Health Care & Benefits Division

Dental Plan

Delta Dental is the State Plan's dental benefit administrator.  Active Employees, Legislators, and Retirees under age 65 on the State Benefit Plan must have dental coverage. Dental coverage is an optional benefit for Retirees over age 65 and eligible dependents. 

Group Number: 15855

 

Eligibility 

 Deductibles

 $50 per person / $150 per family per calendar year

 Deductibles are waived for Diagnostic & Preventive (D&P)

 Maximums*

 $1,800 per person per calendar year

 D&P counts towards maximum

 Waiting Periods    

 None for Basic, Major, or Prosthodontics services.

 

 

Benefits and Covered Services*

Delta Dental

PPO dentists**

Delta Dental

Premier dentists**

Non-Delta

Dental dentists**

 Diagnostic & Preventive Services (D&P)

 Exams, Cleanings, X-Rays, Sealants

100% 100% 100%

 Basic Benefits

 Fillings, Posterior Composites

80% 80% 80%

 Endodontics (Root Canals)

 Covered Under Basic Services 

80% 80% 80%

 Periodontics (Gum Treatment)

 Covered Under Basic Services

80% 80% 80%

 Oral Surgery

 Covered Under Basic Services

80% 80% 80%

 Major Benefits

 Crowns, Inlays, Onlays, Cast Restorations

50% 50% 50%

 Prosthodontics

 Bridges, Dentures, Implants

50% 50% 50%

 Implant Maximums

$1,500 Lifetime $1,500 Lifetime $1,500 Lifetime

 

* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees.

** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Dental PPO dentists.

 

 

 

 

Dental Resources

Delta Dental Logo

Delta Dental Insurance Company

1130 Sanctuary Parkway
Suite 600
Alpharetta, GA 30009

(866) 496-2370

deltadentalins.com/stateofmontana

Claims Address
PO Box 1809
Alpharetta, GA 30023-1809

 

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