PPO BASE PLAN - Features BASS PRO, INC. / CABELA S BASE PLAN 2019 PPO Dentist Based on PPO reduced maximum plan allowance Premier Dentist Based on Premiermaximum plan allowance Non-Participating Dentist Based on maximum plan allowance; Balance billing possible Diagnostic and Preventive Services Oral exams (all types), twice per calendar year Bitewing and periapical x-rays as required Full-mouth x-rays once in any 36 consecutive months Prophylaxis (cleanings-all types), twice per calendar year Topical fluoride for dependents to age 19, once per calendar year Emergency palliative treatment Space maintainers for dependents to age 16, once in 5 years 100% 100% 100% Basic Services Sealants for dependents to age 19, once in 5 years Fillings Simple and surgical extractions General anesthesia Endodontics-root canal filling and pulpal therapy Periodontics-treatment for gum disease and bone supporting the teeth Denture repairs and relines 80% 80% 80% Major Services Oral surgery Prosthetics-bridges and dentures; replacements covered once in 5 years, after the participant has been covered by this plan 12 consecutive months Crowns, jackets, labial veneers, inlays and onlays; replacements are covered once in 5 years Calendar Year Deductible (applies to Basic and Major Services only) $50 per person $50 per person $50 per person Calendar Year Maximum $1,000 per person Dependent children are eligible for coverage until they reach age 26. This is intended to be a summary only. If discrepancies arise the Summary Plan Document will govern. Please refer to your SPD for a more complete listing of services including plan limitations and exclusions.
PPO ENHANCED PLAN - Features BASS PRO, INC. / CABELA S ENHANCED PLAN 2019 PPO Dentist Based on PPO reduced maximum plan allowance Premier Dentist Based on Premiermaximum plan allowance Non-Participating Dentist Based on maximum plan allowance; Balance billing possible Diagnostic and Preventive Services Oral exams (all types), twice per calendar year Bitewing and periapical x-rays as required Full-mouth x-rays once in any 36 consecutive months Prophylaxis (cleanings-all types), twice per calendar year Topical fluoride for dependents to age 19, once per calendar year Emergency palliative treatment Space maintainers for dependents to age 16, once in 5 years 100% 100% 100% Basic Services Sealants for dependents to age 19, once in 5 years Fillings Simple and surgical extractions General anesthesia Endodontics-root canal filling and pulpal therapy Periodontics-treatment for gum disease and bone supporting the teeth Denture repairs and relines 80% 80% 80% Major Services Oral surgery Prosthetics-bridges and dentures; replacements covered once in 5 years, after the participant has been covered by this plan 12 consecutive months Crowns, jackets, labial veneers, inlays and onlays; replacements are covered once in 5 years Orthodontic Services (for children to under age 19) Calendar Year Deductible (applies to Basic and Major Services only) Calendar Year Maximum Lifetime Orthodontic Maximum $50 per person $50 per person $50 per person $1,500 per person $1,500 per child. Dependent children are eligible for coverage until they reach age 26. This is intended to be a summary only. If discrepancies arise the Summary Plan Document will govern. Please refer to your SPD for a more complete listing of services including plan limitations and exclusions.
gives you the freedom to visit the dentist of your choice and to select any dentist on a treatment by treatment basis. It is important to remember your out-of-pocket costs may vary depending on your choice. You have three options and the information below describes what you can expect depending on whether you receive services from a PPO dentist, a Premier dentist or a non-participating dentist. In PPO Network 1. PPO Network* Comprised of a select panel of dentists, over 97,000 dental offices participate in the PPO program. will provide the highest level of benefits (see benefit highlights) for covered services when care is received from a PPO dentist. These dentists agree to: Accept payment based on a reduced fee schedule reducing your out-of-pocket expenses with no balance billing for charges that exceed the fee schedule. Submit dental claims for members and abide by Delta s policies. Charge members only their deductible, co-insurance, and costs for non-covered services at the time of visit because pays the dentist directly. *Your out-of-pocket expenses will be lowest when you see a PPO dentist. In Premier Network 2. Premier Network Comprised of over 174,000 participating dental offices, Premier offers you greater access to dentists while still offering the advantages of a network. These dentists have participating agreements with which require them to: Accept payment based on Delta s contractual agreement which means no balance billing for charges that exceed the contracted amount. Submit dental claims for members and abide by Delta s policies. Charge members only their deductible, co-insurance, and costs for non-covered services at the time of visit because pays the dentist directly. If your dentist is not a PPO dentist but is a Premier dentist, your benefit will be based on the Premier benefit level; however, you will receive the cost control and claims filing advantages noted above. Out of Network 3. Non-participating Dentist If you receive services from a non-participating dentist (does not participate in either network) benefits for covered services are based on the maximum plan allowance and : You will be responsible for filing your own claim forms. s benefit payment will be made directly to you. You will be responsible for the difference between the dentist s charge and the maximum plan allowance. Your out-of-pocket expenses may be more when you use a non-participating dentist. Locating a Participating Dentist To determine if your dentist participates with or to select a participating dentist in your area: Ask your dentist if he or she participates in the PPO or Premier program Search on-line at www.deltadental.com, Call Customer Service at 1-800-335-8266 Or Scan the image below to search for a PPO or Premier participating dentist:
TO SAVE THE MOST MONEY: SEE A DELTA DENTAL PPO SM NETWORK DENTIST Dentists can participate with of Missouri through two networks: PPO SM network or Premier network. Be sure to ask your dentist, WHICH network are you in? Here s why: COST SAVINGS EXAMPLE (ASSUMES YOUR DEDUCTIBLE HAS BEEN PAID AND SHOWS APPLICABLE COINSURANCE PERCENT) SAVE THE MOST WITH A DELTA DENTAL PPO SM DENTIST allows: $300 PPO dentist accepts: $300 SAVE MONEY WITH A DELTA DENTAL PREMIER DENTIST allows: $420 Premier dentist accepts: $420 PAY MORE WITH AN OUT-OF-NETWORK DENTIST (O-O-N) allows: $300 O-O-N dentist accepts: $500 Your plan pays 80% of $300: $240 YOU PAY 20% of $300 (20% x $300): $60 Your plan pays 80% of $420: $336 YOU PAY 20% of $420: $84 Your plan pays 80% of $300: $240 YOU PAY 20% of $300: $60 Plus, you pay the difference: $200 TOTAL YOU PAY: $60 TOTAL YOU PAY: $84 TOTAL YOU PAY: $260 SAVE THE MOST MONEY WHEN YOU SEE A DELTA DENTAL PPO SM NETWORK DENTIST - Before you visit your dentist, ask if he or she is in the PPO SM Network. - Your coinsurance costs are calculated on a lesser amount. - You will pay less out of your pocket at a PPO dentist. - Your benefits dollars stretch farther. SAVE MONEY WHEN YOU SEE A DENTAL PREMIER NETWORK DENTIST - When you visit a dentist in the Premier Network, you still enjoy valuable savings. PAY MORE WITH AN OUT-OF-NETWORK DENTIST - When your dentist is not in a network, you will pay more. - You may have to pay your dentist up front, file your own claim and receive payment from. To find a dentist in the PPO SM network or Premier network, go to: www.deltadentalmo.com
24/7 Online Access to Benefits and Service Review and print your dental plan s coverage levels, deductibles, maximums, age limits and limitations Verify your eligibility Request or download a claim form Find a provider Order or print an ID card Download our mobile app Get answers to frequently asked questions Register Today Visit www.deltadentalmo.com/members/register to receive electronic delivery of your benefit information Log In to View Your Benefits Just visit www.deltadentalmo.com, and click on one of the Member or Sign In links. To register, follow the steps under Member Sign In. Find a Participating Dentist Visit our website, www.deltadentalmo.com, and click on Find a Provider then on Find a Dentist. Customer Service Call: 800-335-8266 We are here to help you every Monday through Friday from 7 a.m. to 5 p.m. Central Time. Mobile App Your dental health is important to and to your overall health! We ve designed our mobile app to make it easy for you to make the most of your dental benefits. Maximize your health, wherever you are! Access dentist search, check claims and coverage, view ID cards and more, right on your mobile device. Mobile ID card - no more looking for ID cards! Claims and coverage information on the go, putting benefits information right at your fingertips. A dentist search tool that helps you quickly select an in-network provider nearby, and even book an appointment with participating dentists! Our toothbrush timer motivates you to brush for the recommended two minutes. DDMO-180110-1272