Kaiser Permanente California Dental Insurance Plan Brochure KPIF 2011
Kaiser Permanente California Dental Insurance Plan Brochure KPIF 2011
Kaiser Permanente California Dental Insurance Plan Brochure KPIF 2011
1 The
Table of Allowances lists the maximum amount, or allowance, that the plan will pay for each covered dental service. The plan will pay
the lowest dollar amount among the following three: the dentist’s usual, customary, and reasonable fee; the fee actually charged; or the
allowance. Any difference between the allowance and the dentist’s fee will be the responsibility of the patient.
2 Service charges vary.
3 The
waiting period is the period of time during which you are required to have been continuously covered under the Dental Insurance Plan
before a specific dental service will be a covered benefit.
Sample list of allowable services1
Plan Plan
Procedure pays2 Procedure pays2
Diagnostic Prosthodontics
Comprehensive oral evaluation—new or established patient $25.20 Complete denture—mandibular $241.00
X-rays—complete intraoral series including bitewings $54.00 Note: Coverage includes routine post-delivery care. Procedures
are subject to a 12-month waiting period. Procedures relating to
Preventive dentures, partial dentures, and relines include adjustments for
Prophylaxis/cleaning a six-month period following installation. Such procedures do
not include specialized techniques involving precision dentures,
Adult $43.20 personalization, or characterizations.
Child through age 13 $33.60 Oral and maxillofacial surgery
Restorative Extraction, erupted tooth, or exposed root $39.00
Fillings (elevation and/or forceps removal)
Amalgam—one surface, primary or permanent $35.00 Note: Coverage includes local anesthesia; suturing, if needed;
and routine postoperative care. Procedures are subject to a
Resin-based composite—one surface, anterior $46.00 six‑month waiting period.
Note: Procedures are subject to a six-month waiting period. Surgical removal of erupted tooth requiring elevation of $74.00
Crown mucoperiosteal flap and removal of bone and/or section
of tooth
Resin with high noble metal $182.00
Note: Extraction includes local anesthesia; suturing, if needed;
Note: Procedures are subject to a six-month waiting period.
and routine postoperative care. Procedures are subject to a
Endodontics six‑month waiting period.
To make an appointment
Simply contact the dentist of your choice and let him or her know you are covered under Delta Dental.
Have a question?
Call Delta Dental at 1-800-933-9312 (if you are already enrolled, call 1-888-335-8227), 5 a.m. to 5 p.m.,
Monday through Friday, or visit deltadentalins.com.
1 There
are certain limitations and exclusions to the benefits of this plan. Please refer to the Certificate of Insurance for an accurate and
complete list of treatments and services not covered. To receive a Certificate of Insurance, call Delta Dental of California.
2 Plan
payment amounts are only a sample and are to be used for illustrative purposes only. Please refer to the Table of Allowances in the
Certificate of Insurance for an accurate and complete list of benefits and allowances. To receive a Certificate of Insurance, call Delta Dental
of California.