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
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
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.
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 (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.
