Delta Dental Plan of Iowa
Benefit Summary
hawk-i

Product: DeltaPremier USA DEDUCTIBLE COINSURANCE BENEFIT PERIOD MAX
BENEFITS CATEGORIES $0   $1,000
Check Ups and Teeth Cleaning
(Diagnostic and Preventive Services)
  • Dental Cleaning
  • Oral Evaluations
  • Fluoride Applications(to age 19)
  • X-rays
  • Sealant Application (to age 19)
  • Space Maintainers
 Waived 0% Yes
Cavity Repair and Tooth Extractions
(Routine and Restorative Services)
  • Emergency Treatment
  • General Anesthesia/Sedation
  • Restoration of Decayed or Fractured Teeth
  • Limited Occlusal Adjustment
  • Routine Oral Surgery
 Waived 0% Yes
Root Cancals
(Endodontic Services)
  • Apicoectomy
  • Direct Pulp Cap
  • Pulpotomy
  • Retrograde Fillings
  • Root Canal Therapy
 Waived 0% Yes
Gum and Bone Diseases
(Periodontal Services)
  • Conservative Procedures (Non-Surgical)
  • Complex Procedures (Surgical)
  • Maintenance Therapy
 Waived 0% Yes
High Cost Restorations
(Cast Restorations)
  • Cast Restorations
    • Crowns
    • Inlays
    • Onlays
    • Posts and Cores
 Waived 0% Yes
Dentures and Bridges
(Prosthetics - replacement of missing teeth)
  • Bridges
  • Dentures
 Waived 0% Yes
This is a general description of coverage. It is not a statement of your contract. Actual coverage is subject to terms and conditions specified in the benefit certificate itself and enrollment regulations in force when the benefit certificate becomes effective. Certain exclusions and limitations apply

** If a non-participating dentist is seen, no benefits will be paid unless services are to treat an emergency.