Dental Plan
Delta Dental is the State Plan’s Dental Plan third party administrator and processes dental claims for the State Plan. Dental coverage is an option benefit.
Eligibility
Employees, Legislators, Retirees, COBRA participants, and eligible spouse/domestic partners and child(ren). For detailed information on who’s eligible for the State Plan, please refer to the Wrap Plan Document.
coverage
|
Deductible* |
$50 Per Enrollee per Calendar Year $150 Per family per Calendar Year |
| Maximum Amount Plan Pays Per Member |
$1,800 per Member per Calendar Year $1,500 Lifetime for Implant Benefits |
| Waiting Periods |
None for Basic, Major, or Prosthodontics services |
*Diagnostic & Preventive Benefits are not subject to the deductible.
Deductibles and maximums will be based upon a Plan Year, which is January 1 through December 31.
Benefits and Covered Services
|
Preferred Provider* (PPO Dentist) |
Premier Dentists* |
Out-of-Network Dentist* |
|
|---|---|---|---|
|
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 |
*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.
Note: 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.
Dental Resources
Phone: (866) 496-2370
1130 Sanctuary Parkway
Suite 600
Alpharetta, GA 30009
Alpharetta, GA 30023-1809
Website: deltadentalins.com/stateofmontana
App: Delta Dental Mobile App
Group Number: 15855