Premier-1

Benefit Maximum

Individual: $1000

Deductible

Individual: $50

Family: $150

Waiting Periods

Restorative & Other Basic Services: 6 months
Complex Dental Services: 12 months

Benefits Summary

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Network

Delta Dental Premier

The Delta Dental Premier network gives you access to the nation’s largest dental network, with 341,000 dentist locations all across the United States. In fact, three out of four dentists nationwide participate in this network.

Description

Our most comprehensive plan. With 96% of Massachusetts dentists participating in the Delta Dental Premier network, it’s the largest network of dentists available. Thanks to Delta Dental’s nationwide presence and negotiating strength, this super-flexible plan provides access to a Delta Dental dentist almost anywhere in the country — with up to 10% claims savings over traditional dental plans.

Coverage for diagnostic and preventive care, including routine checkups, restorative care, and oral surgery.
No claims forms to fill out when services are provided by a participating dentist.
No balance billing by participating dentists.
Coverage for services performed by non-participating dentists at a lower benefit level.

Coverage (In Network & Out of Network)

This plan has out of network coverage. Delta Dental will pay the same percentage of the allowable charges for covered services received in and out of network. If you choose to see a non-contracting dentist, you will be responsible for the difference between the plan’s allowable charges (what contracting dentists receive for payment from Delta Dental) and the dentist’s usual and customary fees (what the dentist charges cash-paying patients).Delta Dental will pay the same percentage of the allowable charges for covered services received in and out of network.

Diagnostic/Preventative

Category/Procedure	Frequency

Category/Procedure	Frequency
Bite-wing X-rays	Twice per twelve months

Category/Procedure	Frequency
Cleanings & Exams	Twice per twelve months

Category/Procedure	Frequency
Sealants	Once per 48 months

Category/Procedure	Frequency
Topical fluoride treatment	Twice per twelve months

In Network (We Pay)	Out of network (We Pay)

In Network (We Pay)	Out of Network (We Pay)
100%	100%

In Network (We Pay)	Out of Network (We Pay)
100%	100%

In Network (We Pay)	Out of Network (We Pay)
100%	100%

In Network (We Pay)	Out of Network (We Pay)
100%	100%

Restorative & Other Basic Services

Category/Procedure	Frequency

Category/Procedure	Frequency
Palliative (emergency) treatment of dental plan	Three times per twelve months

Category/Procedure	Frequency
Silver Fillings	Once per 24 Months

Category/Procedure	Frequency
Simple Tooth Extraction	As needed

Category/Procedure	Frequency
White Fillings (Front Teeth)	Once per 24 Months

In Network (We Pay)	Out of network (We Pay)

In Network (We Pay)	Out of Network (We Pay)
50%	50%

In Network (We Pay)	Out of Network (We Pay)
50%	50%

In Network (We Pay)	Out of Network (We Pay)
50%	50%

In Network (We Pay)	Out of Network (We Pay)
50%	50%

Complex Dental Services

Category/Procedure	Frequency

Category/Procedure	Frequency
Crowns	Once per 60 Months

Category/Procedure	Frequency
Dentures/Bridges	Once per 60 Months

Category/Procedure	Frequency
Periodontics	Once per 24 Months

Category/Procedure	Frequency
Root canals	Once per Tooth

In Network (We Pay)	Out of network (We Pay)

In Network (We Pay)	Out of Network (We Pay)
40%	40%

In Network (We Pay)	Out of Network (We Pay)
40%	40%

In Network (We Pay)	Out of Network (We Pay)
50%	50%

In Network (We Pay)	Out of Network (We Pay)
50%	50%