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.

Delta Dental Claim Form

 






Basic Plan Preventive Coverage

Select Plan Coverage
Who May be Enrolled &
Monthly Rates
  • Employee Only $16
  • Employee & Spouse/Adult Dep. $31
  • Employee & Child(ren) $31
  • Employee & Family $43
  • Employee Only $42
  • Employee & Spouse/Adult Dep. $80
  • Employee & Child(ren) $80
  • Employee & Family $113
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

 

 

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