Dental Benefits

Benefit Description

This benefit is available to all qualified participants and their eligible dependents who have selected Kaiser Permanente, Western Health Advantage or Aetna for their medical coverage. Dental Benefits are provided by Delta Dental Plan of California, Group Policy Number 3736.

Eligibility Requirements

Primary enrollee, spouse and eligible dependent children to the end of the month dependent turn age 26.

Principal Benefits And Covered Services

Deductibles And Benefits
Maximum
$50 per person, $150 per family per calendar year. The maximum benefit paid per the calendar year is $2,000 per person
Diagnostic And Preventive
Benefits* - oral examinations, cleanings, x-rays biopsy/tissue examinations, fluoride treatment, space maintainers, specialist consultation
100% of Delta dentist’s fee (no deductible applies for these services)
Basic Benefits – oral surgery (extractions), fillings, root canals, periodontic (gum) treatment, sealants 80% of Delta dentist’s fee
Crowns, Jackets, And Cast Restorations 80% of Delta dentist’s fee
Prosthodontic Benefits – bridges, partial dentures, full dentures 80% of Delta dentist’s fee (subject to a maximum allowance)
Orthodontic Benefits* - for adults and dependent children 80% of Delta dentist’s fee (subject to a $2,000 lifetime maximum per person)
*Please refer to your Evidence of Coverage contained within your separate Delta Dental benefit booklet for limitations on these benefits. Some examples of limitations on services are the number of cleanings and oral exams covered in a calendar year, and time limitations on filling and crown replacements.