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:

 
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%

 
Basic Restorative (A six month waiting period may apply)
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

 
80%

 
50%

 
Major Restorative (A 12 month waiting period may apply)
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)
* No benefits are available for the replacement of teeth missing prior to the member’s effective date of coverage.

 
50%

 
40%

 
Waiting Period: There is a six month waiting period on Type II services and a twelve month waiting period on Type III services. The waiting period may be waived for former Delta Dental of Massachusetts members under limited circumstances. In order for the waiting period to be waived, your coverage on a comparable plan would need to have terminated for no more than 60 days prior to enrollment in the Premier Individual Plan. A comparable plan must include substantially similar coverage. Members with an in-force dental plan will be subject to the waiting periods under this policy.

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.