Health Care & Benefits Division

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

 

 

Delta Dental Logo

Phone: (866) 496-2370

Mailing Address:

1130 Sanctuary Parkway
Suite 600
Alpharetta, GA 30009

Claims Mailing Address:
PO Box 1809

Alpharetta, GA 30023-1809

Website: deltadentalins.com/stateofmontana

App: Delta Dental Mobile App

Group Number: 15855

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