Notice
Change Healthcare announced a breach of HIPAA privacy and is reaching out to individuals whose personal information may have been compromised. Although this incident does not involve Delta Dental of New Jersey or Connecticut, Change Healthcare is a vendor we used and we are providing this information to help our members who might be affected.
Basic plan benefit summary
Delta Dental Unlimited Program for UPFFA CT Locals (endorsed and administrated by the IAFF Health & Wellness Trust)
Plan Highlights
- Unlimited calendar year maximum for all networks
- 100% coverage for most services if seeing a PPO Dentist
| Service | In-Network If a Delta Dental PPO™ Dentist is Used |
In-Network If a Delta Dental Premier® Dentist is Used |
Out-of-Network If a Non-Participating Dentist is Used |
|---|---|---|---|
| Calendar year maximum (per person) | Unlimited | Unlimited | Unlimited |
| Annual deductible (waived on Preventive & Diagnostic) | |||
| Per person | None | $200 | $200 |
| Family maximum | None | $600 | $600 |
| Preventive | |||
| Exams | 100% | 80% | 80% |
| Bitewing X-rays | 100% | 80% | 80% |
| Full mouth X-rays (a series of individual X-rays or a panoramic X-ray) | 100% | 80% | 80% |
| Diagnostic | |||
| Cleanings | 100% | 70% | 70% |
| Fluoride (to age 19) | 100% | 70% | 70% |
| Sealants | 100% | 50% | 50% |
| Space maintainers | 100% | 50% | 50% |
| Basic | |||
| Fillings (composite fillings on all teeth) | 100% | 50% | 50% |
| Simple extractions | 100% | 50% | 50% |
| Cone Beam Radiographs | 100% | 50% | 50% |
| Repair of Dentures | 100% | 50% | 50% |
| Oral Surgery | 100% | 50% | 50% |
| Anesthesia/IV Sedation | 100% | 50% | 50% |
| Major Services | |||
| Endodontics – The care of teeth with damaged nerves, such as root canal treatment | 100% | 50% | 50% |
| General services (Consultation) | 60% | 50% | 50% |
| Crowns – Repair of teeth with crowns when they cannot be restored with other filling materials | 50% | 50% | 50% |
| Periodontics – The treatment of disease of the gums and supporting bone, such as scaling and root planing | 50% | 50% | 50% |
| Oral surgery – Surgical extractions and other dental surgery | 50% | 50% | 50% |
| Bridgework; bridges | 50% | 50% | 50% |
| Implants | |||
| Treatment | 50% | 50% | 50% |
| Annual TMJ maximum (per person) | $1,500 | $1,500 | $1,500 |
| TMJ | |||
| Treatment | 50% | 50% | 50% |
| Annual TMJ maximum (per person) | $1,000 | $1,000 | $1,000 |
| Lifetime TMJ maximum (per person) | $5,000 | $5,000 | $5,000 |
| Orthodontics | |||
| Treatment (Adult & Child) | Not covered | Not covered | Not covered |
More information
Delta Dental of Connecticut is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.
