Dental Comparison Tool—Benefits 2000

$0

$100 individual/$200 family

$0

$0

$0

You must choose a dentist in the DMO Managed Dental Network

You choose your own dentist. If you choose a Preferred Provider Organization (PPO) dentist, your expenses will be lower

You choose your own dentist. If you choose a Preferred Provider Organization (PPO) dentist or Delta Dental dentist in Connecticut, your expenses will be lower

You must choose a dentist within the DMO Managed Dental Network

You choose your own dentist. If you choose a Preferred Provider Organization (PPO) dentist, your expenses will be lower

100%

Please note: One flouride treatment allowed per calendar year to age 18

• 100%
• Annual deductible does not apply

Please note: No frequency limitations on flouride treatments allowed per calendar year to age 18

100%

Please note: No frequency limitation on flouride treatments allowed per calendar year to age 19

100%

Please note: One flouride treatment allowed per calendar year to age 18

First $250 of covered expenses paid at 100%; next $1,500 of covered expenses paid at 80%

No maximum benefit

$750 per participant annual maximum

Up to $1,700 per member per year (not including orthodontia)

No maximum benefit

• $1,450 per family on $1,750 of annual eligible expenses (including orthodontics)
• You can submit a maximum of $300 in eligible expenses for vision care as part of the $1,750 annual plan maximum

• 60%-80%; referral required
• Dental implants are not covered

50%

50%

• 100%; referral required
• Dental implants are not covered

Combined with above

• 50% and no lifetime maximum per dependent child
• The orthodontic appliance must be in place prior to the child's 19th birthday to obtain any orthodontic benefit

• 50% and maximum reimbursement of $1,000 per lifetime per eligible dependent child
• The orthodontic appliance must be in place prior to the child's 19th birthday to obtain any orthodontic benefit

• 50%, up to $1,700 per dependent child per lifetime and is in addition to the maximum reimbursement for other dental services (orthodontic coverage is separate from annual dental maximum of $1,700 per person)
• The orthodontic appliance must be in place prior to the child's 18th birthday to obtain any orthodontic benefit regardless of eligibility for other benefits because of student status over age 18
• Payment for orthodontic treatment is made in 2 equal installments, paid approximately 12 months apart

• 50% up to a maximum out-of-pocket limit of $1,250 per dependent child
• The orthodontic appliance must be in place prior to the child's 19th birthday to obtain any orthodontic benefit
• For orthodontia, limited to one course of treatment per lifetime (does not cover orthodontic procedures if appliance was installed prior to the effective date of dental coverage)
• If you switch from a non-DMO option while orthodontic treatment is in progress, the orthodontic treatment can continue with the original dentist, even though he or she may not be a participating DMO dentist. The DMO will reimburse the lesser of the remaining charges or $800

• Orthodontia for dependent children combined with above
• The orthodontic appliance must be in place prior to the child's 18th birthday to obtain any orthodontic benefit regardless of eligibility for other benefits because of student status over age 18
• Must file a plan of treatment including the total charge for the orthodontic services and the payment arrangement between you and your dentist when you first file for benefits. You will be reimbursed for the services only after the services have been performed. Also, future reimbursement will only be made for expenses according to the original contract you presented with the first claim. Pre-payment or delayed payment does not change the date of the service for claim consideration

60%

50%

• 50%
• This option won’t cover the replacement of an appliance within 5 years from the installation unless either the original appliance can’t be made serviceable

60%

Combined with above

60%-80%

50%

• 80%
• Replacement of crowns, inlays, or gold restorations are covered only after 5 years from the initial placement that occurred while you were covered by the Plan. Note: Implant supported crowns will be reimbursed at the same level as implants (i.e., 50%)

60% for selected major restorative services

Combined with above

• If you enroll while orthodontic treatment is in progress, orthodontic treatment may continue but with limited coverage
• Removal of tissue-impacted teeth is generally covered under the Dental Benefits Program. Surgical removal of bony-impacted teeth is generally covered under your Medical Benefits Program and may be covered under certain dental options (PCP referral is needed for POS and HMO options). Consult your carrier for additional information
• FOC requirement to choose in- or out-of-network

• You can call for a pre-treatment review for dental work expected to exceed $350
• Removal of tissue-impacted teeth is generally covered under the Dental Benefits Program. Surgical removal of bony-impacted teeth is generally covered under your Medical Benefits Program and may be covered under certain dental options (PCP referral is needed for POS and HMO options). Consult your carrier for additional information
• Implant supported crowns will be reimbursed at the same level as implants (i.e., 50%)

Removal of tissue-impacted teeth is generally covered under the Dental Benefits Program. Surgical removal of bony-impacted teeth is generally covered under your Medical Benefits Program and may be covered under certain dental options. (PCP referral is needed for POS and HMO options.) Consult your carrier for additional information

Removal of tissue-impacted teeth is covered under the Dental Benefits Program. Surgical removal of bony-impacted teeth is generally covered under your Medical Benefits Program and may be covered under certain dental options. (PCP referral is needed for POS and HMO options.) Consult your carrier for additional information