Following are highlights of Dental
Plan B.
Please note, the plan features a network
of dentists who offer discounts not available outside
the network. You can choose to use either in-network
or out-of-network dentists, but you'll save money—for
you and the Trust—when you use Washington Dental
Service (WDS) member dentists. For questions about
your dental benefits or dental claims or to find a WDS
member dentist near you, call WDS toll-free at 800-554-1907. WDS
also has a website at www.DeltaDentalWA.com where
you can access certain information.
|
PLAN FEATURES |
DENTAL PLAN
B |
BENEFIT MAXIMUMS |
Calendar Year Maximum Benefit |
$1,800 per eligible |
Orthodontia Benefit for dependent children
under age 19 only |
Plan pays 70% of eligible expenses |
Orthodontia Lifetime Maximum |
$1,800 per eligible |
| |
|
| CLASS 1—DIAGNOSTIC
AND PREVENTIVE |
| PLAN COVERS UP TO %100 OF THE
LISTED SCHEDULE: |
| Periodic Oral Exam |
$33.00 |
| Bitewing x-rays - two films |
$26.00 |
| Adult Prophylaxis (teeth cleaning) |
$65.00 |
| Child Prophylaxis (teeth cleaning) |
$45.00 |
| Topical application of fluoride
(excluding cleaning) - child |
$25.00 |
| Sealants for Children - per tooth |
$28.00 |
| |
|
| CLASS
2—GENERAL AND MINOR RESTORATIVE |
| PLAN COVERS UP TO %100 OF THE LISTED SCHEDULE: |
| Periodontal scaling and root planing
- per quadrant |
$182.00 |
| Amalgam Restoration (one surface) |
$83.00 |
| Root Canal Therapy - molar |
$732.00 |
| Simple Extraction Single |
$88.00 |
| Surgical Extraction Erupted Tooth |
$179.00 |
| Surgical Extraction Impacted Teeth
- Completely Bony |
$350.00 |
| |
|
| CLASS 3 —PROSTHETIC
AND MAJOR RESTORATIVE |
| PLAN COVERS UP TO %100 OF THE LISTED SCHEDULE: |
| Crowns - single restoration only |
|
| Porcelain fused to high noble metal |
$409.00 |
| Porcelain fused to noble metal |
$390.00 |
|
