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Delta Dental Plans

Current Rates & Plan Overview

Individual Plan Options for Delta Dental Premier

 

Coverage Options:  

Option 1     

 

Option  2           

Annual Benefit Maximum

$1,000

 

$1,000

Coverage Options:  

Option 1

 

Option 2

Examples of Covered Services and Co-Insurance Levels:

 

 

 

Co-Insurance Type 1
Preventive (No Waiting Period)


Diagnostic Services

Oral exams (once every 6 months), Full-mouth X-rays (once every 60 months), Bitewing X-rays (once every 6 months), Single tooth X-rays (as needed)

Preventive

Cleanings (limited to 1 in a 6-month period), Periodontal cleanings (once every 3 months following active periodontal treatment, not to be combined with preventive cleanings)
Fluoride treatments (limited to 1 in a 6-month period, under age 19)

 100%

 

100%


Co-Insurance Type 2

Basic Restorative (A 6-month waiting period may apply)


80%

 

50%

Restorative

Silver fillings (once every 24 months per surface per tooth), White fillings (once every 24 months per surface per tooth on front teeth; single surface only on back teeth), Temporary fillings (once per tooth)

Endodontics

Root canal treatment

Oral Surgery*

Simple extractions, Surgical extractions

Periodontics*

Periodontal surgery, Scaling and root planning (once in 24 months, per quadrant)
* benefits not provided when rendered in a surgical day care or a hospital setting

 

 

 


Co-Insurance Type 3
Major Restorative (A 12-month waiting period may apply)


50%

 

40%

 

Prosthodontics*

Dentures (once within 60 months), Fixed bridges and crowns, when part of a bridge (once within 60 months)

Major Restorative

Crowns: when teeth cannot be restored with regular fillings (once within 60 months per tooth),
Endosteal Implant: in lieu of a three-unit bridge, and when the adjacent teeth do not require crowns (Once per 60 months per implant)

* No benefits are available for the replacement of teeth missing prior to the member’s effective date of coverage.

 

 

 


 


 

 

 

Monthly Premium for Subscribers that are age 50 and older:

Option 1   

 

Option  2     

Single:

$57.18

 

$45.93

Single +1:

$115.39

 

$92.71

Family:

$177.78

 

$142.83

Monthly Premium for subscribers that are under the age of 50

Option 1    

 

Option  2     

 

Single:

$54.06

 

$43.43

Single +1:

$101.88

 

$81.86

Family:

$173.61

 

$139.47


 


 

 

 


Above rates are valid for applications postmarked before December 10, 2016. Applications postmarked by the 10th of the
month will become effective the 1st of the following month. Examples: Applications postmarked June 10 will have an Effective Date of July 1. Applications postmarked June 11 will have an Effective Date of August 1.


Note: No benefits are available for the replacement of teeth missing prior to the member’s effective date of coverage.

Deductible: 

There is a $50 deductible per person up to $150 per family, on Basic and Major Restorative Services.
 

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  1. Additional terms and conditions do apply..
  2. Delta Dental of Massachusetts PPO and Premier insurance products are offered by Dental Service of Massachusetts, Inc.
    Delta Dental of Massachusetts EPO and DeltaCare insurance products are offered by DSM Massachusetts Insurance Company, Inc.
  3. May only be purchased and used by those who have primary residence in Massachusetts.
 
The information provided in this website is a summary and is intended for illustration purposes only. Please see your subscriber certification or other contract with Delta Dental of Massachusetts for complete details of your rights and obligations. Should any discrepancy arise, any such contract supersedes this illustration.