Monthly Premium Eastern/Western WA |
Plan year maximum |
Shared Maximum Benefit |
---|---|---|
Family Rate (2 adults (ages 26–50) + 2 children)i $123.50 / $168.10 Actual rate may be higher or lower depending on age |
None | None |
Deductible |
Office Visit Copay |
Preventive Care Cleanings, exams, x-rays and fluoride |
None | None | $65 Copay |
Fillingsi | Crownsii | Root Canal |
$115 Copay | $740 Copay 1 crown per person |
$535 Copay 2 teeth in 12 months after purchase or renewal, once per tooth every two years after |
Non-Surgical Extractions | Periodontal Maintenance | Orthodontics |
$115 Copay | Included in Preventive Care Visit | Not Covered |
Annual Contract | Waiting Periods | |
None | None |
This Plan | |||
---|---|---|---|
Clear Plan | Enhanced Plan | Ascent Plan | |
Monthly Premium Family Rate (2 adults + 1 or more children) |
Eastern WA / Western WA $123.50 / $168.10i for 2 adults (ages 26-50) + 2 children Actual rate may be higher or lower depending on age |
Eastern WA / Western WA $157.70 / $181.25i |
Eastern WA / Western WA $171.50 / $197.10i |
Plan Year Maximum per person |
None | $1000 | 1st Year, 2nd Year, 3rd Year $1000/$1250/$1500 |
Shared Maximum Benefit | None | None | None |
Deductible | None | $50 | $50 |
Office Visit Copay | None | None | None |
Preventive Care Cleanings, exams, x-rays, and fluoride |
$65 Copay |
100% | 100% |
Fillings | $115 Copay |
50% Excludes back teeth toothcolored fillings |
1st Year, 2nd Year, 3rd Year 50%/60%/70% |
Crowns | $740ii Copay 1 crown per person |
50%ii | 50%ii |
Root Canal | $535 Copay 2 teeth in 12 months after purchase or renewal, once per tooth every two years after |
50% | 50% |
Non-Surgical Extractions | $115 Copay |
50% | 50% |
Periodontal Maintenance | Included in Preventive Care Visit | 50% | 1st Year, 2nd Year, 3rd Year 50%/60%/70% |
Orthodontics | Not Covered | Not Covered | Not Covered |
Annual Contract | Yes | Yes | Yes |
Waiting Periods | None | May Apply | None |
i These are benefit highlights only. Monthly premiums shown are examples of monthly rates for subscriber-only in Washington, effective January 2023. Actual rates may vary (higher or lower) based on plan choice, your age, your location, number of people insured, their age, and relationship to you. For full details of plan, benefits, and pricing, please visit DeltaDentalCoversMe.com.
ii Clinical requirements must be met, crowns covered at 50% per tooth every seven years.