Dear KRTA member:  

Thank you for considering Delta Dental of Kentucky for your dental insurance needs. You can select the Delta Dental  PPO plan,  Delta Dental PPO Plus Premier Plan, or  the  DeltaCare  plan (available to KY residents only).  You  can  also  purchase  the  DeltaVision®  plan with one of the Delta Dental plans and receive a rate discount.  

The enclosed materials will help explain the benefit options and the costs.  

• Delta Dental overview (provides comparison of the PPO, PPO Plus Premier and DeltaCare benefits)• A rate sheet that gives the monthly and annual prices of the options available• Enrollment form• DeltaVision plan overview• Automatic Debit form for monthly payment

• Copayment Schedule for the DeltaCare (DHMO plan) (Available to KY residents only)

Delta Dental is a Kentucky headquartered company, and the oldest and largest dental carrier in the state. If you have questions after reviewing this information, please call 1‐800‐955-2030.  

Sincerely,  

Delta Dental of Kentucky 

What each plan pays:

Select the plan that bestmeets your needs...

Diagnostic & Preventive Services(excluded from the benefit maximum)u Oral examination

(limited to 2 per calendar year)u Emergency Examu Palliative emergency treatmentu Periapical, bitewing, panoramic or

complete series x-rayu Topical fluoride application

(up to age 19)u Routine cleaningsu Sealants (up to age 16)u Space maintainers (up to age 11)

Minor Servicesu Routine fillings (including composites)u Simple extractionsu Periodontic services

Major Services

u Inlays or crownsu Prosthetic services

(bridges, dentures and partials)u Root canal therapyu Oral surgeryu Simple denture repairu Implants

Deductibles

Benefit Period MaximumDiagnostic & Preventive Services are excluded from the maximum.

Age Limits

Option ADelta Dental PPO

Delta Dental PPO Network Out-of-Network (Percent of Allowable Amount)

100% 75%

100% 75%

100% 75%

100% 75%

100% 75%

100% 75%

100% 75%

100% 75%

50% 25%

50% 25%

50% 25% There is a 12-month waiting

period on Major Services.**50% 25%

50% 25%

50% 25%

50% 25%

50% 25%

50% 25%

$50 Individual/$150 Family

$1,500

Dependents to age 19 Full-time Students

to age 23

Option BDelta Dental

PPO Plus Premier

Dual Network Option* (Percent of Allowable Amount)

100%

100%

100%

100%

100%

100%

100%

100%

50%

50%

50%There is a 12-month waiting period on Major Services.**

25%

25%

25%

25%

25%

25%

$50 Individual/$150 Family

$1,500

Dependents to age 19 Full-time Students

to age 23

Option C DeltaCare

Member Copayment

$0

$25

$35

$0

$0

$0

$22

$115-$220

$47-$105

$32

$57-$420

$203-$400

$290-$448

$229-$380

$50-$195

$35-$57

Not covered.

No deductible.

No maximum.

Dependents to age 19 Full-time Students

to age 23

The oldest and largest dental insurance carrier in Kentucky with the largest dentist networks offers you a choice of three dental programs. You have several different ways to pay the premium. We offer monthly bank draft, monthly credit card, annual check, and annual credit card payments.

KRTA eligible for Delta Dental coverage!

For more information, please call 1-800-955-2030.You can enroll online at deltadentalky.com/KRTA or by phone at 1-800-955-2030.

* This dental program allows members to utilize any licensed provider. Members who choose a Delta Dental PPO networkprovider have the lowest out of pocket expenses and cannot be balance billed. Members who choose a Delta Dental Premiernetwork provider cannot be balance billed.

** Credit provided with proof of 12 months of prior dental coverage.

KRTA 2013 01 R. 5/18

(KY residents only)

You’ll see the difference with DeltaVision®

Personalized Care. DeltaVision members receive quality care that focuses on their eyes and overall wellness. Our eye care provider will look for vision problems and signs of other health conditions.

Eyewear. Choose eyewear that’s right for you and your budget. From classic styles to the latest designer fashions, there are hundreds of options for DeltaVision members.

Value and Savings. DeltaVision members receive great benefits on exams and eyewear at an affordable price.

Enroll Today!

3 in 4adults need

vision correction.1

1 in 4 children need vision correction.1

Only 1 in 5 Americans get an

annual medical exam.2

Sources: 1. Vision Council, VisionWatch December 2014; 2. American Journal of Preventative Medicine 2012, 42, Issue 2:164-173.

deltadentalky.com/KRTA | (800) 955-2030

KRTA DeltaVision®

VSP Choice Network 38,000 preferred providers - 91,000 Access Points

DeltaVision® by Delta Dental of Kentuckyadministered by VSP

Your coverage with Out-of-Network Providers

Exam - up to $45Frame - up to $70Single Vision Lenses - up to $30

Lined Bifocal Lenses - up to $50Lined Trifocal Lenses - up to $65Lenticular Lenses - up to $100

Progressive Lenses - up to $50Contacts - up to $105Necessary Contact Lenses - up to $210

Benefit Description CopayWellVision Exam

Exams1 exam every 12 months

Comprehensive eye exam to ensure overall visual wellness

$10

Prescription Glasses $25

Frames1 pair every 12 months

$130 allowance for wide selection of frames20% savings on amount over allowance

$70 Costco frame allowance

Included in Prescription Glasses Copay

Lenses1 pair every 12 months

Single vision, lined bifocal and lined trifocal lensesPolycarbonate lenses for children

Included in Prescription Glasses Copay

CoveredLens Enhancements Standard Progressive Lenses $0

OptionalLens Enhancements

Standard Anti-Reflective Coating Premium Progressive LensesCustom Progressive Lenses

Average savings of 20-25% on other lens enhancements

$41$95 - $105$150 - $175

Contact Lenses - instead of glassesContacts

every 12 months$130 allowance for contacts; copay does not apply

Contact lens exam (fitting and evaluation) up to $60

Extra SavingsFeatured Frames $150 allowance on featured frame brands. Check vsp.com for current offers.

Glasses and Sunglasses 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam

Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam

Additional Programs

Included Primary Eyecare, Eye Health Management (including Diabetic Exam Reminder Letters)

KRTA DeltaVision®

KRTA Rate SheetEffective dates of 7/1/2019-6/30/2020

Monthly Rates - Bank Draft or Credit Card

Annual Rates - Check or Credit Card

Effective Date of Coverage

Member OnlyMember Plus One DependentMember Plus Two or More Dependents

Option A – Delta Dental PPO

KRTA 2013 02 R. 5/19 Underwritten by Delta Dental of Kentucky, Inc.® Registered Marks Delta Dental Plans Association

Option ADelta Dental

PPO

$36.60

$70.25

$120.77

Contract Type

Member Only

Member Plus One Dependent

Member Plus Two or More Dependents

Option BDelta Dental

PPO PlusPremier

$38.25

$73.46

$126.23

Option CDeltaCare

Available to KY residents only

$16.20

$30.93

$48.87

Dental Only

7/1/2019 - 6/30/2020

$439.20$843.00

$1,449.24

Option B – Delta Dental PPO plus Premier

Option C – DeltaCare (Available to KY residents only)

Applications received by the 20th of the month are effective the 1st of the following month.

Option AVPPO with

DeltaVision®

$48.29

$87.20

$151.17

Option BVPPO Plus

Premier withDeltaVision®

$49.94

$90.41

$156.63

Option CV DeltaCare with

DeltaVision®

$27.89

$47.88

$79.27

Dental with DeltaVision

7/1/2019 - 6/30/2020$579.48

$1,046.40$1,814.04

Effective Date of Coverage

Member OnlyMember Plus One DependentMember Plus Two or More Dependents

Dental Only

7/1/2019 - 6/30/2020

$459.00$881.52

$1,514.76

Dental with DeltaVision

7/1/2019 - 6/30/2020

$599.28$1,084.92$1,879.56

Effective Date of Coverage

Member OnlyMember Plus One DependentMember Plus Two or More Dependents

Dental Only

7/1/2019 - 6/30/2020

$194.40$371.16$586.44

Dental with DeltaVision

7/1/2019 - 6/30/2020

$334.68$574.56$951.24

Available to KY residents only

q Credit Card – q Annual q SemiAnnual q Quarterly q Monthly

q Visa  q MasterCard  q American Express  q Discover

Check the type of contract and list all covered dependents below, if applicable:q Member Only q Member Plus One q Member Plus Family

KRTAEnrollment/Renewal Form

You must be a KY resident to enroll in Option C or Option CV.

® Registered Marks Delta Dental Plans Association

q Option A - Delta Dental PPO

q Option B - Delta Dental PPO Plus Premier

q Option C - DeltaCare

Please select the plan in which you would like to enroll.

Home Address – Number and Street City State ZipDate of BirthMO  DAY   YR

Sex (Circle one)

M or F

KRTA 2013 03 R. 2/17

COVERED DEPENDENTS List all Covered Dependents below. If additional space is required, attach a list to this form.

Last First MI SSN

Spouse

Date of BirthMO  DAY   YR

SexM    F

Dependent

Dependent

Dependent

Dependent

Card Number _________________________________________________

Expiration Date _______________________________________________

Signature ____________________________________________________

Please select one of the three payment methods below. Please provide all necessary information.

q Paper Check –Annual premium only

(Please include your check with this form.)

Dependents covered through the end of the benefit year in which they turn age 19. Full-time students are covered through the end of the benefit year in which they turn 23.

Please carefully read the Contract Provisions on the back of this form. Signature required.

q Bank Draft – q Annual q SemiAnnual q Quarterly q Monthly

A) Please complete the enclosed “Did You Know?” authorization form or send a voided check with this form in order to accuratelyestablish your new withdrawal. The draft process will originate on date of enrollment and then the 1st of each month thereafter and should reach your account for processing within three working days.

B) Monthly bank drafts will remain in full force and effective until Delta Dental of Kentucky/Morgan White and your bank (depository)have received written notification from you of termination and in such time and in such manner as to afford the depository areasonable time to act on it.

1. 2.

3.

q Option AV - Delta Dental PPO with DeltaVision®

q Option BV - Delta Dental PPO Plus Premier with DeltaVision®

q Option CV - DeltaCare with DeltaVision®

Social Security Number Name – Last First MI Home Phone

( )

Email Address

Effective Date Process Date Processed By

SHADED AREA FOR OFFICE USE ONLY

IMPORTANT: If you do not want the contract for any reason, you may return it to us within 10 days after you receive it. Upon return, the contract will be deemed void, and any money you have paid will be refunded.This is an annual contract. If you have elected the annual payment option, you may not terminate this contract prior to the end of the term. If you have elected the monthly payment option and we do not receive your premium within 30 days of the date the premium is due, your contract will be cancelled effective the due date of your premium, whether or not a specific condition was incurred prior to the termination date. Your Covered Dependents will terminate on your termination date. Covered Services are eligible for payment only if your contract is in effect at the time such services are provided.

I acknowledge that I have read the provisions of this enrollment form and I expressly accept such provisions as a condition of coverage. I understand that my membership is for a 12-month period and on my anniversary date I can renew or cancel or change how I pay my premium. I represent the answers given to all questions on this form are true and accurate to the best of my knowledge and I understand they are being relied on by Delta Dental of Kentucky, Inc. in accepting this form. Any material misrepresentation found in this application may result in denial of benefits or cancellation of my coverage(s). Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. If accepted, this form, the dental contract, and the identification card will constitute the contract.

Applicant Signature_________________________________________________________ Date _____________________________

KRTA Contract Provisions

Please carefully read the Contract Provisions below. Signature required.

If you wish to terminate your contract, please sign below and return this form to Delta Dental.

Signature ___________________________________________________________________Date _________________________

Contract Termination

You can enroll online at www.deltadentalky.com/KRTA,

by phone at 1-800-955-2030

or, by mail:

Delta Dental of Kentucky, Inc.ATTN: IPU

PO Box 242810Louisville, KY 40224

If enrolling by mail, please make a copy for your records.

DID YOU KNOW?Delta Dental can automatically debit your monthly payment from a checking or savings account.

If you would like to be set up for the automatic debit process, please fill out the form below, attach a copy of your blank voided check and mail it with your enrollment form.

Bank Name: ________________________________________________________________________________

Account Holder Name: _______________________________________________________________________

Checking Account

Savings Account

________________________________  ______________________________________________________BankRoutingNumber BankAccountNumber

Please do not include the check number.

IherebyauthorizeDeltaDental,subsidiaries,andaffiliatestoinitiateautomaticwithdrawals(ACH)fromtheaccountindicatedabove.ThisauthorizationwillremainineffectuntilIchoosetonottorenewmycontractwithDeltaDentalorchangepaymentmethods.

Nameonaccount(pleaseprint): _______________________________________________________________________

AccountHolderSignature:_____________________________________________ Date: __________________________

VOID

Resin Restorations (continued):2391 Resin-based composite – 1 surface, posterior $ 772392 Resin-based composite – 2 surfaces, posterior 982393 Resin-based composite – 3 surfaces, posterior 1182394 Resin-based composite – 4 or more surfaces 122Inlay/Onlay Restorations:2510* Inlay, metallic – 1 surface 3242520* Inlay, metallic – 2 surfaces 3242530* Inlay, metallic – 3 or more surfaces 3362542* Onlay, metallic – 2 surfaces 3242543* Onlay, metallic – 3 surfaces 3362544* Onlay, metallic – 4 or more surfaces 336Crowns:2710 Crown, resin based composite 2192720* Crown, resin with high noble metal 3352721 Crown, resin with predominantly base metal 2932722 Crown, resin with noble metal 2932740 Crown, porcelain/ceramic 4482750* Crown, porcelain fused to high noble 4482751 Crown, porcelain fused to predominantly base metal 4482752 Crown, porcelain fused to noble 4482780* Crown – 3/4 cast high noble metal 4482781 Crown – 3/4 cast predominantly base metal 4022782 Crown – 3/4 cast noble metal 4482783 Crown – 3/4 porcelain/ceramic 4482790* Crown, full cast high noble metal 4482791 Crown, full cast predominantly base metal 4022792 Crown, full cast noble metal 4482794* Crown–titanium 4482910 Recementinlay,onlayorpartialcoveragerestoration 432915 Recement cast or prefabricated post and core 452920 Recement crown 402930 Prefabricated stainless steel primary 1192931 Prefabricated stainless steel permanent 1222932 Prefabricated resin crown (anterior teeth only) 1342940 Sedativefilling 392950 Core build-up, including any pins 1182951 Pinretention–pertooth,inadditiontorestoration 192952* Postandcore,inadditiontocrown– 153

 indirectlyfabricated2954 Prefabricatedpostandcore,inadditiontocrown 1472971 Additionalprocedurestoconstructnewcrownunder 73

 existingpartialdentureframework2980 Crown repair 92 + lab*Baseornoblemetalisthebenefit.Highnoblemetal(precious),ifused,willbechargedtotheMemberattheadditionallaboratorycostofthehighnoblemetal.Thisappliestocrowns,bridges,indirectlyfabricatedpostandcores,inlaysandonlays.Crownslimitedto1per5yearperiod.Anadditionallaboratorychargealsoappliestoatitaniumcrown.

ENDODONTICS3110/3120 Pulpcapping–direct/indirect(excludesfinal 35

 restoration)3220 Therapeuticpulpotomy(excludesfinalrestoration) 653221 Pulpaldebridement(primary/perm.) 473230/3240 Pulpaltherapy(resorbablefilling),primarytooth 92

 (excludesfinalrestoration)3310 Rootcanal,anterior(excludesfinalrestoration) 2553320 Rootcanal,bicuspid(excludesfinalrestoration) 3153330 Rootcanal,molar(excludesfinalrestoration) 4153346 Retreatmentofpreviousrootcanaltherapy–anterior 3193347 Retreatmentofpreviousrootcanaltherapy–bicuspid 3653348 Retreatmentofpreviousrootcanaltherapy–molar 442

ADA Codes Member PaysVISITS & DIAGNOSTIC0120 Periodicoralevaluation $ 00140 Limitedoralevaluation(emergency)– 28

 problemfocused0145 Oralevaluationforpatientsunder3yearsofage 00150 Comprehensiveoralevaluation 00160 Detailedandextensiveoralevaluation– 0

 problemfocused0170 Re-evaluation–limited,problem-focused 280180 Comprehensiveperiodontalevaluation 00460 Pulpvitalitytests 00470 Diagnosticcasts 0X-RAYS0210 Full mouth X-rays – complete series (including 0

 bitewings(1 per 60 month period)0220 Periapical X-ray 00230 PeriapicalX-ray–eachadditionalfilm 00240 Intraoral,occlusalfilm 00270/0272 BitewingX-rays(oneandtwofilms) 00273 BitewingX-rays(threefilms) 00274 BitewingX-rays(fourfilms)(1 set per 12 month period) 00277 Verticalbitewings(seventoeightfilms) 00330 Panoramic X-ray (1 per 60 month period) 0PROPHYLAXIS & FLUORIDE TREATMENTS1110/1120 Prophylaxis(teethcleaning)adult/child 0

(2 per 12 month period)1206 Topicalfluoridevarnish 0

(1per6monthperiodforcoveredpersonstoage19)1208 Topicalapplicationoffluoride 0

(1per6monthperiodforcoveredpersonstoage19)1351 Sealant per tooth through age 15 – occlusal 24

 surfacepermanentmolars(Benefitsforreplacementaredisallowedifperformedwithin3yearsofinitialplacement)

SPACE MAINTAINERS*1510 Spacemaintainer,fixed(unilateral)* 1301515 Spacemaintainer,fixed(bilateral)* 2111520 Spacemaintainer,removable(unilateral)* 1741525 Spacemaintainer,removable(bilateral)* 2331550 Recementationofspacemaintainer 331555 Removaloffixedspacemaintainer 33*Spacemaintainersarelimitedtochildrenunder12yearsofage.

RESTORATIVE DENTISTRYAmalgam Restorations – Primary or Permanent Teeth:2140 Amalgam – 1 surface 492150 Amalgam – 2 surfaces 592160 Amalgam – 3 surfaces 712161 Amalgam – 4 or more surfaces 77Resin Restorations:2330 Resin-based composite – 1 surface, anterior 552331 Resin-based composite – 2 surfaces, anterior 672332 Resin-based composite – 3 surfaces, anterior 792335 Resin-based composite – 4 or more surfaces, 102

 anteriororinvolvingincisalangle2390 Resin-based composite crown – anterior 122

PLAN 20173AMEMBER COPAYMENT SCHEDULEBenefits are provided for the following services (“covered services”). Covered services must be performed by a network provider or by a network specialist. This is not a contract. Covered services are subject to the limitations, exclusions, and other terms and conditions of your member certificate. No benefits are provided for services received from a provider other than a network provider or for procedures not listed below.

2016-016-DC

(Continued)

ADA Codes Member Pays

®RegisteredMarkofDeltaDentalPlansAssociation

DeltaCareExclusive Provider Option

Must be a KY resident to enroll

ENDODONTICS (CONTINUED)3410 Apicoectomy/periradicular surgery, anterior $2453421 Apicoectomy/periradicular surgery, bicuspid 236

 (1stroot)3425 Apicoectomy/periradicularsurgery,molar(firstroot) 3483426 Apicoectomy/periradicular surgery, 216

 eachadditionalroot3430 Retrogradefilling,perroot 823450 Rootamputation,perroot 158PERIODONTICS4210 Gingivectomyorgingivoplasty,4ormore 216

 contiguousteethperquadrant4211 Gingivectomyorgingivoplasty,1to3contiguous 102

 teethorboundedteethspacesperquadrant4240 Gingivalflapprocedures,includingrootplaning, 253

 4ormorecontiguousteeth4241 Gingivalflapprocedures,includingrootplaning, 217

 1to3contiguousteethorboundedteethspaces perquadrant

4245 Apicallypositionedflap 2474249 Clinicalcrownlengthening–hardtissue 2524260 Osseoussurgery,4ormorecontiguousteeth 4534261 Osseoussurgery,1to3contiguousteethor 304

 boundedteethspacesperquadrant4341 Periodontal scaling and root planing, 102

 4ormoreteethperquadrant4342 Periodontal scaling and root planing, 71

 1to3teethperquadrant4355 Fullmouthdebridementtoenablecomprehensive 74

 evaluationanddiagnosis4910 Periodontalmaintenance(followingactivetherapy) 69PROSTHETICS – REMOVABLE Includes any adjustments for 6 months5110/5120 Complete denture, upper or lower 4225130/5140 Immediate denture, upper or lower 4875211/5212 Partialdenture,resinbase,upperorlower 416

 (includinganyconventionalclasps,rests andteeth)

5213/5214 Partialdenture,upperorlower,castmetal 499 frameworkwithresindenturebases(including anyconventionalclasps,restsandteeth)

5225 Maxillarypartialdenture–flexiblebase 496 (includinganyclasps,restsandteeth)

5226 Mandibularpartialdenture–flexiblebase 496 (includinganyclasps,restsandteeth)

5281 Removableunilateralpartialdenture,onepiece 328cast metal (including clasps and teeth)

5410/5411 Dentureandpartialadjustments–upperorlower 415421/5422 Adjustpartialdenture-upperandlower  465510/5610 Dentureandpartialrepairs(perrepair) 65+lab 56205520/5640 Addingorreplacingteethtoexisting 65+lab

 partial/denture(pertooth)5630 Repairorreplacebrokenclasp 65+lab5650/5660 Addtoothorclasptoexistingpartialdenture 65+lab5670/5671 Replace all teeth and acrylic on cast metal 285

 framework,upperorlower5710/5711 Rebase complete upper or lower denture 1805720/5721 Rebaseupperorlowerpartialdenture 1455730/5731 Officereline,completeorpartialdenture 120 5740/5741  5750/5751 Laboratoryreline,completeorpartialdenture 165 5760/57615850/5851 Tissueconditioning,upperorlower 58

PROSTHETICS – FIXED (EACH RETAINER AND EACH PONTIC CONSTITUTES A UNIT IN A FIXED PARTIAL DENTURE)6210* Pontic,casthighnoblemetal $4356211 Pontic,castpredominantlybasemetal 4226212 Pontic,castnoblemetal 4486240* Pontic,porcelainfusedtohighnoblemetal 4486241 Pontic,porcelainfusedtopredominantlybasemetal 4486242 Pontic,porcelainfusedtonoblemetal 4486245 Pontic,porcelain/ceramic 4486250* Pontic,resinwithhighnoblemetal 4486251 Pontic,resinwithpredominantlybasemetal 4486252 Pontic,resinwithnoblemetal 4486602* Inlay cast high noble metal, 2 surfaces 3176603* Inlay cast high noble metal, 3 or more surfaces 3176604 Inlay cast predominantly base metal, 2 surfaces 2956605 Inlay cast predominantly base metal, 295

 3ormoresurfaces6606 Inlay cast noble metal, 2 surfaces 3056607 Inlay cast noble metal, 3 or more surfaces 3166610* Onlay cast high noble metal, 2 surfaces 3016611* Onlay cast high noble metal, 3 or more surfaces 3016612 Onlay cast predominantly base metal, 2 surfaces 2816613 Onlay cast predominantly base metal, 281

 3ormoresurfaces6614 Onlay cast noble metal, 2 surfaces 2926615 Onlay cast noble metal, 3 or more surfaces 2926720* Crown, resin with high noble metal 3356721 Crown, resin with predominantly base metal 2936722 Crown, resin with noble metal 2936740 Crown, porcelain/ceramic 4486750* Crown, porcelain fused to high noble metal 4486751 Crown, porcelain fused to predominantly 448

 base metal6752 Crown, porcelain fused to noble metal 4486780* Crown, 3/4 cast high noble metal 3766781 Crown, 3/4 cast predominantly base metal 3676782 Crown, 3/4 cast noble metal 4486790* Crown, full cast high noble metal 4486791 Crown, full cast predominantly base metal 4096792 Crown, full cast noble metal 4486930 Recementbridge(fixedpartialdenture) 576940 Stressbreaker 156*Baseornoblemetalisthebenefit.Highnoblemetal(precious),ifused,willbechargedtotheMemberattheadditionallaboratorycostofthehighnoblemetal.Thisappliestocrowns,bridges,indirectlyfabricatedpostandcores,inlaysandonlays.Crownslimitedto1per5yearperiod.Anadditionallaboratorychargealsoappliestoatitaniumcrown.

ORAL & MAXILLOFACIAL SURGERY7111 Extraction,coronalremnants–decidioustooth 387140 Extraction,eruptedtoothorexposedroot 57

 (elevationand/orforcepsremoval);includes routineremovaloftoothstructure,minor smoothingofsocketboneandclosure, asnecessary

7210 Surgicalremovaloferuptedtooth,requiring 104 elevationofmucoperiostealflapandremoval

 ofboneand/orsectionoftooth,minor smoothingofsocketboneandclosure

7220 Removalofimpactedtooth(softtissue) 1327230 Removalofimpactedtooth(partiallybony) 1737240 Removalofimpactedtooth(completelybony) 1837241 Removalofimpactedtooth(completelybony, 206

 withunusualsurgicalcomplications)

DELTACARE PLAN 20173AADA Codes Member PaysADA Codes Member Pays

(Continued)2016-016-DC

DELTACARE PLAN 20173A

ORAL & MAXILLOFACIAL SURGERY (CONTINUED)7250 Surgicalremovalofresidualtoothroots $135

 (cuttingprocedure)7286 Biopsyoforaltissue(soft) 1117310 Alveoloplasty,withextractions,fourormoreteeth 98

 ortoothspaces,perquadrant7311 Alveoloplasty,withextractions,1to3teethor 93

 toothspaces,perquadrant7320 Alveoloplasty,withoutextractions,fourormore 131

 teethortoothspaces,perquadrant7321 Alveoloplasty,withoutextractions,1to3teethor 131

 toothspaces,perquadrant7960 Frenulectomy – separate procedure 185MISCELLANEOUS9110 Palliativeemergencytreatmentofdentalpain 42

 (minorprocedure)9310 Specialistconsultation 609440 Officevisit,afterregularlyscheduledhours 44

ORTHODONTIC COVERAGE MEMBER PAYS24-month treatment plan including treatment records $4,100

Youmaygodirectlytoparticipatingorthodontistsfortreatment.Coverage is available only in areaswhere there are networkorthodontists.

Services include initial examination, diagnosis, consultation, initial banding, 24 months of active treatment, debanding, and the retention phase of treatment. The retention phase includes the initial construction, placement and adjustments to retainers and office visits for a maximum of 24 months. Fees for treatment records include X-rays, diagnostic casts and photographs.

SPECIALIST COVERAGEThis plan includes coverage for oral surgery, periodontic, andendodonticspecialists.Networkspecialistsareavailableinmostareasweserve. In order to receive benefits, services must be rendered by a network specialist.

PREAUTHORIZATIONThefollowingservicesaresubjecttoreviewforbenefitcoverageasstatedinyourmembercertificate:crowns,periodontics,partialdenturesandbridges.Yourdentistmustsubmitatreatmentplanforreview,priortoservicesbeingrendered.

MISSED APPOINTMENTSDeltaCare plans do not cover missed appointment charges.You should follow your dentist’s policy regarding missedappointments.

SECOND OPINIONSFor cases where you feel a second opinion is necessary, contact a CustomerServicerepresentativeat(800)955-2030.

OUT-OF-AREA EMERGENCY CAREIfyouare50milesormorefromhome,benefitsareprovidedfor out-of-area emergency care once per 12-month calendar year.You may seek treatment from any licensed dentist only for the relief of pain.Benefitsarepayable, inaccordancewiththeMember Copayment Schedule, up to a maximum of $50 perbenefitperiod, less anyapplicable copayments. To claim thesebenefits,mail theoriginal receiptandoriginalbill toourofficewithin60daysofreceiptofservices.

2016-016-DC

How to find a Delta Dental participating provider:Determine the Delta Dental plan(s) you are looking at for your dental benefits and then search using below methods:t Delta Dental PPO – In-network benefits are available through providers who participate in the Delta Dental PPO

network.

t Delta Dental Premier – In-network benefits are available through providers who participate in the Delta DentalPremier network.

t Delta Dental PPO Plus Premier – In-network benefits are available through providers who participate in the DeltaDental PPO or Delta Dental Premier network.

t DeltaCare – Benefits are only avilable through providers who participate in the DeltaCare network.

It is important that you verify a provider’s status each time you seek care as a provider contract may change. It is your responsibility to verify that the provider you use is contracted with the Delta Dental or VSP network associated with the plan that you have chosen. If you receive treatment from a non-network provider, your benefits may be paid at a lower percentage or you may be balance billed.DDPK PROV DV R. 1/18 ® Registered Marks Delta Dental Plans Association

OnlineVisit DeltaDentalKY.com and request the information by city, state, zip code, provider’s name or specialty.

Mobile AppDownload the mobile app for Apple or Andriod. To download, visit the App Store (Apple) or Google Play (Android) and search for Delta Dental.

Customer ServiceCall Delta Dental customer service representative at the 800-955-2030 and ask if your provider is participating in the network associated with the plan that you have chosen.

Provider OfficeCall your provider’s office and ask if he/she participates in the network associated with the plan that you have chosen.

How to find a VSP participating provider:Search under the VSP Choice Network for any DeltaVision plan:

OnlineVisit VSP.com and request the information by city, state, zip code, provider’s name or specialty.

Mobile AppDownload the mobile app for Apple or Andriod. To download, visit the App Store (Apple) or Google Play (Android) and search for VSP.

Customer ServiceCall VSP customer service representatives at 800-877-7195 and ask if your provider is participating in the VSP Choice Network

Provider OfficeCall your provider’s office and ask if he/she participates in the network associated with the plan that you have chosen.

You can enroll online at deltadentalky.com/krta, or by phone at 1-800-955-2030

or, by mail:Delta Dental of Kentucky, Inc.

ATTN: IPUPO Box 242810

Louisville, KY 40224

If enrolling by mail, please make a copy for your records.

Once enrolled, you can call our Customer Service department at 800.955.2030 or visit our consumer toolkit at toolkitsonline.com for benefit information.

Thank you for choosing Delta Dental as your dental benefits carrier!