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.
UPFFA Retirees Benefits
Plan Highlights
Lifetime deductible – $100 (once per lifetime as long as the policy is in force - does not apply to preventive and diagnostic)
Waiting period – None, coverage begins as the coverage effective date if you enroll when initially eligible
These plans include extra benefits not typically included in individual plans, such as:
Plan changes are allowed at the next annual enrollment period for an effective date of January 1st for the new plan.
You will be notified of rate changes at least 60 days in advance.
Enroll Today!
Lifetime deductible – $100 (once per lifetime as long as the policy is in force - does not apply to preventive and diagnostic)
Waiting period – None, coverage begins as the coverage effective date if you enroll when initially eligible
| Service | Premium plan | Standard plan | Basic plan |
|---|---|---|---|
| Calendar year maximum (per person) | $2,000 | $1,500 | $1,000 |
| Lifetime deductible (waived on Preventive & Diagnostic) | |||
| Per person | $100 | $100 | $100 |
| Preventive & Diagnostic | |||
| Dental evaluations | 100% | 100% | 100% |
| Routine cleanings | 100% | 100% | 100% |
| Bitewing X-rays | 100% | 100% | 100% |
| Full mouth X-rays (a series of individual X-rays or a panoramic X-ray) | 100% | 100% | 100% |
| Fluoride (to age 19) | 100% | 100% | 100% |
| Sealants on the decay-free, biting surface of permanent molars | 100% | 100% | 100% |
| Space maintainers when primary molar tooth is prematurely lost | 100% | 100% | 100% |
| Emergency treatment to relieve pain | 100% | 100% | 100% |
| Basic Services | |||
| Fillings (composite fillings on all teeth) | 80% | 50% | 50% |
| Non-surgical extractions | 50% | 50% | 50% |
| Major Services | |||
| Crowns – Repair of teeth with crowns when they cannot be restored with other filling materials | 50% | 50% | 50% |
| Endodontics – The care of teeth with damaged nerves, such as root canal treatment | 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% |
| Surgical Fixed and removable prosthodontics – Dental services and appliances to replace missing teeth, such as dentures and bridges (excluding implants), including repairs | 50% | 50% | 50% |
| Implants – Dental services for surgical placement of implant body and implant abutment supported crowns | 50% | 50% | 50% |
| Adjunctive general services – Dental services including general anesthesia, and palliative care (temporary treatment of dental pain) | 50% | 50% | 50% |
| Additional services | |||
| Oral Health Enhancement – two additional cleanings per year for members with a history of periodontal disease | ✓ | ✓ | ✓ |
| Integrative Care – two additional cleanings per year for members with certain chronic health conditions | ✓ | ✓ | ✓ |
| Monthly Rates Valid for 1/1/2024 - 12/31/2025 Rates are subject to change; see below. |
|||
| You only | $66.71 | $57.85 | $50.13 |
| You plus spouse | $142.05 | $123.19 | $106.75 |
| You plus child(ren) – end of month to age 27 | $130.06 | $112.78 | $97.73 |
| You plus family | $224.20 | $194.42 | $168.47 |
These plans include extra benefits not typically included in individual plans, such as:
- a lifetime versus annual deductible
- extra cleanings for members with periodontal disease
- certain health conditions
- implant coverage from day 1
- and the ability to see network dentists nationwide
Plan changes are allowed at the next annual enrollment period for an effective date of January 1st for the new plan.
You will be notified of rate changes at least 60 days in advance.
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.
