Delta Dental Ppo Application Form Instructions Page 6
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6The following information is not intended or designed to replace or serve as an Evidence of Coverage or Summary Plan
Description for the program. If you have specific questions regarding benefit structure, limitations or exclusions, consult
your company’s benefits representative.
BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO
WHO’S ELIGIBLE
Primary enrollee, spouse and eligible dependent children to age 19 or to age 25 if
dependent is full-time student (includes domestic partner)
In-network:
$50 per person, $150 per family, per calendar year
DEDUCTIBLES
Out-of-network:
$75 per person, $225 per family, per calendar year
Yes
No
In-network:
DEDUCTIBLE WAIVED FOR DIAGNOSTIC &
Yes
No
PREVENTIVE?
Out-of-network:
The maximum benefit paid per calendar year is $1,000 per person in-network
ANNUAL MAXIMUM
The maximum benefit paid per calendar year is $1,000 per person out-of-network
Basic Benefits
Crowns & Casts
Prosthodontics
Orthodontics
WAITING PERIOD(S)
None
None
None
None
BENEFITS AND COVERED SERVICES*
In-PPO Network**
Out-Of-PPO Network**
DIAGNOSTIC & PREVENTIVE BENEFITS
100 %
80 %
-- Oral examinations, routine cleanings, x-rays, fluoride
treatment, space maintainers, specialist consultations
BASIC BENEFITS
80 %
80 %
-- Fillings, root canals, periodontics (gum treatment), tissue
removal (biopsy), oral surgery (extractions), sealants
CROWNS, OTHER CAST RESTORATIONS
50 %
50 %
-- Crowns, inlays, onlays and cast restorations
PROSTHODONTICS
50 %
50 %
-- Bridges, partial dentures, full dentures, implants
ORTHODONTIC BENEFITS
50 %
50 %
dependent children only
ORTHODONTIC MAXIMUMS
$ 1,000 Lifetime
$ 1,000 Lifetime
*
Limitations or waiting periods may apply for some benefits; some services may be excluded. Please refer to your Evidence of
Coverage or Summary Plan Description for waiting periods and a list of benefit limitations and exclusions.
**
Fees are based on PPO fees for in-network dentists and PPO fees for out-of-network dentists. Reimbursement is paid on Delta
Dental contract allowances and not necessarily each dentist’s actual fees.
Delta Dental of California
Customer Service
100 First Street
800-765-6003
San Francisco, CA 94105
Online Services
Claims Address
P.O. Box 997330
Sacramento, CA 95899-7330
(Grp# 10/30/09 dh)
FORM # HLT PPO2 DDC STR
Rev#1 8/07
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