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Four Plan Options

Find the one that’s right for you! Let’s help you get the right plan!

 

**New for 2020** The Right Start 4 KidsSM (RS4K) program has been added to all four plan options. With RS4K, kids 12 and under receive coverage at 100% for all services covered under the plan when an in-network dentist is seen. Learn more by choosing a plan below.

 

Select how many people will be covered under your dental plan

Platinum Plan

individual coverage

$71.98
per month
Annual Maximum $2,500
Preventative (exams, cleanings) 100%
Basic (fillings, non-surgical extractions) 80%
Major (root canals, crowns, gum disease treatment) 70%
Implants 70%
Select

Gold Plan

individual coverage

$45.32
per month
Annual Maximum $1,500
Preventative (exams, cleanings) 100%
Basic (fillings, non-surgical extractions) 80%
Major (root canals, crowns, gum disease treatment) 50%
Implants N/A
Select

Silver Plan

individual coverage

$37.80
per month
Annual Maximum $1,000
Preventative (exams, cleanings) 100%
Basic (fillings, non-surgical extractions) 50%
Major (root canals, crowns, gum disease treatment) 50%
Implants N/A
Select

Bronze Plan

individual coverage

$32.59
per month
Annual Maximum $1,000
Preventative (exams, cleanings) 100%
Basic (fillings, non-surgical extractions) 80%
Major (root canals, crowns, gum disease treatment) N/A
Implants N/A
Select
Delta Dental PPO Dentist Delta Dental Premier Dentist Out-of-Network Dentist

Deductible

per person, per contract year; 

maximum of $150 per family.

Deductible does not apply to Diagnostic & Preventative Services.

$50 $50 $50
Benefit Categories Coinsurance paid by Delta Dental

Right Start 4 KidsSM (RS4K) - Applies to Kids 12 & Under

Kids 12 and under receive coverage at 100% for all services covered under the plan. Must see an in-network dentist or the plan's underlying contract applies including waiting periods, deductibles and coinsurance levels.

No waiting period, no deductible

Subject to plan's Annual Maximum, frequencies and limitations apply

100% 100% RS4K does not apply

Diagnostic & Preventative Services

check-ups, teeth cleanings, x-rays, sealants, fluoride, space maintainers

No waiting period, no deductible

100% 80% 80%

Basic Services

fillings, non-surgical extractions

6 month waiting period

80% 60% 60%

Major Services

dentures, root canals, gum disease treatment, crowns, bridges, surgical tooth extractions

12 month waiting period

50% 40% 40%

Implants

artificial teeth secured to the jaw, certain limitations may apply

12 month waiting period 

N/A N/A N/A

Occlusal Guards

tooth grinding & jaw clenching prevention

12 month waiting period

N/A N/A N/A

Certain services listed above have frequencies and limitations.

Exclusions and Limitations. For a complete list of exclusions and limitations, refer to your contract. Common non-covered services (exclusions) include the following: services which are available from any Federal or State government agency, or similar entity; services for injuries compensable under an automobile policy or worker’s compensation or similar employer coverage; cosmetic services (unless stated otherwise); services started prior to coverage; services that are not completed; administrative fees such as missed appointments; temporary services and procedures; duplicate dentures; prescription drugs, premedications and relative analgesia, including hospital, healthcare facility or medical emergency room charges; laboratory charges; anesthesia for restorative dentistry; preventive control programs; injuries or disease intentionally self-inflicted or occurring during or as a result of participation in riots or civil disobedience of any form, acts of war, or criminal activity; appliances or restorations to restore occlusion, splinting, equilibration, or replace tooth structure lost by attrition; restorations in conjunction with overdenture; services provided outside of the United States or Canada; dental implants (except for the Platinum plan); services related to TMJ; and services, supplies or treatments not specifically listed as covered in the member’s contract. Common limitations include: the least costly professionally accepted treatment to achieve reasonable functionality; costs of procedures necessary to prevent or eliminate oral disease and for appliances or restorations to replace missing teeth as allowed by the plan; frequency and combined service limitations related to restorations, individual crowns, prosthetic appliances, and periodontal procedures as identified within the contract; and other frequency, age or contractual limitations as specified. Additionally, for implant procedures, benefits are allowed for a bilateral partial if teeth are missing in both quadrants of the same arch. See Benefit Booklet for additional details on exclusions and limitations.

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