Download Delta Dental Plan Summary

Redi Services, LLC - Group #527
Premier Plan (Off Exchange)
Summary of Benefits
(Please refer to the handbook for more detailed benefits)
Covered Services
Preventive and Diagnostic (Type I)
 Oral Exams once every 6 months
 Prophylaxis once every 6 months
 Bitewing x-rays once every 6 months
 Fluoride once every 12 months (to age 19)
 Space maintainers (to age 19)
Basic (Type II)
 Emergency treatment for relief of pain
 Extractions & other oral surgery
 Full mouth x-rays once every 36 months
 Sealants on posterior permanent teeth once every 3 years (to
age 19)
 Preformed crowns, amalgam and synthetic restorations
 Synthetic restorations on posterior teeth are optional and are
payable as an amalgam benefit
 Pulpal & root canal filling
 Treatment of diseases of the tissues supporting the teeth
($1000 Lifetime Periodontal Maximum)
Major (Type III)
 Crowns
 Prosthetics (bridges, partial dentures and complete dentures)
Benefit Waiting Period
None
% Paid by DDWY
100%
Not subject to
deductible
None
80%
6 months
50%
The Effective Date of this Policy is the first of the month following three (3) months of your full-time employment.
DEDUCTIBLE LIMITATIONS
Individual Deductible
Family Deductible
$50
$150
ANNUAL MAXIMUM BENEFIT
Plan Year
Yearly Maximum (per person)
January - December
$2,000
WAITING PERIOD
Preventive & Diagnostic Services (Type I)
Basic Services (Type II)
Major Services (Type III)
None
None
6 months
DEPENDENT ELIGIBILITY
End of month age 26 is attained
Underwriting Guidelines:
100% enrollment of eligible employees and 75% dependent enrollment
The above pediatric coverage (under age 19) is not Exchange-Certified as part of the Affordable Care
Act/Health Care Reform. An Exchange-Certified pediatric plan can be substituted for the above pediatric
coverage or purchased in addition to the coverage above.
Delta Dental of Wyoming
6234 Yellowstone Rd * P.O. Box 29 * Cheyenne, WY 82003-0029
307-632-3313 or 1-800-735-DDPW (3379)
Hours: 8:00 a.m. to 5:00 p.m. Monday through Thursday/8:00 a.m. to 4:00 p.m. Friday
www.deltadentalwy.org
10000-6/2013