Product_Family_DeltaCare

Benefit Maximum

Individual: $1250

Deductible

Individual: $100

Family: $300

Waiting Periods

Restorative & Other Basic Services: 6 months
Complex Dental Services: 18 months

Benefits Summary

Network

Delta Dental of Massachusetts

Description

Our most comprehensive plan. With 96% of Massachusetts dentists participating in the Delta Dental Premier network, it’s the largest network of dentists available. Thanks to Delta Dental’s nationwide presence and negotiating strength, this super-flexible plan provides access to a Delta Dental dentist almost anywhere in the country — with up to 10% claims savings over traditional dental plans.

Coverage for diagnostic and preventive care, including routine checkups, restorative care, and oral surgery.
No claims forms to fill out when services are provided by a participating dentist.
No balance billing by participating dentists.
Coverage for services performed by non-participating dentists at a lower benefit level.

Coverage (In Network & Out of Network)

This plan has out of network coverage. Delta Dental will pay the same percentage of the allowable charges for covered services received in and out of network. If you choose to see a non-contracting dentist, you will be responsible for the difference between the plan’s allowable charges (what contracting dentists receive for payment from Delta Dental) and the dentist’s usual and customary fees (what the dentist charges cash-paying patients).Delta Dental will pay the same percentage of the allowable charges for covered services received in and out of network.

Diagnostic/Preventive

Category/Procedure	Qualification	In Network (We Pay)	Out of Network (We Pay)
Bite-wing X-rays	Once per 6 months	100% under 19, 100% 19 and older	100% under 19, 100% 19 and older
Cleaning & Exams	Once per 6 months	100% under 19, 100% 19 and older	100% under 19, 100% 19 and older
Sealants	Once per 48 months	100% under 19, 100% 19 and older	100% under 19, 100% 19 and older
Topical fluoride treatment	Once per 6 months	100% under 19, 100% 19 and older	100% under 19, 100% 19 and older

Restorative & Other Basic Services

Category/Procedure	Qualification	In Network (We Pay)	Out of Network (We Pay)
Palliative (emergency) treatment of dental plan	Three times per twelve months	50% under 19, 50% 19 and older	50% under 19, 50% 19 and older
Silver fillings	Once per 24 months	50% under 19, 50% 19 and older	50% under 19, 50% 19 and older
Simple tooth extraction	As needed	50% under 19, 50% 19 and older	50% under 19, 50% 19 and older
White fillings (front teeth)	Once per 24 months	50% under 19, 50% 19 and older	50% under 19, 50% 19 and older

Complex Dental Services

Category/Procedure	Qualification	In Network (We Pay)	Out of Network (We Pay)
Crowns	Once per 60 months	40% under 19, 40% 19 and older	40% under 19, 40% 19 and older
Denture/Bridges	Once per 60 months	40% under 19, 40% 19 and older	40% under 19, 40% 19 and older
Periodontics	Once per 24 months	50% under 19, 50% 19 and older	50% under 19, 50% 19 and older
Root Canals	Once per tooth	50% under 19, 50% 19 and older	50% under 19, 50% 19 and older