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Benefit Design
$50 individual/ $150 family deductible each benefit period.
Dependents covered to age 19. Students covered up to age 23.
This program pays a maximum of $1000 in benefits per Covered Person during any Benefit Period.
Diagnostic and Preventative
In-Network - 100% of the Allowable Amount.
Out-of-Network - 80% of the Allowable Amount.

Not subject to deductible:
- Initial exam
- Periodic exams
- Emergency exams
- X-rays (diagnostic)
- Cleanings (one in a 6 month  period)
- Pulp vitality test
- Child fluoride treatment (up to age 19)
- Space maintainers (for children)
- Emergency treatment (relief of pain)

 Minor Services
In-Network - 50% of the Allowable Amount.
Out-of-Network - 30% of the Allowable Amount.

Subject to deductible:
- Silver fillings (in permanent and primary teeth)
- Anterior resin fillings (tooth colored filling)
- Stainless steel crown
- Sedative filling
- Pin retention
- Crown repair
- Denture repair
- Some oral surgery (excluding any impacted teeth)
- Root canal and pulp therapy (excluding final restoration)

 Major Services
In-Network - 50% of the Allowable Amount.
Out-of-Network - 30% of the Allowable Amount.

Subject to deductible:
- Crowns (permanent)
- Recement crown
- Crown build-up
- Periodontal procedures, dentures (complete and partial)
- Denture/ partial repair
- Bridges

12 month waiting period applies.  Replacement of teeth missing prior to the effective dates are not covered.
Kentucky Rates for effective dates through 6-1-09

 

Monthly

Plan Monthly Premium
Single $26.88
Single + Spouse $53.76
Single + Child(ren) $58.29
Family $83.34

 

Annual

Plan Discounted Annual Premium *
Single $312.60
Single + Spouse $610.92
Single + Child(ren) $673.80
Family $945.48

* If you pay annually your premium is less than the total premium paid monthly.
 

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Send completed applications to:

PlanChoice
c/o Delta Dental Plan of KY
3010 Taylor Springs Drive
Louisville, KY 40220

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For more information, contact PlanChoice at 1-800-466-5182 or delta@planchoice.com Currently available only in Kentucky. This is not a contract.  It is a partial list of benefits and services.  For complete details refer to your certificate.Dental benefits are offered by Delta Dental Plan of Kentucky, Inc.

 
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