 With Delta Dental's
Individual and Family Plan, you save on dental
services – including routine cleanings, fillings,
crowns, X-rays, and much more.
Individual Plan enrollment
is for consecutive 12-month period(s) and monthly
premium payments are drafted by electronic funds transfer (EFT).
NOTE: If you enroll by the 10th of the month, coverage will begin the following month.
Monthly Premium Rates
Three-month premium payment required to enroll. | Green | Blue | Purple | Orange | Yellow | | Individual Dental Only | $44.32 | $41.72 | $30.53 | $25.20 | $16.27 | | Individual and Family Dental | $100.04 | $94.97 | $71.38 | $58.27 | $41.15 |
Coverage Options
Three-month premium payment required to enroll. | Green | Blue | Purple | Orange | Yellow |
|
Annual Maximum
(benefit year) |
$2000 |
$1500 |
$1000 |
$1000 |
$500 |
|
Deductible
(benefit year)
(per person, applies to all services) |
$50 |
$50 |
$75 |
$100 |
$25 |
|
| Type 1 Preventative Services |
100% |
100% |
90% |
70% |
100% |
Exams (limited to 2 per person in benefit year)
Cleanings (limited to 2 per person in a benefit year)
Fluoride Treatments (limited to 1 per person in a benefit period, under age 16)
Space Maintainers (under age 14)
Sealants (under age 15) |
|
|
|
|
Fluoride to age 18;
Sealants to age 19;
Space Maintainers are not covered
|
|
| Type 2 Basic Services |
50% |
50% |
50% |
50% |
100% |
Bitewing X–rays (limited to 1 set per
person in a benefit year)
X–rays (full mouth/ panoramic – limited to
1 per person in 60 months)
Simple Extractions (Not covered on Yellow Plan)
Fillings (Not covered on Yellow Plan) |
|
|
|
|
Extractions and fillings are not covered on the Yellow Plan. |
|
| Type 3A Major Services - 12 month waiting
period* |
50% |
50% |
40% |
30% |
Not Covered |
Gum Disease Treatment
Root Canals
Surgical
Extractions
General Anesthesia
Denture Relines and Rebases,
Adjustments
Repairs to Crowns, Dentures and Bridges |
|
|
|
|
|
|
| Type 3B Major Services – 24 month
waiting period* |
50% |
50% |
40% |
30% |
Not Covered |
Special Restorative
Crowns
Complete
and partial dentures
Fixed Bridgework |
|
|
|
|
|
|
| Monthly Premium |
|
|
|
|
|
| Individual Dental Only | $44.32 | $41.72 | $30.53 | $25.20 | $16.27 | | Individual and Family Dental | $100.04 | $94.97 | $71.38 | $58.27 | $41.15 |
* If within the past 60 days you have been covered under a Delta Dental group plan, and had at least 12 months of continuous coverage under that plan, waiting periods may be waived. Dentists, employees and dependents of dental offices do not qualify for this plan. For additional benefit information and limitations, please refer to the benefit booklet.
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