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Page 1 of 2 DK-1 Effective January 1, 2026- December 31, 2026 Dental II Deductible (Per Calendar Year; applies to all services unless otherwise indicated) None Benefit Maximum per Calendar Year $2,000 Dental Office Visit Charge – Per visit $10 Preventive and Diagnostic Services (not subject to or counted toward the deductible or benefit maximum) – includes oral examinations and x-rays, teeth cleaning (prophylaxis), fluoride treatments, instruction in the care of your teeth and gums, and prescribed space maintainers No additional charge Minor Restoration Services – includes routine fillings, plastic and stainless steel crowns No additional charge Simple Extractions No additional charge Oral Surgery Services No additional charge Periodontics – includes diagnosis, evaluation, and treatment of disease of the gums, including scaling and root planing No additional charge Endodontics – includes root canal and related therapy, including diagnosis and evaluation No additional charge Major Restoration Services – includes gold or porcelain crowns, inlays, bridge abutments and pontics $45 for each Removable Prosthetic Services – Full and partial dentures Relines Rebases $95 for each partial denture, $65 for each full denture $25 $25 Teledentistry - Telephone and video visits $0 Orthodontics Not covered Implants 50% up to benefit maximum PLEASE NOTE: ♦ You will be charged a $50 fee when you miss a dental appointment without calling in advance to cancel. ♦ You pay $25 for nitrous oxide. ♦ You pay 35% of charges for a custom lab made occlusal nightguard. Limit of 1 custom lab made occlusal nightguard every 5 years. Kaiser Permanente offers a high quality, lower-cost over the counter SOVA occlusal nightguard option to members at $20 per occlusal nightguard. The over-the-counter option is available same day. EXCLUSIONS The following are not covered: ---PAGE BREAK--- Page 2 of 2 DK-1 ♦ Service not approved by a Kaiser Permanente dentist. Kaiser Permanente does not pay for unauthorized services from dentists or facilities not affiliated with Kaiser Permanente, except as indicated under “Emergency Treatment.” ♦ Conditions covered by workers’ compensation or that are the employer’s responsibility. ♦ Procedures not generally and customarily available in the service area. ♦ Surgery to correct malocclusion or temporomandibular joint disorders; treatment for problems of the jaw joint, including temporomandibular joint and craniomadibular disorders; and treatment of conditions of the joint linking the jaw bone and skull and of the complex of muscles, nerves, and other tissues related to that joint. ♦ Restorative or reconstructive treatment for specific congenital or developmental malformations. ♦ Full-mouth reconstruction and occlusal rehabilitation including appliances, restorations, and procedures needed to alter vertical dimension or occlusion or to splint or correct attrition or abrasion. ♦ Cosmetic services. ♦ Prescription Drugs. ♦ Experimental or investigational services. ♦ Orthodontic services. ♦ More than two visits for routine teeth cleaning (oral prophylaxis) in any twelve consecutive month period. ♦ Conditions covered by government agencies or programs other than Medicaid. ♦ Genetic testing. ♦ Dental implants, including bone augmentation and fixed or removable prosthetic devices attached to or covering the implants; all related services, including diagnostic consultations, impressions, oral surgery, placement, removal, and cleaning; and services associated with postoperative conditions and complications arising from implants. ♦ Removal and replacement, with alternative materials, of clinically acceptable material or restorations for any reason except the pathological condition of the tooth or teeth. ♦ General anesthesia and intravenous sedation. ♦ Medical, hospital, and certain dental services. ♦ Work in progress before your coverage is effective. ♦ Replacement of prefabricated, non-cast crowns, including stainless steel crowns, that were not placed by a Kaiser Permanente dentist. ♦ Repair or replacement of fixed prosthetics or removable prosthetic appliances that are less than five years old. This summary provides a brief description of your dental plan benefits. Any errors or omissions are unintentional. Plan is subject to exclusions and limitations. A complete list of the exclusions and limitations is included in the Evidence of Coverage (EOC). EOCs are available upon request or you may go to kp.org/plandocuments. Questions? Call Member Services (M-F, 8 am-6 pm) or visit kp.org Portland area: [PHONE REDACTED] All other areas: 1-[PHONE REDACTED] TTY.711. Language Interpretation Services, all areas 1-[PHONE REDACTED] This is not a contract. This benefit summary does not fully describe your benefit coverage with Kaiser Foundation Health Plan of the Northwest. For more details on benefit coverage, claims review, and adjudication procedures, please see your EOC or call Member Services. In the case of a conflict between this summary and the EOC, the EOC will prevail.