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 Insurance Company
1130 Sanctuary Parkway
Suite 600
Alpharetta, GA 30009
(866) 496-2370
deltadentalins.com/stateofmontana
Claims AddressPO Box 1809
Alpharetta, GA 30023-1809