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Kaiser Permanente HMO Medical Plan Child
Dental Plan (Children Only)
When you and your dependents enroll within the Kaiser HMO medical plan, children will also
be enrolled within a child dental program administered by Kaiser and Delta Dental of California.
Child Dental Plan GOLD 80 HMO
3/30*+ CHILD DENTAL
(Only available for children
enrolled in the Kaiser HMO Plan)
In-Network
Calendar Year Deductible
None
Annual Plan Maximum
Child
Multichild
$350
$750
Diagnostic and Preventive Services
Includes: Oral Evaluations, Bitewing X-
rays, Prophylaxis Cleaning, Fluoride
treatments, Space Maintainers, Sealant
Repair
Plan pays 100%
Periodontics
Maintenance
Scaling and Root Planning
Surgery – Osseous
$30
$30
$265
Restorative
Fillings
Composite crowns – resin based
Crown - Porcelain
$25
$30
$300
Endodontics
Therapeutic pulpotomy
Root Canal- Anterior or Molar
$40
$195 - $300
Prosthodontics
Complete Denture
Reline Maxillary Denture “partial”
$300
$60
$90
Oral Maxillofacial Surgery
Extraction – erupted tooth/ exposed root
Surgical removal of erupted tooth
$65
$120
Orthodontics* (medically necessary only)
$350*
Standard Dental PPO
Helpful Tips:
Don’t forget your
dental cleanings!
Make sure to see an
in-network provider
Once you receive a
welcome kit, you can
schedule an
appointment
You can change your
selected network
dentist at anytime by
phone
If you require
specialty care, your
Delta Dental dentist
will coordinate it for
you
To find a dentist,
please call Delta
Dental at
800-422-4234
*Orthodontics includes medically necessary orthodontia only