Dental Plan

Rockwood School District
Group #9127
Effective 11/1/2024

Services	PPO	Premier	Out-of-Network
Preventive Services: Oral examinations, twice in any benefit period Bitewing and periapical x-rays as required Full-mouth x-rays once in any benefit period Prophylaxis (cleaning, scaling, and polishing including periodontal maintenance visits), twice in any benefit period Topical fluoride application for children under age 19, once in any benefit period Sealants for dependent children under age 19, limited to caries-free occlusal surfaces of the first and second permanent molars, once in 4 years Brush biopsy	100%	100%	100%
Basic Services: Space maintainers for dependent children under age 16, once in 5 years Emergency palliative treatment as needed Fillings Periodontics Endodontics Oral surgery including simple and surgical extractions. Extractions of bony impacted wisdom teeth are not covered under the dental plan but are covered under the medical plan. General anesthesia in conjunction with covered surgical procedures	90%	80%	80%
Major Services: Bridges and dentures, once in 5 years Crowns, jackets, labial veneers, inlays and onlays Implants and bone grafts	90%	80%	80%
Orthodontia (for dependent children under age 19)	80% up to $2,000	50% up to $1,500	50% up to $1,500
Calendar Year Deductible (applied to Basic, Major and Orthodontic Services)	$50 individual 2X family	$50 individual 2X family	$50 individual 2X family
Annual Maximum (applied to Preventive, Basic and Major services)	$1,000	$1,000	$1,000

Charges for exams, cleanings, x-rays, and fluoride treatments do not apply towards your annual maximum.

Two additional cleanings are covered per benefit period for patients who are pregnant, diabetic, have a suppressed immune system, or have a history of periodontal therapy. To be eligible for the additional cleaning benefits, you must submit a completed Self-Report Form. If periodontal therapy has already been reported on your claims, the Self-Report form is not necessary.

Download the Healthy Smiles, Healthy Lives Self-Report Form (PDF)

With predetermination estimates, or pre-treatment estimates, Delta Dental makes it easy for you to find out whether a proposed dental treatment is covered, what amount the plan will pay and the difference you will be responsible for. Please note predetermination estimates are not required; we offer this free service as a helpful tool to our Delta Dental members.

A predetermination estimate is a special feature available for you where Delta Dental issues a written estimate of benefits that may be available under your plan for your proposed dental treatment. Your dentist submits the proposed dental treatment to Delta Dental in advance of providing the care. When your predetermination estimate is ready, Delta Dental provides it to your dentist to review with you. This service is free for Delta Dental members.

You can request a predetermination estimate at any time. However, examples when you may want to request one include:

• If your dentist is recommending extensive treatment (over $200)
• If you need information on benefit coverage and plan limitations
• If you are discussing different care options available and costs with your dentist
• If you would like an estimate of how much you may have to pay

If all information is received with the initial request for predetermination estimate, please allow 10–14 business days for processing.

Note: Predetermination estimate is provided for informational purposes only and is not required before you receive any dental care. It is not required or necessary for approval of future dental benefit payments. You will receive the same benefits under your plan whether or not a predetermination estimate is requested. The benefits estimate provided on a predetermination estimate notice is based on benefits available on the date the notice is issued. A predetermination estimate is NOT a guarantee of future dental benefits or payment. When the services are complete, Delta Dental will calculate its payment based on your current eligibility, the benefit requirements of the service provided, remaining maximum and any deductible requirements.

Availability of benefits at the time your treatment is completed depends on several factors such as, but not limited to, your continued eligibility for benefits, your available annual or lifetime maximum payments, any coordination of benefits, the status of your plan and the dentist, your plan's limitations and any other plan provisions. A request for a predetermination estimate is not a claim for benefits or a preauthorization, precertification or other reservation of future benefits.

Delta Dental Virtual Visits, delivered by TeleDentistry.com, provides 24/7 access to a dentist, 365 days a year for Delta Dental of Missouri members.

It's Safe

Teledentistry is included in your existing coverage and is considered an oral examination under the plan. It's a safe and effective way to receive care and avoid the emergency room. You can use Delta Dental Virtual Visits when:

• having a dental emergency and do not have an established dentist
• needing access to a dentist after hours
• needing to consult with a dentist without leaving your home

It's Easy

You can conveniently access this service from your home with the use of a smartphone, tablet or computer with audio/visual capabilities.

Simply follow these four easy steps:

1. Login to the Delta Dental Virtual Visits patient portal.
2. Fill out your electronic documents.
3. Take photos of the problem area.
4. Connect with a TeleDentistry.com dentist and begin your consultation.

TeleDentistry.com dentists provide initial consultation services and can write prescriptions when appropriate. You will be referred to a Delta Dental network dentist for definitive diagnosis and treatment.

After the Initial Consultation

The TeleDentistry.com dentist will email consultation notes to your Delta Dental network dentist for further treatment. If you have not established care with a Delta Dental network dentist, with your authorization, TeleDentistry.com will refer you to an in-network dentist.

Note: A teledentistry visit is counted as an oral examination under your plan. The copay depends on your dental plan.

Click here to see the Delta Dental Summary Plan Description that went into effect November 1, 2024.

Eligible dependents include: Your lawful spouse, your children, step-children, foster children, legally adopted children, children placed and approved for adoption in the employee's home whose principal place of residence is with the employee, residing with you in a parent-child relationship. (There is an exception for a dependent who is physically or mentally disabled.)

Dependents may be covered under dental insurance until the end of the month when they turn 26 years of age, regardless of whether or not they are a full-time student.

Health and dental coverage are provided by different companies and require separate enrollments. Enrolling a dependent for health insurance does not include dental coverage.

Yes. Dental insurance is separate from health insurance. You can carry health insurance for dependents without dental or dental without the health insurance.

All employees can change their elections at Open Enrollment which is held the first part of September for the following November plan year. If you have a qualified life event, you can request to update your benefits provided you make that request within 30 days of the event. Visit Alight (formerly SmartBen) to request an update to your benefits or contact the Benefit Office at 636-733-2006 for more information.

Insurance cards are issued by Delta Dental after you elect your benefits. Contact Delta Dental of Missouri at 1-800-335-8266 or visit the Delta Dental website.