DENTAL INSURANCE

Schedule of Benefits
Administered by Delta Dental Plan of South Dakota
1-800-627-3961




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The Schedule is a summary of benefits under this plan.
100% DIAGNOSTIC Provides all necessary procedures to assist the Dentist in evaluating the conditions existing and the dental care required.   Examinations - once each six months.
100% PREVENTIVE Provides for:
****Prophylaxis(cleaning) once each six months
****Topical Fluoride once each twelve months
****Space Maintainers fixed, band type
80% ANCILLARY Provides for emergency treatment for relief of pain.
80% ORAL SURGERY Provides for extractions and other oral surgery including pre and post operative care.
80% REGULAR RESTORATIVE DENTISTRY Provides amalgam, synthetic porcelain and plastic restorations (fillings) and stainless steel crowns.
80% ENDODONTICS Includes necessary procedures for root canal treatments and root canal fillings.
80% PERIODONTICS Includes procedures necessary for the treatment of diseases of the tissues supporting the teeth.
60% SPECIAL RESTORATIVE DENTISTRY Provides gold restorations when the teeth cannot be filled with another filling material; crowns and jackets when the teeth cannot be restored with filling material.
60% PROSTHETICS Procedures for the construction or repair of fixed bridges, partial dentures or complete dentures (includes crowns when used as abutments to bridge).
60% ORTHODONTICS Treatment necessary for the proper alignment of teeth.  MAXIMUM BENEFITS - The maximum payment for covered dental services (excluding Orthodontics) per person per calendar year is $1,500.00  The maximum lifetime payment for Orthodontics is $1,500.00 per person.
DEDUCTIBLE Starting 7/01/2006, There is a $50 deductible.
 THE CURRENT COST FOR THE PLAN IS:
 
 
District share
Employee Share
Total Cost
Employee
$32.50
$0.00
$32.50
2-Party
$32.50
$28.80
$61.30
Family
$32.50
$63.60
$96.10

 
 

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Douglas School District
400 Patriot Drive
Box Elder, South Dakota
USA, 57719
605-923-0000
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Updated: 8/7/2006