Monthly Premium Eastern/Western WA |
Plan year maximum |
Shared Maximum Benefit |
---|---|---|
Family Rate (2 adults + 1 or more children)iv $157.70 / $181.25 |
$1000 per person | None |
Deductible |
Office Visit Copay |
Preventive Care Cleanings, exams, x-rays and fluoride |
$50 | None | 100% |
Fillingsi | Crownsii | Root Canal |
50% | 50% | 50% |
Non-Surgical Extractions | Periodontal Maintenance | Orthodontics |
50% | 50% | Not Covered |
Annual Contract | Waiting Periods | |
Yes | May Apply |
This Plan | |||
---|---|---|---|
Enhanced Plan | Clear Plan | Ascent Plan | |
Monthly Premium Family Rate (2 adults + 1 or more children) |
Eastern WA / Western WA $157.70 / $181.25iv |
Eastern WA / Western WA $123.50 / $168.10iv for 2 adults (ages 26-50) + 2 children Actual rate may be higher or lower depending on age |
Eastern WA / Western WA $171.50 / $197.10iv |
Plan Year Maximum per person |
$1000 | None | 1st Year, 2nd Year, 3rd Year $1000/$1250/$1500 |
Shared Maximum Benefit | None | None | None |
Deductible | $50 | None | $50 |
Office Visit Copay | None | None | None |
Preventive Care Cleanings, exams, x-rays, and fluoride |
100% | $65 Copay |
100% |
Fillings | 50%i | $115 Copay |
1st Year, 2nd Year, 3rd Year 50%/60%/70% |
Crowns | 50%ii | $740ii Copay 1 crown per person |
50%ii |
Root Canal | 50% | $535 Copay 2 teeth in 12 months after purchase or renewal, once per tooth every two years after |
50% |
Non-Surgical Extractions | 50% | $115 Copay |
50% |
Periodontal Maintenance | 50% | Covered in Preventive Care Visit | 1st Year, 2nd Year, 3rd Year 50%/60%/70% |
Orthodontics | Not Covered | Not Covered | Not Covered |
Annual Contract | Yes | Yes | Yes |
Waiting Periods | May Apply | None | None |
i Tooth-colored fillings on back teeth not included
ii Clinical requirements must be met, crowns covered at 50% per tooth every seven years.
iii Frequency limits per service apply as outlined in the Plan Features per benefit year table.
iv 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.