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Benefits • Dental - Basic Coverage

Annual Maximum Benefit
The maximum payment for all covered dental procedures for each Eligible Person in any one calendar year is $750.

Deductible
The deductible is $150 per family for Basic Plan.

Resources

Benefit Handbooks

2009 Benefits Guide

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Eligibility Information

Price Sheets FT / PT

Contact Information:
www.deltadentalks.com
1-800-234-3375

Diagnotic and Preventive (Not subject to deductible)
PPO	Premier
100%	100%	Diagnostic:	Includes procedures to assist the dentist in evaluating the conditions existing and the dental care required:
		Oral examinations - two (2) per calendar year. Diagnostic x-rays - bitewings two (2) per calendar year for dependents under age nineteen (19) and once each twelve (12) months for adults age nineteen (19) and over. Fulll mouth x-rays - once each five (5) years.
100%	100%	Preventive:	Provides for the following:
		Prophylaxis (Cleanings) - two (2) per calendar year. Topical Fluoride - two (2) per calendar year for dependent children under age nineteen (19). Space Maintainers - for dependent children under age (19) nineteen (19) and only for premature loss of primary molars. Sealants - once per lifetime for dependent children under age nineteen (19) when applied only to permanent molars with no caries (decay) or restorations on the occlusal surface.
Basic
PPO	Premier
80%	80%	Ancillary:	Provides for one emergency examination per calendar year by the dentist for the relief of pain.
80%	80%	Oral Surgery:	Provides for extractions and other oral surgery including pre and post-operative care.
80%	80%	Regular Restorative:	Provides amalgam (silver) restorations; composite (white) resin restorations on anterior (front) teeth; and stainless steel crowns.
80%	80%	Endodontics:	Includes procedures for root canal treatments and root canal fillings
80%	80%	Periodontics:	Includes procedures for the treatment of diseases of the gums and bone supporting the teeth.

This is a summary of benefits only and does not bind Delta Dental of Kansas to any coverage. Please refer to the Description of Dental Care Coverage for complete coverage information, including exclusions and limitations. Coverage as described in the employer group's Agreement to Provide Dental Benefits (contract) is binding on all parties and supercedes all other written or oral communications.

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