Home / Individuals / Individual Plan / Rates and Coverage

Rates and Coverage

Delta Dental's two Individual and Family plan options offer the same coverage, but slightly different rate structures so you can choose the option that works best for you. Both plans are ACA Marketplace-certified and offer ACA-compliant pediatric oral services.

Standard Plan

Options

Monthly Premium*

Annual Premium

Individual $32.78 $393.36
Individual & 1 Dependent $63.76 $765.12
Individual & 2 or more Dependents $112.46 $1,349.52

 

Co-pay Plan**

Options

Monthly Premium*

Annual Premium

Individual $29.99 $359.88
Individual & 1 Dependent $58.69 $704.28
Individual & 2 or more Dependents $105.97 $1,271.64

Rates valid through 12/31/17
*For monthly billing option, add $1.50 monthly transaction fee. Avoid this fee by paying annually.
**Co-pay option requires $20 office visit co-pay for diagnostic & preventive services for adults.

 

Who is Eligible:

Membership is open to all Tennessee adult residents and their dependents. Pediatric benefits are for youth up to age 19. If you have been covered by a Delta Dental individual policy and you drop your coverage, you cannot enroll for another 12 months and waiting periods will apply. 

Effective Date:

Your benefits will become effective the first day of the month following receipt of application and initial premium if received on or before the 15th of the month. If received after the 15th, effective date will be the first of the following month.

Example: If payment and application are received between January 1 and January 15, the member’s effective date is February 1. If payment and application are received January 16 through January 31, the effective date is March 1.

 

Adult Benefits

Pediatric Benefits

Out-of-Pocket Limit N/A

Out-of-Pocket Limit
(for children 18 and younger)

$350 per individual child; $700 for two or more
Contract Year Maximum Benefits $1,000 Contract Year Maximum Benefits N/A
Deductible (Contract year; applies to all services except Preventive services) Per person/family max. $50/$150 Deductible  (Contract year; applies to all services except Preventive services) Per person/family max. $50/$150

Covered Dental Services

Preventive Services
- Exams^
- Cleanings^
- Bitewing X-rays (limited to one set per person in a 12-month period)
- X-rays (full mouth/panoramic – limited to 1 per person in 36-months)
100% in network

80% Delta Dental Premier® & Out-of-network
Preventive Services
- Exams^
- Cleanings^
- Bitewing X-rays (limited to two sets per person in a 12-month period)
- X-rays (full mouth/panoramic – limited to one per person in a 60-month)
- Fluoride Treatments^
- Space Maintainers
- Sealants (once in any 36-month period)
90% in network

70%  Delta Dental Premier® & Out-of-network
Basic Services
- Fillings/Amalgams*
- Simple Extractions
80% in network

60% Delta Dental Premier® & Out-of-network
Basic Services
- Fillings/Amalgams
- Simple Extractions
- Gum Disease Treatment
- Root Canals
- Surgical Extractions
50% in network

50% Delta Dental Premier® & Out-of-network
Major Services
- Gum Disease Treatment*
- Root Canals*
- Surgical Extractions*
- Special Restorative**
- Crowns**
- Complete and Partial
   Dentures**
- Fixed Bridgework**
- Implants**
50% in network

40% Delta Dental Premier® & Out-of-network
Major Services
- Denture Reline and
   Rebases, Adjustments
- Repairs to Crowns,
   Dentures and Bridges
- Special Restorative
- Crowns
- Complete and Partial
   Dentures
- Fixed Bridgework
50% in network

50% Delta Dental Premier® & Out-of-network
Orthodontia Not Included Orthodontia (medically necessary orthodontia only, and 24-month waiting period) 50% in network

50% Delta Dental Premier® & Out-of-network


See Schedule of Benefits for this policy for a comprehensive explanation of services covered and not covered.
Deductible does not apply to in-network diagnostic & preventive services.
*6 month waiting period.
**12 month waiting period.
^Limited to 2 per person in a benefit year.