Dental Plan
Covered Dental Expenses
Covered dental expenses are the expenses that are eligible for payment under your Dental Plan. This section summarizes the plan’s covered services and expenses.
DEFINITION OF “COVERED EXPENSE”
Your Dental Plan will pay for covered expenses only. In order to be considered a covered expense, any dental service or supply that you or an eligible dependent receives must be:
- covered by the plan;
- necessary and appropriate for treatment of the dental condition;
- ordered by an eligible provider (see below);
- within the range of charges by other providers in your area for the same service; and
- not specifically excluded by the plan (see Exclusions and Limitations).
ELIGIBLE DENTAL CARE PROVIDERS
The plan covers dental services provided by eligible providers only. The plan does not cover services provided by an ineligible provider.
For plan purposes, an “eligible provider” is:
- a licensed dentist or dental surgeon; or
- a hygienist who is employed by a licensed dentist.
COVERED SERVICES AND PLAN BENEFITS
The charts below show the Dental Plan’s covered services and benefits. When you are reviewing these charts, keep in mind that:
- the maximum annual benefit payable from the plan is:
Standard Plan: $1,500 per person;
High Option Plan: $2,000 per person;
- the maximum lifetime benefit for orthodontic care is:
Standard Plan: $1,500 per person;
High Option Plan: $2,000 per person
- your cost will generally be lower if you use a network provider (as explained under Network Care in How Your Dental Plan Works), and
- your dentist should submit a treatment plan to Delta Dental if expenses for a given course of treatment are expected to exceed $300 (see Pre-Treatment Plan in How Your Dental Plan Works).
The Company has contracted with Delta Dental to process claims and assist in the day-to-day operation of your Dental Plan. If you have any questions concerning the plan’s covered services and expenses, you can contact Delta Dental Customer Service at 1-800-872-0500. You can also log on to their website at www.deltamass.com.
Preventive and Diagnostic Services (no deductible) | |||
Covered Services | Conditions | Plan Payment | |
Standard | High | ||
Comprehensive evaluation | Once every 60 months per dentist |
100% of Covered Expenses
|
100% of Covered Expenses |
Periodic oral exam | Twice per calendar year | ||
Full mouth X-rays | Once every 60 months | ||
Bitewing X-rays | Once every 6 months | ||
Single tooth X-ray | As needed | ||
Teeth cleaning | Twice per calendar year | ||
Periodontal cleaning | Once every 3 months following active periodontal treatment, not to exceed 2 cleanings in a calendar year if combined with preventive cleanings | ||
Fluoride treatment | Twice per calendar year, to age 19 | ||
Fluoride toothpaste | Administered in dentist’s office following periodontal surgery | ||
Space maintainers | To age 14 if required due to premature loss of teeth and not for replacement of primary or permanent anterior teeth | ||
Sealants |
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Chlorhexidine Mouthrinse | Administered in dentist’s office following scaling and root planing |
Basic Restorative Services (deductible applies) | |||
Covered Services | Conditions | Plan Payment | |
Standard | High | ||
Silver filling | Once every 24 months, per surface per tooth |
80% of Covered Expenses
|
90% of Covered Expenses
|
White filling |
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Temporary filling | Once per tooth | ||
Stainless steel crown | Once every 24 months per tooth | ||
Oral Surgery |
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Periodontics |
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Endodontics |
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Prosthetic Maintenance |
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Emergency dental care |
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Major Restorative Services (deductible applies) | |||
Covered Services | Conditions | Plan Payment | |
Standard | High | ||
Dentures | Once every 60 months |
50% of Covered Expenses
|
60% of Covered Expenses |
Fixed bridges and crowns | When part of a bridge: Once every 60 months | ||
Crowns | When teeth cannot be restored with regular fillings: Once every 60 months per tooth | ||
Endosteal implant |
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Orthodontic Care (no deductible) | |||
Covered Services | Conditions | Plan Payment | |
Standard | High | ||
Orthodontic treatment |
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50% of Covered Expenses $1,500 lifetime maximum for each covered person |
50% of Covered Expenses $2,000 lifetime maximum for each covered person |