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Individual and Family

 

Percentages shown are what Delta Dental pays after deductible has been met.

 Delta Dental Individual and FamilySM


Plan Name


Platinum


Gold


Silver


Bronze

Network: PPO, Premier  (Prmr) or Out-of-Network (OON). Percentages show what Delta Dental pays after the deductible is met.      

 PPO PrmrOON 

PPO

Prmr

OON

PPO

Prmr

OON

PPO

Prmr

OON

Deductible per person, per contract year (up to $150) $50

$50

$50

$50

Diagnostic and Preventive  
no waiting period
Not subject to Deductible


Exams and cleanings (once every 6 months),
X-rays, Fluoride, Sealants, Space Maintainers
 100% 80% 80%

100%

80%

80%

100%

80%

80%

100%

80%

80%

Basic Services
6-month waiting period
Subject to Deductible


Fillings, Non-Surgical Extractions

Platinum, Gold, Silver only - Emergency exams (no waiting period)
 80% 70% 70%

80%

60%

60%

50%

40%

40%

80%

60%

60% 

Major Services
12-month waiting period
Subject to Deductible

Root Canals, Gum Disease Treatment, Crowns, Dentures, Bridges, Surgical Tooth Extractions

 70% 50% 50%

50%

40%

40%

50%

40%

40%

Not Covered

Implants (artificial teeth secured to the jaw) coverage must be pre-determined

 Occlusal Guards (tooth grinding and jaw clenching prevention)

12-month waiting period
Subject to Deductible

 70% 50% 50% Not CoveredNot CoveredNot Covered
Annual Benefit Maximum per person, per contract year

Diagnostic and Preventive services do not apply toward the Annual Benefit Maximum
 $2,500

 $1,500

$1,000

$1,000

Monthly Premiums

Individual*

Individual + 1*

Family*


$56.33

$108.75

$154.98


$43.20

$83.40

$118.85


$36.03

$69.78

$99.42


$31.07

$62.10

$88.48

*Delta Dental reserves the right to change rates upon the rates being placed on file by the Kansas Insurance Department. 

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  This is a summary of benefits only and does not bind Delta Dental of Kansas to any coverage.