The Delta Dental PPO plan makes it easy for you to 64257nd a dentist and easy to control your costs when you visit a network dentist Here are some of the great things youll need to know about enrolling with Delta Dental E HLPPO2col 73286 rev 513 Sav ID: 33960
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Copyright © 2020 Delta Dental. All rights reserved. HL_PPO_UCSHIP #129291D (rev. 7/20) In Texas, Delta Dental Insurance Company provides a dental provider organization (DPO) plan.You can still visit any licensed dentist, but your out-of-pocket costs may be higher if you choose a non-PPO dentist. Network dentists are paid contracted fees. NON–PPO Keep Smiling UC SHIP 2020-2021 Primary enrollee, spouse (or domestic partner) and eligible dependent children to the end of the end of the month dependent turns Delta Dental PPO dentists: $25 per person each plan yearNon–Delta Dental PPO dentists: $50 per person each plan yearDeductibles waived for Diagnostic& Preventive (D&P)?YesDelta Dental PPO dentists: $1,000 per person each plan yearNon- Delta Dental PPO dentists: $750 per person each plan yearYesProsthodontics Covered Services*Non–Delta Dental Exams, cleanings and x-raysBasic ServicesFillings, posterior composites Covered Under Basic ServicesPeriodontics (gum treatment) Covered Under Basic ServicesOral SurgeryCovered Under Basic ServicesNight GuardsMajor Services70%Bridges, dentures and implants70%Limitations or waiting periods may apply for some benets; 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 the program allowance for non-Delta Dental dentists.The maximum amount for in and out-of-network services are combined; no member will have more than $1,000 in benets per plan year.deltadentalins.com/ucshipThis benet information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specic questions regarding the benets, limitations or exclusions for your plan, please consult your company’s benets representative.For: UC Student Health Insurance Plan (UC SHIP)Group No: 20096 (Graduates) 20097 (Undergraduates)Delta Dental of California560 Mission St., Suite 1300San Francisco, CA 94105Customer Service888-335-8227Claims AddressP.O. Box 997330Sacramento, CA 95899-7330