Page 16 - Benefit Guide Stamford Residence and Rehab

Dental Option:

Delta Dental

Rate Per Pay Period

Dependent Information

The Stamford Residence and Rehabilitation Center
Employee Only $13.96
offers employees the opportunity to cover their
Employee + One $31.80 dependent children. Children can join or remain on a
parent’s dental plan until age 26.
Employee + Two or More $47.70
When a child turns 26, they will lose dental coverage
on the last day of their birth month.

Type of Service (In-Network) Amount Paid

Best Savings is USE Delta Dental PPO Network

Preventive Services Covered at 100%; No Deductible
Basic Services Covered at 80% after Calendar Year Deductible

Major Services Covered at 50% after Calendar Year Deductible
Covered at 50% No Deductible to a Lifetime Maximum of $1,000
Orthodontia Services
person
Calendar Year Deductible $50 Individual / $150 Family
$1,000 Annual Maximum Basic and Major Services
Annual Maximum
$500 Annual Maximum Orthodontia

Waiting Periods for Major Services or Ortho 12 Months

Type of Service Benefit Description

Preventive Services Oral Exams, Cleanings, X-rays, Fluoride Treatment

Fillings, Simple Extractions, Space Maintainers,
Basic Services
Sealants, General Anesthesia, Endodontics and Periodontics
Oral Surgery, Crowns, Bridges, Dentures, Inlays & Onlays and
Major Services
Implants
Annual Maximum Applies January 1 to December 31

Orthodontia Only applies to children under age 19

NOTE: This is only a brief overview. Please see the Benefit Summary for more details.

Website: or Customer Service : deltadentalins.com or 800-521-2651

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