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Simply Blue Dental Benefits and Rates effective April 1, 2010 |
| Your Coverage* |
Plan A $250 annual deductible with $1,250 annual coverage maximum |
Plan B $100 annual deductible with $1,250 annual coverage maximum |
Plan C $100 annual deductible with $1,250 annual coverage maximum. Plan includes coverage for major restorative services. |
| Services covered immediately | |||
| Diagnostic/ preventive – routine exams and cleanings, including periodontal cleaning | 100% No deductible for routine check ups with a network dentist | 100% No deductible for routine check ups with a network dentist | 100% No deductible for routine check ups with a network dentist |
| Prosthodontic – (denture) repairs and adjustments | 80% | 80% | 80% |
| Basic restorative – fillings and sealants | 80% | 80% | 80% |
| Oral surgery – including extractions | 50% | 50% | 50% |
| Endodontic – root canals | 50% | 50% | 50% |
| Services covered after a 12-month period | |||
| Periodontal care – Treatment of gum disease | Not covered | Not covered | 50% |
| Crown and cast restorations | Not covered | Not covered | 50% |
| Prosthodontic – dentures, partial dentures and bridges | Not covered | Not covered | 50% |
| R a t e s | |||
| Plan A | Monthly | Quarterly | Annual |
| Subscriber age 18 – 49 | $21.14 | $63.42 | $253.68 |
| Subscriber age 50+ | $18.93 | $56.79 | $227.16 |
| Plan B | |||
| Subscriber age 18 – 49 | $34.26 | $102.78 | $411.12 |
| Subscriber age 50+ | $30.60 | $91.80 | $367.20 |
| Plan C | |||
| Subscriber age 18 – 49 | $45.83 | $137.49 | $549.96 |
| Subscriber age 50+ | $40.94 | $122.82 | $491.28 |
| * Coverage at non-network dentists is subject to the maximum amount payable (MAP), which is the maximum amount Delta Dental will pay for a given procedure. If you receive care from a non-network dentist who charges more than the MAP, you’ll be responsible for the additional amount. Delta Dental network dentists agree not to charge more than the MAP. |
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