2023 Benefits Guide Dental WestCareoffers two dental plans through Delta Dental. Your choice of dentists can determine the cost savings you receive. In-network providers are paid directly by Delta Dental and agree to accept negotiated fees as “payment in full” for services rendered. When you use out-of-network providers, Delta Dental will apply the applicable percentage of the allowed amount, and you are responsible for paying the balance of the bill. In-network coverage is provided when you use Delta Dental providers. To set up your online account or search for in- network providers, go to www.deltadentalins.com. You may also contact Delta Dental at (800) 521-2651. No ID card will be provided; give the group number and your SSN to your provider when obtaining services. Delta Dental Delta Dental PPO Middle Plan** Delta Dental PPO High Plan** In-Network Out-of-Network In-Network Out-of-Network Calendar Year Maximum * Up to $1,000 per person Up to $1,500 per person (plan pays ) Plan Pays Plan Pays Plan Pays Plan Pays Calendar Year Deductible * $25 Individual / $75 Family $50 Individual / $150 Family (applies to Basic and Major Services) Preventive Services (no deductible) 100% 100% Basic Services (after deductible) 80% 90% Major Services (after deductible) 50% 60% Orthodontia (to age 19) Not Covered 50% Orthodontia Lifetime Maximum N/A $2,000 (per person) * Plan deductibles and maximums accumulate on a calendar year (January 1 –December 31). These amounts reset on January 1 of each year. ** Reimbursement is based on PPO contracted fees for PPO dentists, Delta Dental Premier® contracted fees for Premier dentists and the program allowance for non-Delta Dental dentists. Important Information! Did you start on a dental treatment plan before your PPO coverage kicked in? Generally, multi-stage procedures are only covered under your current plan if treatment began after your plan’s effective date of coverage. You can find this date by logging in to Online Services. 20 WestCare