Plans for Retirees
Individual and Family Dental Plans for Retireesi
|
High maximum, three periodontal maintenance cleanings, and policy lifetime deductible. |
No waiting period and coverage that increases over the first two years you renew. |
100% coverage on most preventive care services and 50% on most major procedures. |
No guessing, fixed-out-of-pocket costs, no waiting periods or dollar maximums. |
|
|---|---|---|---|---|
|
Monthly Premium |
$62.75ii |
$54.45ii |
$50.85ii |
$40.70iii |
|
Monthly Premium |
$72.10ii |
$62.60ii |
$58.50ii |
$51.10iii |
|
Plan Year Maximum |
$2000 |
1st Yr, 2nd Yr, 3rd Yr |
$1000 |
None |
|
|
None |
None |
None |
None |
|
Deductible |
$100 Preventive Care |
$50 |
$50 |
None |
|
Office Visit Copay |
None |
None |
None |
None |
|
Preventive Care |
100% |
100% |
100% |
$65 Copay |
|
Fillings |
80% |
1st Yr, 2nd Yr, 3rd Yr |
50%iv |
$115 Copay |
|
Crowns |
50%v |
50%v |
50%v |
$740 Copayvi |
|
Root Canal |
50% |
50% |
50% |
$535 Copayvii |
|
Implants |
50% |
50% |
50% |
$2600 Copayvi |
|
Non-Surgical Extractions |
50% |
50% |
50% |
$115 Copay |
|
Surgical Extractions |
50% |
Not Covered |
Not Covered |
$230 Copay |
|
Periodontal Maintenance |
50%viii |
1st Yr, 2nd Yr, 3rd Yr |
50% |
Included in Preventive Care Visit |
|
Orthodontics |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
|
Annual Contract |
Yes |
Yes |
Yes |
Yes |
|
Waiting Period |
May Apply |
None |
May Apply |
None |
Premium PlanHigh maximum, three periodontal maintenance cleanings, and lifetime policy deductible. Monthly Premium |
|---|
Ascent PlanNo waiting period and coverage that increases over the first two years you renew. Monthly Premium |
|---|
Enhanced Plan100% coverage on most preventive care services and 50% on most major procedures. Monthly Premium |
|---|
Clear PlanNo guessing, fixed-out-of-pocket costs, no waiting periods or dollar maximums. Monthly Premium |
|---|
Not sure which dental plan is right for you? Try our new
Interactive Plan Finder
Plan Finder only for Individual and Family Dental Plans. Does not include DeltaVision® or Affordable Care Health Act Plans.
Individual DeltaVision® Plans
Choose from our standard DeltaVision® Essential Plan 150 or our premium DeltaVision® Brilliance 200 Plan, available to add to your new dental plan at checkout or to your current dental plan at any time.xi xii xiii
For more information about our DeltaVision® Plans or to add vision to your dental plan, please call us at 844-764-5350.
| DeltaVision® Brilliance 200 Plan |
DeltaVision® Essential 150 Plan |
|
|---|---|---|
| Monthly Premium Individual Starting Ratexiv |
$15.55 | $12.50 |
| WellVision Exam® Copay benefit frequency every 12 months |
$0 | $10 |
| Prescription Glasses (frames, lenses) Copay benefit frequency every 12-months |
$0 | $10 |
| Retail Frame Allowance included in prescription glasses benefit frequency every 12-months |
$200 | $150 |
| Costco/Walmart Frame Allowance | $110 | $80 |
| Lenses (single vision, lined bifocal and lined trifocal)
included in prescription glasses copay |
Covered | Covered |
| Polycarbonate Lens Enhancements for Children Copay included in prescription glasses copay |
$0 | $0 |
| Contact Lens Exam Copay Maximum fitting and evaluation |
$0 | $40 |
| Elective Contact Lenses Allowance in lieu of glasses |
$200 | $150 |
| Percentage Saved on Purchases over the Plan Allowance for Frames within 12 months of last WellVision® exam |
20% | 20% |
| Out-of-Network Providers |
Not covered | Not covered |
VSP, eyeconic.com, and WellVision Exam are registered trademarks of Vision Service Plan.
i. These are benefit highlights only. Monthly premiums shown are examples of monthly rates for subscriber-only in Washington, effective January 2024. 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. Individual 12-month contracted rate.
iii. Individual 12-month contracted rate for ages 51+. Actual rate may be lower depending on age.
iv. Excludes back teeth tooth-colored fillings.
v. A predetermination is suggested. Clinical requirements must be met, crowns covered at 50% per tooth every seven years.
vi. A predetermination is suggested. Clinical requirements must be met, 1 crown per person per 12-month policy period. 1 implant per person per 12-month policy period.
vii. 2 teeth in 12 months after purchase or renewal, once per tooth every two years after.
viii. No waiting period.
ix. $1500 lifetime maximum with 12-month waiting period.
x. For Orthodontia covered procedures a 12-month waiting period applies. This means that DDWA will not pay towards any of these procedures until the covered members have been enrolled in this policy for 12 continuous months. The waiting period for Orthodontia treatment will be waived for your family if all family members were covered under another insured dental plan with orthodontic coverage for at least 12 continuous months before you enrolled in this plan, but only if there was no more than a 63-day gap between the previous plan and this plan. Documentation is required to waive the 12-month waiting period.
xi. Eligibility: Vision benefits are only offered in conjunction with Delta Dental of Washington individual dental plans sold through Delta Dental Covers Me. All other eligibility requirements are shared with the dental plan.
xii. Administration: We make it easy to pair dental and vision benefits. Application, enrollment and billing processes are coordinated for your convenience through Delta Dental Covers Me.
xiii. Enrollment: You may enroll in vision benefits up to 2 months prior to the requested effective date. After your application is approved, your coverage starts the first day of the month and continues for 12 months.
xiv. These are benefit highlights only. Monthly premiums shown are examples of monthly rates for subscriber-only in Washington, effective January 2024. 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 pricings, please visit DeltaDentalCoversMe.com.
