Dental Benefits

Dental insurance offers coverage for preventive care like routine exams, cleanings, and X-rays as well as basic and major services like fillings, extractions, root canals and crowns.

Keep in mind that your costs will generally be lower if you choose an in-network dentist. To find an in-network dentist, please visit www.deltadentalmo.com.

Core Plan Benefits	Delta PPO Network	Out-of-Network
Diagnostic and Preventive Services • Oral exams (all types), twice per benefit period. • Bitewing x-ray, one set per benefit period; Periapical x-ray, up to 4 x-rays per benefit period. • Full-mouth x-rays once in any 60 consecutive months. • Cleanings (all types), twice per benefit period. • Fluoride, once per benefit period for dependents under age 14. • Emergency palliative treatment. • Sealants for dependent children under 16, once per tooth per lifetime, limited to non-decayed 1st and 2nd permanent molars. • Space maintainers, once in 5 years, to age 16.	100%	90%
Basic Services • Restorative services using synthetic porcelain and plastic material (white) on front teeth and amalgam. • Simple extractions	80%	70%
Major Services • Surgical Extractions and other Oral Surgery Periodontics: treatment for diseases of gums and bone supporting the teeth. • Endodontics: root canal filling and pulpal therapy. • Prosthetics: bridges and dentures; a replacement will be covered only once in 5 years, but not during the first 12 months of Major Services coverage. • Crowns, jackets, labial veneers, inlays and onlays when required for restorative purposes, once in 5 years.	Not Covered	Not Covered
Orthodontic Services • For eligible dependents to age 19 who begin treatment while covered by this plan. • Note: a 24 month waiting period applies	Not Covered	Not Covered
Deductible (Applies to Basic Services Only)	$50 Per Person	$50 Per Person
Policy Year Benefit Max	$1,000 Per Person	$1,000 Per Person
Separate Lifetime Orthodontic Maximum	Not Covered	Not Covered
MAXAdvantage - Claims paid for cleanings, exams, x-rays, fluoride treatments do not apply to benefit maximum.	Not Covered	Not Covered

Monthly Premium	Total Premium	Employer Pays	Employee Pays
Individual	$26.00	$10.00	$16.00
Individual+ 1	$45.00	$10.00	$35.00
Family	$84.00	$10.00	$74.00

Dental insurance offers coverage for preventive care like routine exams, cleanings, and X-rays as well as basic and major services like fillings, extractions, root canals and crowns.

Keep in mind that your costs will generally be lower if you choose an in-network dentist. To find an in-network dentist, please visit www.deltadentalmo.com.

Enhanced Plan Benefits	Delta PPO Network	Out-of-Network
Diagnostic and Preventive Services • Oral exams (all types), twice per benefit period. • Bitewing x-ray, one set per benefit period; Periapical x-ray, up to 4 x-rays per benefit period. • Full-mouth x-rays once in any 60 consecutive months. • Cleanings (all types), twice per benefit period. • Fluoride, once per benefit period for dependents under age 14. • Emergency palliative treatment. • Sealants for dependent children under 16, once per tooth per lifetime, limited to non-decayed 1st and 2nd permanent molars. • Space maintainers, once in 5 years, to age 16.	100%	100%
Basic Services • Restorative services using synthetic porcelain and plastic material (white) on front teeth and amalgam. • Simple extractions	90%	80%
Major Services • Surgical Extractions and other Oral Surgery Periodontics: treatment for diseases of gums and bone supporting the teeth. • Endodontics: root canal filling and pulpal therapy. • Prosthetics: bridges and dentures; a replacement will be covered only once in 5 years, but not during the first 12 months of Major Services coverage. • Crowns, jackets, labial veneers, inlays and onlays when required for restorative purposes, once in 5 years.	60%	50%
Orthodontic Services • For eligible dependents to age 19 who begin treatment while covered by this plan. • Note: a 24 month waiting period applies	50%	50%
Deductible (Applies to Basic Services Only)	$50 per person	$50 per person
Policy Year Benefit Max	$2,000 per person	$2,000 per person
Separate Lifetime Orthodontic Max	$1,500 per child to age 19	$1,500 per child to age 19
MAXAdvantage - Claims paid for cleanings, exams, x-rays, fluoride treatments do not apply to benefit maximum.	Applies	Applies

Monthly Premium	Total Premium	Employer Pays	Employee Pays
Individual	$50.00	$10.00	$40.00
Individual + 1	$88.00	$10.00	$78.00
Family	$151.00	$10.00	$141.00

Group Number

Group Number, Core - 9182-1000
Group Number, Enhanced - 9183-1000

Provided By

Delta Dental

Provider Website

www.deltadentalmo.com

Customer Service

800.335.8266