Delta Dental of California - Ppo Plan 3 40 120 2000 Max 01

DELTA DENTAL PPO :
YOUR SMILE IS
COVERED
GO PPO
Visit a PPO1 dentist to maximize your savings.2 These dentists
have agreed to reduced fees, and you won’t get charged more
under your plan, they will need your name, birth date and
enrollee or social security number. Prefer to take a paper or
electronic ID card with you? Simply sign in to Online Services,
than your expected share of the bill.3 Find a PPO dentist at where you can view or print your card with the click of a
deltadentalins.com.4 button. If you’re covered under two plans, ask your dental
office to include information about both plans with your claim,
ACCESS ONLINE SERVICES and we’ll handle the rest.
Get information about your plan anytime, anywhere by signing
up for an Online Services account at deltadentalins.com. This UNDERSTAND TRANSITION OF CARE
free service lets you check benefits and eligibility information, Did you start on a dental treatment plan before your PPO
find a network dentist and more. coverage kicked in? Multi-stage procedures are only covered
under your current plan if treatment began after your plan’s
CHECK IN WITH EASE effective date of coverage.5 You can find this date by logging in
You don’t need a Delta Dental ID card when you visit the
dentist. Just provide your name, birth date and enrollee ID or to Online Services.
social security number. If your family members are covered NEWLY COVERED? Visit deltadentalins.com/welcome.
SAVE WITH A
Copyright © 2015 Delta Dental. All rights reserved.
PPO DENTIST HL_PPO_2col #92056R (rev. 10/15)
PPO NON-PPO
LEGAL NOTICES: Access federal and state legal notices related to your plan at deltadentalins.com/about/legal/index-enrollee.html
1 5
In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan. Applies only to procedures covered under your plan. If you began treatment prior to
2
You can still visit any licensed dentist, but your out-of-pocket costs may be higher if you your effective date of coverage, you or your prior carrier are responsible for any costs.
choose a non-PPO dentist. Network dentists are paid contracted fees. Group- and state-specific exceptions may apply. Enrollees currently undergoing active
3 orthodontic treatment may be eligible to continue treatment under Delta Dental PPO.
You are responsible for any applicable deductibles, coinsurance, amounts over plan Review your Evidence of Coverage, Summary Plan Description or Group Dental Service
maximums and charges for non-covered services.
4 Contract for specific details about your plan.
Verify that your dentist is a PPO dentist before each appointment.
E
deltadentalins.com/enrollees WE KEEP YOU SMILING

SMALL BUSINESS PROGRAM EFFECTIVE DATE: 01/01/2021
BENEFIT HIGHLIGHTS PLAN: PPO 3
DELTA DENTAL PPOSM
GROUP NAME: AYLA NETWORKS
GROUP NUMBER: 03292-06051
> ELIGIBILITY: WHO MAY RECEIVE BENEFITS? > DEDUCTIBLES1
• Primary enrollee and spouse $40/$120 per person/family each calendar year (inside
(includes domestic partner) PPO network)
• Eligible dependent children to: $50/$150 per person/family each calendar year (outside
age 26 PPO network)
> WAITING PERIODS > MAXIMUMS

Basic Services: 0 months Major Services: 0 months $2,000 per person each calendar year
Orthodontics: 0 months Other Services: 0 months
BENEFITS AND COVERED SERVICES PPO Non-Delta Dental

dentists1,2 PPO dentists1,2,3
Diagnostic & Preventive Services (D&P) 100% 100%
Exams, cleanings and x-rays Your deductible does not apply to D&P.
Enhanced pregnancy benefit

Basic Services
80% 80%
Fillings, simple tooth extractions and sealants
Endodontics
80% 80%
Root canals
Oral Surgery
80% 80%
Periodontics
80% 80%
Gum treatment
Major Services
50% 50%
Crowns, inlays, onlays and cast restorations
Prosthodontics
50% 50%
Bridges, dentures, implants
Orthodontics
50%
For adults and dependent children
Lifetime maximum per person $1,000
Other:
1. Delta Dental Premier® dentists are considered out-of-network dentists.
2. 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.
3. Non-Delta Dental dentists may balance bill the difference between the contracted rate and their usual fee for services.
Delta Dental Of California Customer Service Claims Address

100 First Street 800-765-6003 P.O. Box 997330
San Francisco, CA 94105 Sacramento, CA 95899-7330
This benefit information is not intended to replace or serve as the plan’s Evidence of Coverage, Summary Plan Description, or Group Dental Service Contract.
If you have specific questions regarding the benefits eligibility, limitations, or exclusions of your plan, please consult your company’s benefits representative.

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DELTA DENTAL PPO :

deltadentalins.com/enrollees WE KEEP YOU SMILING

> WAITING PERIODS > MAXIMUMS

BENEFITS AND COVERED SERVICES PPO Non-Delta Dental

Enhanced pregnancy benefit

Delta Dental Of California Customer Service Claims Address

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