Dental

 

(Must Choose)

 

The Dental Benefit is administered by Delta Dental: 1-866-579-5717,
www.deltadentalins.com/mus

Because dental coverage is an annual required benefit choice, you can select from two options: Basic Plan and Select Plan. Review the chart below and pay close attention to the different benefits and the different rates to help you make your selection.

Dental claims are reimbursed based on a Schedule of Benefits. The following subsets of the Select and Basic Plan Schedules include the most commonly used procedure codes. Note: the Basic Plan provides coverage for a limited range of services including diagnostic, and preventive. The Schedule dollar amount is the maximum reimbursement for the specified procedure code.

Covered individuals are responsible for the difference (if any) between the provider’s charge and the
Schedule reimbursement amount. See the Choices Benefits Ernollment Workbook or the Summary Plan Description for listing.


Basic Plan Preventive Coverage

Select Plan Coverage
Who May be Enrolled &
Monthly Rates
  • Employee Only $17
  • Employee & Spouse/Adult Dep. $31
  • Employee & Child(ren) $31
  • Employee & Family $45
  • Employee Only $43
  • Employee & Spouse/Adult Dep. $82
  • Employee & Child(ren) $82
  • Employee & Family $116
Maximum Annual Benefit
$750 per covered individual
$1,500 per covered individual
Preventive and Diagnostic Services
  • Twice Per Benefit Year
  • Initial and Periodic oral exam
  • Cleaning
  • Complete series of intraoral X-rays
  • Twice Per Benefit Year
  • Initial and Periodic oral exam
  • Cleaning
  • Complete series of intraoral X-rays

The Preventive & Diagnostic Services listed above do not apply to the $1,500 annual maximum

Basic Restorative Services
  • Not covered
  • Amalgam filling
  • Endodontic treatment
  • Periodontic treatment
  • Oral surgery
Major Dental Services
  • Not covered
  • Crown
  • Root canal
  • Complete lower and upper denture
  • Dental implant
  • Occlusal guards
Removal of impacted teeth
  • Not covered
  • Covered benefit

Orthodonitic Benefit
The Choices Select Plan provides a $1,500 lifetime orthodontic benefit per covered individual. Benefits are paid at 50% of the allowable charge for authorized services. Treatment plans usually include an initial down payment and ongoing monthly fees. If an initial down payment is required, Choices will pay up to 50% of the initial payment, up to 1/3 of the total treatment charge. In addition, Delta Dental (our dental plan administrator) will establish a monthly reimbursement based on your provider’s monthly fee and your prescribed treatment plan.

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