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| Coverage Options |
Option 1 |
Option 2 |
Option 3 |
|
Annual Maximum
(benefit year) |
$1500 |
$1000 |
$1000 |
|
Deductible
(benefit year)
(per person, applies to all services) |
$50 |
$75 |
$100 |
|
| Covered Dental Services |
Option 1 |
Option 2 |
Option 3 |
|
| Type 1 Preventative Services |
100% |
90% |
70% |
Exams (limited to 2 per person in
benefit year)
Cleanings (limited to 2 per person in a benefit year)
Fluoride
Treatments (limited to 1 per person in a benefit period,
under age 16)
Space Maintainers (under age 14)
Sealants (under age 15) |
|
|
|
|
| Type 2 Basic Services |
50% |
50% |
50% |
Bitewing X-rays (limited to 1 set per
person in a benefit year)
X-rays (full mouth/ panoramic – limited to
1 per person in 60 months)
Simple Extractions
Fillings |
|
|
|
|
| Type 3A Major Services - 12 month waiting
period* |
50% |
40% |
30% |
Gum Disease Treatment
Root Canals
Surgical
Extractions
General Anesthesia
Denture Relines and Rebases,
Adjustments
Repairs to Crowns, Dentures and Bridges |
|
|
|
|
| Type 3B Major Services – 24 month
waiting period* |
50% |
40% |
30% |
Special Restorative
Crowns
Complete
and partial dentures
Fixed Bridgework |
|
|
|
|
Monthly Premium Rates
Three-month premium payment required to enroll
|
|
|
|
| Individual Only | $38.38 | $30.14 | $23.69 | | Individual + Family | $87.36 | $70.48 | $54.78 |
* If within the past 60 days you have been covered under a Delta Dental group plan, and had at least 12 months of continuous coverage under that plan, waiting periods may be waived.
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