Voluntary Dental Benefit Options Chart

Rates are guaranteed for one year from the initial effective date of coverage for groups effective July 2010 through June 2011. Dental Implant coverage is included in options 1, 2, 3, 4, 5, and 6.

Employers have a choice of nine benefit options.

Only one option may be offered to all employees. Employers may change options only on the anniversary of the original effective date each year. This is a brief description of features and benefits. Coverage is subject to the terms, conditions, limitations, and exclusions of the Voluntary Group Contract Benefits and Dental Plan Description Booklet.

Diagnostic and Preventive - Coverage A (No Waiting Period)

Diagnostic

  • Evaluations once in a 6-month period
  • Full mouth/panorex X-rays once in a 3-year period
  • Bitewing X-rays once each 12-month period
  • X-rays of individual teeth as necessary
  • Oral cancer screening once in a 12 month period

Preventive

  • Cleanings four times in a 12-month period
  • Fluoride twice in a 12-month period to age 19
  • Space maintainers to age 16
  • Sealants for children to age 19 on permanent molars once in a 3-year period
 100% 100% 100%
Basic - Coverage B (After a 6-Month Waiting Period1)

Restorative

  • Fillings amalgam (silver) and composite (white-anterior teeth only)

Oral Surgery

  • Extractions and other surgical procedures

Endodontics

  • Root canal therapy

Periodontics

  • Treatment of gum disease
  • Periodontal maintenance (cleaning)

Clinical Crown Lengthening
 

  • Once per lifetime per site

Denture Repair

  • Repair of removable dentures

Emergency Palliative Treatment

 80% 60% 60%
Major - Coverage C (After a 12-Month Waiting Period1)

Prosthodontics

  • Removable and fixed partial dentures (bridge)
  • complete denture
  • Rebase and reline (denture)
  • Crowns
  • Onlays
  • Implants
 50% 50% not covered
Lifetime Deductible Per Person/Family

(Applies to Coverage B and C services)

 $100/$300 $75/$225 $50/$150
Orthodontics - Coverage D (After a 24-Month Waiting Period1)

Orthodontics

  • Correction of crooked teeth for adults and children
 50% not covered not covered
Choose Your Option: Option 12 Option 2 Option 3 Option 42 Option 5 Option 6 Option 7 Option 8 Option 9
Diagnostic and Preventative (Coverage A), Basic (Coverage B), and Major (Coverage C) Calendar Year Maximum Per Person: $2,000 $1,500 $1,000 $2,000 $1,500 $1,000 $1,500 $1,000 $750
Orthodontics (Coverage D) Lifetime Maximum Per Person: $2,000 $1,500 $1,000 N/A N/A N/A N/A N/A N/A

Benefit percentages shown are based upon the actual charge submitted to a maximum of the participating dentist's approved fees, or Northeast Delta Dental's allowance for non-participating dentists.

1Waiting Periods apply from the effective date of each employee. If your business had a group dental coverage in force with another carrier immediately prior to the effective date of this Northeast Delta Dental program, each employee and their dependents' waiting periods for Coverage B, C, and D will be waived. This applies only to those individuals who enroll on the original effective date of this voluntary dental program; there must be no lapse in coverage between carriers. Dental services received prior to the satisfaction of applicable waiting periods do not apply toward satisfaction of the lifetime deductible.

2Carryover Benefit Options 1 and 4 include a carryover benefit feature that can extend your employees' annual benefit. Download the Carryover Benefit Flyer for additional information on this program.