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
  • Through age 15: unrestored permanent molars, once every 4 years per tooth
  • Ages 16-19: for recent cavity that is at risk for decay
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

  • Front teeth: Once every 24 months, per surface per tooth
  • Back teeth: Single surface only
Temporary filling Once per tooth
Stainless steel crown Once every 24 months per tooth

Oral Surgery

  • Simple or surgical extractions
  • Not covered if performed in surgical day care or hospital setting

Periodontics

  • Scaling and root planing once in 24 months, per quadrant
  • Not covered if performed in surgical day care or hospital setting

Endodontics

  • Root canal: Once per tooth
  • Vital pulpotomy: Limited to deciduous teeth

Prosthetic Maintenance

  • Bridge or denture repair: Once every 12 months, same repair
  • Rebase or reline of dentures: Once every 36 months
  • Recement of crowns and onlays: Once per tooth

Emergency dental care

  • Minor treatment for pain relief: Three occurrences in 12 months
  • General anesthesia: Allowed with covered surgical services only

 

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
  • Once per abutment only when surgical implant is benefitted
  • Once every 60 months per implant

 

Orthodontic Care (no deductible)
Covered Services Conditions Plan Payment
Standard High

Orthodontic treatment

  • To age 19

 

50% of Covered Expenses

$1,500 lifetime maximum for each covered person

50% of Covered Expenses

$2,000 lifetime maximum for each covered person