PPOPREF
De
lta Dental PPO Plus Premier
On
the reverse side of this sheet is a summary of
your plan coverage. Please also see the enclosed
sh
eet, “How You Can Save with a Delta Dental
Network Dentist,” which provides an example of
your out-of-pockets costs with network dentists and
a non-network dentist.
With Delta Dental PPO Plus Premier:
You can go to any licensed general or specialty
dentist.
You will maximize your benefits by receiving
care from a Delta Dental PPO or Delta Dental
Premier network dentist.
Delta Dental’s network dentists have agreed to
reduced fees as payment in full, which means you
will likely save money by going to a Delta Dental
PPO or Delta Dental Premier network dentist.
Non-network dentists have not agreed to accept
our reduced fees as payment in full, which means
they may bill you for any charges over our allowed
fees.
You are charged only the patient’s share** at the
time of treatment. Delta Dental pays its portion
directly to network dentists.
Delta Dental of Illinois is pleased to be your dental benefits carrier. Your group plan offers you the
dental benefits program: Delta Dental PPO Plus Delta Dental Premier.
Discount Tire Co., Group #20100
Delta Dental PPO Plus Premier Plan Features
Yo
ur Delta Dental PPO Plus Premier plan includes the
following features:
ToGo
SM
, a
feature that allows you to carryover
qualified unused portions of your annual maximum
to the next year.
Enhanced Benefit Program offers additional
coverage for individuals who have specific health
conditions (including pregnancy, diabetes, high-
risk cardiac conditions, and suppressed immune
systems) that can be positively affected by
additional oral health care.
Fin
ding a Dentist
Vi
sit our web site at www.deltadentalil.com and click
on
Provider Search. Please see the enclosed “How to
Find a Network Dentist” sheet for more details.
Example of Your Copayment with Delta Dental
Network Dentists and Non-Network Dentists
De
lta Dental PPO: Lowest out-of-pocket costs and
network protection.
De
lta Dental Premier: Higher out-of-pocket costs
than PPO, but may be lower than non-network and
network protection.
Non
-network: You may have the highest out-of-
pocket costs
.
Customer Service
The enclosed Member Connection sheet explains how to
register on Delta Dental of Illinois’ website,
www.deltadentalil.com. Once registered, you can get
rea
l time benefit information, check claim status, sign
up for electronic Explanation of Benefits and print a
temporary ID card.
Call 1-800-323-1743 to access our automated phone
system or speak to a customer service representative
from 7 am to 7 pm Monday through Thursday and 7 am
to 6 pm Friday, Central Time. Our automated phone
system is available 24 hours a day, seven days a week,
and offers dentist listings and claim information.
You can also connect with us through our mobile app,
Facebook, Twitter, our blog and more.
***The
information on the reverse side of this sheet is a brief summary of your dental plan and the services it covers.
T
here are some lim
o
n the expenses for which your dental plan pays
If you have specific questions regarding benefit coverage, limitations, exclusions, or non-
covered services, please refer to your certificate of coverage/dental benefit booklet or contact Delta Dental of Illinois.
**Patient’s share is the coinsurance/copayment, any remaining deductible any amount over the annual maximum and any services your plan does
not cover.
Note: Delta Dental imposes no restrictions on the method of diagnosis or treatment by a treating dentist. A benefit determination relates only to the
level of payment that your group dental plan is required to make
.
Learn More
You
can learn more about your Delta Dental of
Illinois dental plan by reading the information
included in your enrollment kit.
A
nnual Deductible (applies to
Basic and Major Services
Only
)
$50/person; $150/family
A
nnual Maximum
$1
,
75
0/per
son
ToGo
SM
Ca
rryover Feature
Your
plan allows you and your covered dependents to carry over qualified
unus
ed portions of your annual maximum from one year to the next.
Enha
nced Benefits Program
Your
plan provides additional cleanings and/or applications of topical
fluoride to people with specific health conditions that put them at risk for
ora
l health disease. The costs of the additional cleanings and fluoride
tre
atments will be applied to your annual maximum.
Li
fetime Orthodontic
Maximum
$2
,000/dependent
De
lta Dental PPO
Ne
twork
De
ntist
De
lta Dental
Pre
mier® Network
De
ntist
Non
-
Ne
twork
De
ntist
PR
EVENTIVE/DIAGNOSTIC SERVICES
Routine exams (two per benefit year)
Cleanings (two per benefit year)
X-rays (bitewings – two per benefit year; full mouth -
every three years)
Fl
uoride treatments (once per benefit year to age 19)
Sp
ace maintainers (to age 14)
S
ealants (to age 19)
Emergency exams & palliative treatment
100%*
100% **
100%***
BASIC SERVICES
Fillings (silver (amalgam) and tooth colored (composite)
on front teeth)
Posterior composites
Periodontics
Endodontics
Oral surgery
General anesthesia (in conjunction with oral surgery)
80%
* 80%** 80%***
MA
JOR RESTORATIVE SERVICES
Implants
Crowns, onlays, and other ceramic restorations to
permanent teeth
Partial/full dentures
Denture (repair, reline, rebase and adjustments)
Fixed/removable bridges
50%
* 50%** 50%***
OR
THODONTICS (to age 26) and Adults
T
reatment necessary for proper alignment of teeth
50%
* 50%** 50%***
*De
lta Dental PPO dentists accept payment based on the lesser of the submitted fee (their usual fee) or Delta Dental’s allowed
PPO fee. PPO network dentists cannot charge you for costs exceeding the PPO fee.
**Delta Dental Premier dentists accept payment based on the lesser of the submitted fee (their usual fee) or Delta Dental’s maximum
plan allowance. Premier dentists may not charge you for costs exceeding the maximum plan allowance.
***Non-network dentists (non-Delta Dental PPO/non-Delta Dental Premier) do not agree to accept Delta Dental’s allowed fees as payment
in full; payment is based on the lesser of the submitted fee (their usual fee) or Delta Dental’s maximum plan allowance. These dentists
can charge you for costs exceeding the maximum plan allowance.
Discount Tire Co., Group #20100