Page 12 - CPSS Benefit Guide Class 3 Employee

Dental Plan

Delta Dental of Missouri

It’s important to have regular dental exams and cleanings so problems are detected before they become painful — and
expensive. Keeping your teeth and gums clean and healthy will help prevent most tooth decay and is an important part of
maintaining your overall health.

Dental Plan
Plan Provisions PPO Network Premier Network Out-of-Network

Annual Deductible
(Individual/Family) $50 individual $150 family $50 individual $150 family $50 individual $150 family

Calendar Year Maximum $1,000 per person $1,000 per person $1,000 per person

Orthodontia Lifetime Maximum 50% up to $1,000 50% up to $1,000 50% up to $1,000

Diagnostic and Preventive Services Covered at 100% Covered at 100% Covered at 100%
(e.g., X-rays, cleanings, exams)

Amount you pay after deductible
Basic and Restorative Services (e.g.,
fillings) 80% 80% 80%

Major Services (e.g., dentures, crowns,
bridges) 50% 50% 50%

Orthodontia 50% for children under age 19

MAXRollover: A portion of the unused maximum will roll
over to the next benefit period when qualified claims are
submitted by any provider. If all qualified claims are
submitted by Delta Dental PPO providers, qualified
participants will roll over an additional bonus amount.
Using in-network dental providers:

• PPO Providers: agree to accept contractual
reimbursement as payment in full and will not balance
bill.
• Premier Providers: agree to accept contractual
reimbursement as payment in full and will not balance
bill. Slightly higher contracted fees than those of PPO
providers.
• Out-of-Network: not contracted and therefore may
balance bill.
To find a provider participating in your dental plan
network:
visit www.deltadentalmo.com or call 800-335-8266

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