Payment Example

Stay in Network and Save Money With Delta Dental TM With your Delta Dental PPO (Point-of-Service) plan, you may save more money and receive higher levels of coverage when visiting a Delta Dental PPO dentist. Our PPO dentists have agreed to accept lower fees as full payment for covered services. However, if you go to a dentist who doesn’t participate in Delta Dental PPO, you can still save money if your dentist participates in Delta Dental Premier®. Like our PPO dentists, Delta Dental Premier dentists agree to accept Delta Dental’s fee determination as full payment for covered services. Delta Dental PPO • No balance billing on covered services • Most signi昀椀cant network discounts with more than 368,000 o昀케ce locations nationwide* DELTA DENTAL • Dentists 昀椀le claims for member NETWORKS Delta Dental Premier • No balance billing on covered services • Signi昀椀cant network discounts with the most o昀케ce locations nationwide—more than 434,000* • Dentists 昀椀le claims for member OUT OF Out-of-network dentist • May be balance billed NETWORK • No discounts • May need to 昀椀le own claims *National network statistics: Delta Dental Plans Association, March 2021. Example of how it works As shown below, your lowest out-of-pocket costs result from going to either a Delta Dental PPO or Delta Dental Premier dentist. DELTA DENTAL DELTA DENTAL OUT-OF-NETWORK PPO DENTIST PREMIER DENTIST DENTIST Submitted fee $80 $80 $80 Maximum allowed fee $ $ $ 54 77 63 ADULT Coverage level 100% 100% 100% CLEANING Amount Delta Dental pays $ $ $ 54 77 63 AMOUNT YOU PAY $ $ $ 0 0 17 Submitted fee $ $ $ 1,100 1,100 1,100 Maximum allowed fee $ $ $ 754 989 799 CROWN Coverage level 50% 50% 50% Amount Delta Dental pays $ $ $ 377 494.50 399.50 AMOUNT YOU PAY $ $ $ 377 494.50 700.50 NOTE: Payment examples above are illustrative only. Fees and reimbursements can vary by location and dentist. They do however represent how payment is determined. www.deltadentalmi.com www.deltadentaloh.com www.deltadentalin.com FLI-6203-PPO POS v9 Delta Dental of Michigan, Ohio, and Indiana PA 4/21