Page 17 - 2021_Gray West_Benefits_Guide_Final

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Your Health Phone: 800-955-2030
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Smile! You have access to a large network of dentists through our Delta Dental benefits.

Covered Services*

DIAGNOSTIC & PREVENTIVE PLAN PAYS
*Deductible: $50 Deductible
Diagnostic and Preventive Services – exams, cleanings, 100% per person total per benefit
fluoride, and space maintainers year limited to a maximum
Deductible of $150 per
Emergency Palliative Treatment – to temporarily relieve pain 100%
family per benefit year. The
Sealants – to prevent decay of permanent teeth 100% deductible does not apply to
diagnostic and preventative
Brush Biopsy – to detect oral cancer 100% services, emergency
palliative treatment, brush
Radiographs – X-rays 100% biopsy, X-rays, sealants,
cephalometric films, photos,
BASIC SERVICES
diagnostic casts and
Minor Restorative Services – fillings and crown repair 50% orthodontic services (including
surgical repositioning of teeth).
Endodontic Services – root canals 50%

Periodontic Services – to treat gum disease 50%

Oral Surgery Services – extractions and dental surgery 50%

Major Restorative Services – crowns 50%
Other Basic Services – misc. services 50%

Relines and Repairs – to bridges, implants, and dentures 50%

MAJOR SERVICES

Prosthodontic Services – bridges, implants, and dentures 50%

ORTHODONTIC SERVICES
Orthodontic Services – braces 50%

Orthodontic Age Limit Dependent Children to the
end of the month of age 19

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