80 % Oral Surgery Covered Under Basic Services 80 % 80 % Major Services C rowns, inlays, onlays and cast restorations 60 % 60 % Prosthodontics Bridges, dentures and implants 60 % 60 % Orthodontic B enefits Adults and dependent children 50 % 50 % Orthodontic Maximums $500 Lifetime $500 Lifetime