Basic Dental Plans: 2016 Features & Benefit Details. Small Business Family and Adult plans. Massachusetts Family Basic Dental Plan

Basic Dental Plans: 2016 Features & Benefit Details Small Business Family and Adult plans PLAN NAME Delta Dental Premier Family Value EPO Altus Den...
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Basic Dental Plans: 2016 Features & Benefit Details Small Business Family and Adult plans

PLAN NAME

Delta Dental Premier Family Value EPO

Altus Dental Low Plan

Dental Blue PPO Low Plan

Massachusetts Family – Basic Dental Plan

Guardian Family Essentials

MetLife Preferred Program

DentalGuard Preferred

No

No

Premier

Delta Dental PLAN NETWORK

EPO

Premier

Is this a smaller network?

Yes

No

Altus Dental Participating Dentists No

Is there out-of-network coverage?

Dental Blue PPO Yes Yes

Annual deductible – one enrollee*

$50

Annual deductible – family*

$150

Maximum annual out-of-pocket – child under 19 yrs. Maximum annual out-of-pocket – 2 or more children under 19 yrs. Maximum annual benefit – adults 19 and over only

$350 $700 $750

*Waived for diagnostic and preventive services and for some plans, medically necessary orthodontia.

Page 1 of 9

Basic Dental Plans: 2016 Features & Benefit Details Small Business Family and Adult plans

Delta Dental Premier Family Value

PLAN NAME

EPO

Altus Dental Low Plan

Dental Blue PPO Low Plan

Massachusetts Family – Basic Dental Plan

Guardian Family Essentials

Premier

Type I services: Preventive & Diagnostic Dental Co-insurance percentage (what you pay)

All ages in-network 0% out-of-network 20% For enrollees under 19 yrs.

Benefit  Comprehensive Evaluation  Periodic Oral Exams  Oral Evaluation under 3 Years of Age  Teeth Cleaning  Limited Oral Evaluation  Full Mouth X-Rays  Panoramic X-Rays  Single Tooth X-Rays

Standard Limits 1 per patient per location per lifetime

2 Procedures per patient per 12 months 2 Procedures per patient per 12 months 1 Procedure per patient per 36 months

 Bitewing X-Rays

Covered 2 Procedures per patient per 12 months

 Fluoride Treatments

1 Procedure per 3 months

 Space Maintainers

Covered 1 Procedure per tooth per 36  Sealants months *Not combined with other covered exam procedures.

 means that the limits are the standard limits or the equivalent. 





2 Procedures per patient per 12 months



















*















































4 Procedures per 12 months 1 Procedure per area per lifetime













Page 2 of 9

Basic Dental Plans: 2016 Features & Benefit Details Small Business Family and Adult plans

Delta Dental Premier Family Value

PLAN NAME

EPO

Altus Dental Low Plan

Dental Blue PPO Low Plan

Massachusetts Family – Basic Dental Plan

Guardian Family Essentials

Premier For enrollees 19 yrs. and over

Benefit  Comprehensive Evaluation  Periodic Oral Exams  Teeth Cleaning

Standard Limits 

 Limited Oral Evaluation

1 per patient per 60 months 2 Procedures per patient per 12 months 2 Procedure/s per patient per 12 months

 Full Mouth X-Rays  Panoramic X-Rays

1 Procedure per patient per 60 months

 Single Tooth X-Rays  Bitewing X-Rays

Covered 2 Procedures per patient per 12 months

 Periodontal Cleaning

1 Procedure per patient per 3 months

 means that the limits are the standard limits or the equivalent. 2 Procedures per   patient per 12 months



















*









1 Procedure per patient per 36 months

1 Procedure per patient per 36 months



























4 Procedures per patient per 12 months**

2 Procedures per 12 months

Not covered

Not covered as Type I, see Type II for coverage details

Covered as Type II Service



 Covered (some restrictions  Palliative Care may apply) *Not combined with other covered exam procedures. **Less the number of teeth cleanings [prophylaxis] received during that 12 month period.

Page 3 of 9

Basic Dental Plans: 2016 Features & Benefit Details Small Business Family and Adult plans

Delta Dental Premier Family Value

PLAN NAME

EPO

Altus Dental Low Plan

Dental Blue PPO Low Plan

Massachusetts Family – Basic Dental Plan

Guardian Family Essentials

Premier

Type II services: Basic Restorative Co-insurance percent (what you pay)

All ages: in-network 25% out-of-network 45% For enrollees under 19 yrs.

Benefit

Standard Limits

 Periodontal Cleaning  Silver Fillings  White Fillings

1 Procedure per patient per 3 months 1 Procedure per tooth per surface per 12 months

 Temporary Fillings  Prefabricated Stainless Steel Crowns

Not covered

 Periodontal Scaling and Root Planing  Root canals on permanent teeth  Apicoectomy**

1 Procedure per quadrant per 36 months

 Vital Pulpotomy  Simple Extractions  Surgical Extractions  Anesthesia  Palliative Care

Covered

1 Procedure per tooth per lifetime 1 Procedure per tooth per lifetime Covered (pre-authorization may be required) Covered (some restrictions may apply) Covered (some restrictions may apply)

 means that the limits are the standard limits or the equivalent. 4 Procedures per Not covered patient per 12 § months

Not covered

*





*



1 Procedure per tooth per 60 months**

Covered

Not covered

Covered

Not Covered







1 proedure per tooth per lifetime

Not Covered

1 Procedure per quadrant per 24 months





















Covered

Covered

Covered

Covered





























 Page 4 of 9

Basic Dental Plans: 2016 Features & Benefit Details Small Business Family and Adult plans  Periodontal Surgery  Bridge or Denture Repair  Rebase or Reline Dentures  Recement Crowns and Onlays

1 Procedure per quadrant per 36 months

Covered 1 Procedure per patient per 24 month











**

1 Procedure per patient per 12 months***

1 Procedure per patient per 12 months

1 Procedure per 12 months









**

1 Procedure per arch per 24 months

**

1 Procedure per patient per lifetime***

1 Procedure per tooth per patient per lifetime***

1 Procedure per tooth per 12 months



Covered

* For white fillings, paid as an alternate benefit on restorations on molar teeth, MetLife. *Will not pay more for a composite restoration (white filling) on a primary (deciduous) posterior tooth than an amalgam restoration (silver filling), Delta Dental. **No limitation for this procedure, MetLife only. ***6 months after initial placement. §

Less the number of teeth cleanings [prophylaxis] received during that 12 month period.

Page 5 of 9

Basic Dental Plans: 2016 Features & Benefit Details Small Business Family and Adult plans

Delta Dental Premier Family Value EPO

Benefit  Silver Fillings  White Fillings

Standard Limits 1 Procedure per tooth per surface per 24 months

Altus Dental Low Plan

Dental Blue PPO Low Plan

Massachusetts Family – Basic Dental Plan

Guardian Family Essentials

Premier

 means that the limits are the standard limits or the equivalent. 





1 Procedure per tooth per 60 months*

1 procedure per tooth per lifetime

1 procedure per tooth per lifetime



* Covered

 Temporary Fillings  Prefabricated Stainless Steel Crowns

Not covered Covered (pre-authorization may be required)

 Periodontal Scaling and Root Planing  Root canals on permanent teeth

1 Procedure per quadrant per 24 months









1 Procedure per quadrant per 24 months

1 Procedure per tooth per lifetime 1 Procedure per tooth per lifetime Covered 1 Procedure per tooth per lifetime (pre-authorization may be required) Covered (some restrictions may apply)

















Covered



Not covered





























3 Procedures per 12 months







Covered at Type I Service











 Apicoectomy*  Vital Pulpotomy  Simple Extractions  Surgical Extractions  Anesthesia

Covered (some restrictions may apply) 1 Procedure per quadrant  Periodontal Surgery per 36 months *No limitation for this procedure, MetLife only.  Palliative Care



Not covered

Page 6 of 9

Basic Dental Plans: 2016 Features & Benefit Details Small Business Family and Adult plans 1 Procedure per patient per ***  Bridge or Denture Repair 12 months  Rebase or Reline 1 Procedure per arch per 36 months Dentures 1 Procedure per 36 months  Recement Crowns and 1 Procedure per tooth per *** Onlays lifetime **For white fillings, paid as an alternate benefit on restorations on molar teeth.







Covered





***

1 Procedure per arch per 24 months





1 Procedure per tooth per 12 months

Covered

***6 months after initial installation.

Page 7 of 9

Basic Dental Plans: 2016 Features & Benefit Details Small Business Family and Adult plans

Delta Dental Premier Family Value

PLAN NAME Type III services: Major Restorative Co-insurance percent (what you pay)

EPO Premier Under 19: in-network 50% out-of-network 70%

Altus Dental Low Plan

Dental Blue PPO Low Plan

Massachusetts Family – Basic Dental Plan

Guardian Family Essentials

19 and over: Not covered

For enrollees under 19 yrs. Benefit  Waiting period  Crown, resin  Porcelain/ceramic crowns  Porcelain fused to metal/noble/high noble crowns  Partial & complete dentures

 means that the limits are the standard limits or the equivalent.

Standard Limits

None 1 Procedure per tooth per 60 months 1 Procedure per tooth per 60 months





















1 Procedure per tooth per 60 months











1 Procedure per patient per 84 months

1 Procedure per patient per 84 months

1 Procedure per patient per 84 months



*



*

1 Procedure per arch per 84 months

 Fixed Bridges and  Crowns (when part of a 1 Procedure per tooth per 60 bridge) months *Covered only if no other less expensive adequate dental service is available.

 *

Page 8 of 9

Basic Dental Plans: 2016 Features & Benefit Details Small Business Family and Adult plans

Delta Dental Premier Family Value

PLAN NAME Type IV services: Orthodontia Co-insurance percent (what you pay)

EPO Premier Under 19: in-network 50% out-of-network 70%

Altus Dental Low Plan

Dental Blue PPO Low Plan

Massachusetts Family – Basic Dental Plan

Guardian Family Essentials

19 and over: Not covered

For enrollees under 19 yrs. Benefit  Medically necessary orthodontia

Standard Limits 1 Procedure per patient per lifetime (pre-authorization is required)

 means that the limits are the standard limits or the equivalent. 









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