Page 13 - Caltech

Included in Kaiser Permanente Senior Advantage Plan - DeltaCare Dental HMO Benefits Plan***
Preventive care
Periodic and comprehensive oral evaluation
Bitewing X-rays Prophylaxis Fluoride treatments
Space maintainers
Restorative
Fillings — primary or permanent amalgam
Composite crowns — resin-based Crown — porcelain
Inlay — metallic
Oral and maxillofacial surgery
Extraction
Surgical removal of erupted tooth
Periodontics
Maintenance
Scaling and root planing
Surgery — osseous (includes flap entry and closure)
Prosthodontics
Complete denture
Reline maxillary or mandibular denture — chairside
Reline maxillary or mandibular denture — laboratory
Endodontics
Therapeutic pulpotomy Root amputation
Root canal — anterior Root canal — molar
Retiree pays
Limitations
No cost
Twice in a calendar year
No cost
Once in a calendar year for adults ages 19 and over
$15
Twice in a calendar year
100%
Only for children up to age 19, twice in a calendar year
100%
Removable — unilateral
$50
Four or more surfaces
$55
Anterior
$300
$260
One surface
$35
Elevation and/or forceps removal
$65
Complete or partial
$45
Twice in a calendar year
$55
Limited to four quadrants per calendar year
$450
Four or more teeth per quadrant
$395
The enrollee must continue to be eligible and the service must be provided at the contract dentist facility where the denture was originally delivered
$50
Complete or partial
$150
Complete or partial
No cost
Excludes final restoration
$75
Per root
$180
Excludes final restoration
$375
Excludes final restoration
***Benefits listed above are a sample of services provided and costs.
***Costs will vary; see your Evidence of Coverage for a comprehensive list of all services and associated costs.
***You must pay a $5 copayment each time you receive dental care in addition to any other cost sharing listed above. 13