25 Plus Standard Plan
Delta Dental of
South Dakota
Group #: 2500
Preventive Care — 100% Paid By Delta Dental
T
hese services do not apply to the Annual Maximum Benefit.
• Routine exams and cleanings - two per coverage year.
• Bitewing x-rays - two per coverage year up to age 19, and once per
coverage year age 19 and over.
• Full mouth/panoramic x-rays - once every five years.
• Fluoride applications - two per coverage year up to age 19.
• Space maintainers on primary back teeth up to age 14.
• Dental sealants for unrestored 1st and 2nd permanent molars up to age 16.
Fillings and Extractions — 80% Paid By Delta Dental
• Silver and tooth-colored fillings. If a tooth-colored filling is used to restore
back teeth, benefits are limited to the amount paid for a silver filling.
• Stainless-steel crowns.
• Extractions and other oral surgery.
• Emergency treatment for relief of pain.
Root Canals and Gum Disease — 80% Paid By Delta Dental
• Root canals.
• Treatment of diseases of the tissues supporting the teeth.
• Periodontal maintenance cleanings. These cleanings do not apply to the
Annual Maximum Benefit.
Crowns and Prosthetics — 50% Paid By Delta Dental
• Crowns, bridges, dentures, and implants.
Braces and Teeth Alignment — 0% Paid By Delta Dental
• Treatment necessary for the proper alignment of teeth.
2023 Monthly Rates
• Single $46.70
• Family $119.30
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Network
PPO Plus Premier
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more than 96% of dentists in SD!
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dentist that’s right for you!
Deductible
$25 per person per coverage year
not to exceed $75 per family. The
deductible does not apply to
Preventive Care.
Annual Maximum Benefit
$1,200 per person per coverage
year. All services (except
Preventive Care) are subject to the
Annual Maximum Benefit and will
not be paid if your Annual
Maximum Benefit has been
reached.
Coverage Year
January - December
New employees will be eligible on
the first day of the month following
the employer's probationary
period.
Terminated employees will be
covered through the last day of the
month in which they are employed.
Dependent children are covered to
age 26. There is no age restriction
for unmarried dependent children
who are full-time students.
Health through Oral Wellness®
Visit a participating dentist to take an
oral health risk assessment. You may
be eligible for additional benefits for
preventive care.
Prevention Pays
Many preventive care services are still
covered even when the plan’s annual
maximum benefit has been reached.
Balance Billing Protection
In-network dentists may not charge
the difference if the fee for a covered
service is higher than the plan’s
allowed amount.
See other side for information on plan features. 1/23
Delta Dental of South Dakota
25 Plus Standard Plan
Group #: 2500
Health through Oral Wellness®
Health through Oral Wellness® is a unique,
patient-centered program that adds benefits to a Delta
Dental plan based on individual oral health needs. A Delta
Dental network dentist trained in Health through Oral
Wellness® will conduct a clinical risk assessment during a
regular preventive visit. The assessment measures the risk
and severity of periodontal disease, and the risk of tooth
decay.
If the assessment determines a member is at risk for tooth
decay, additional benefits include fluoride treatments,
sealants, and oral hygiene instruction. If a member is at
risk for periodontal (gum) disease, has periodontal
disease or has had periodontal surgery, the member will
be eligible for two additional cleanings* and four fluoride
treatments.
If a member has any of the following health conditions,
they are eligible for additional benefits.
• Diabetes (2 additional cleanings*)
• High-risk cardiac care (2 additional cleanings*)
• Kidney failure or dialysis (2 additional cleanings*)
• Cancer-related treatment - chemotherapy or radiation
(2 additional cleanings* and 2 applications of fluoride
varnish)
• Suppressed immune system (2 additional cleanings*
and 2 applications of fluoride varnish)
• Rheumatoid arthritis (2 additional cleanings*)
• Stroke (2 additional cleanings*)
• Pregnancy (1 additional cleaning* during the time
of pregnancy)
*
Cleanings can either be a general cleaning (prophylaxi
s)
or a periodontal maintenance cleaning. Periodontal
maintenance cleanings are typically covered under
the “Root Canals and Gum Disease Treatments”
category, not the “Preventive Care” category.
Plan Requirements
This plan is for 25 or more employees. The employer
pays the single cost for each employee and all eligible
employees should be enrolled. The employer determines
the number of hours per week required for employees to
be eligible and the length of the new employee waiting
period before they are eligible to enroll in the plan.
Prevention Pays
The Prevention Pays feature exempts diagnostic and
preventive dental services and some periodontal (gum
disease) services from the calculation of the plan’s
annual maximum benefit. That means preventive
services like exams, cleanings, x-rays, and periodontal
maintenance cleanings are covered when the plan’s
annual maximum benefit has been reached. It also
means more benefits are available to help pay for
treatment procedures like cavity fillings, crowns, and
root canals.
Balance Billing Protection
Your Delta Dental of South Dakota plan protects you from
balance billing. Balance billing is what happens when a
dentist’s fee for a certain service is more the plan’s
allowed amount, and the dentist bills you for the
difference.
Delta Dental’s network dentists have agreed to set fees,
so you shouldn’t be balance billed while visiting a dentist
in your plan’s network. However, you are still responsible
for paying any applicable deductibles, coinsurance,
amounts over your annual maximum, and charges for
non-covered services. You may be balance billed if you
visit a dentist outside of Delta Dental’s networks.
Delta Dental of South Dakota
P.O. Box 1157
720 N Euclid Ave
Pierre, SD 57501
Telephone: (605) 224-7345
Toll Free: (877) 841-1478
Fax: (605) 224-0909
deltadentalsd.com
1/23
