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Delta Dental

Delta Dental Premier 1000 Plan

Network

Delta Dental Premier® Network
The largest dental network in Alaska and the country. Close to 72 percent of dentists in Alaska and more than 152,000 dentists nationwide are covered.
Importance of in-network providers

Plan highlights

With Delta Dental plans you can count on:

  • Savings from participating dentists
  • Cleanings every six months
  • Benefit estimates prior to treatment
  • Superior customer service

Note:

  • This plan only available direct through Delta Dental of Alaska
  • Does not meet federal requirements for pediatric dental coverage

Summary of benefits

Copays & coinsurance

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Delta Dental Premier 1000 Plan Under age 19 Ages 19+
  In-network,
you pay 		Out-of-network,
you pay 		In-network,
you pay 		Out-of-network,
you pay
Calendar year costs
Deductible per person $50 $50 $50 $50
Out-of-pocket max per person
Annual benefit max $1,000 $1,000 $1,000 (all ages) $1,000
Class 1
Exams and X-rays 0% 0% 0% 0%
Cleanings 0% 0% 0% 0%
Periodontal maintenance 0% 0% 0% 0%
Sealants 0% 0% 0% 0%
Topical fluoride 0% (restrictions for ages 19+) 0% (restrictions for ages 19+) 0% 0%
Class 2
Space maintainers 20% after deductible 20% after deductible Not covered Not covered
Restorative fillings1 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Class 3
Oral surgery2 50% after deductible 50% after deductible 50% after deductible 50% after deductible
Endodontics2 50% after deductible 50% after deductible 50% after deductible 50% after deductible
Periodontics2 50% after deductible 50% after deductible 50% after deductible 50% after deductible
Restorative crowns2 50% after deductible 50% after deductible 50% after deductible 50% after deductible
Bridges2 50% after deductible 50% after deductible 50% after deductible 50% after deductible
Partial and complete dentures2 50% after deductible 50% after deductible 50% after deductible 50% after deductible
Anesthesia2 50% after deductible 50% after deductible 50% after deductible 50% after deductible
Orthodontia3 Not covered Not covered Not covered Not covered
Limitations & Exclusions
These are some common limitations and exclusions for our 2025 Delta Dental Plan of Oregon individual and family dental plans. For a full list of limitations and exclusions, see the member handbook.

Limitations

Class 1
  • Bitewing X-rays once in a 12-month period
  • Exam once in a six-month period
  • Fluoride once in a six-month period
  • Full-mouth or panoramic X-rays once in a five-year period
  • Interim caries arresting medicament application is covered twice per tooth per year. Many restorations are not covered within three months of interim caries arresting medicament application.
  • Prophylaxis (cleaning) or periodontal maintenance is covered once in any six-month period. Additional periodontal maintenance is covered for members with periodontal disease, up to a total of two additional periodontal maintenances per year.
  • Sealants limited to unrestored occlusal surface of permanent molars once per tooth in a five-year period except for evidence of clinical failure
Class 2 and Class 3
  • Athletic mouth guard covered once in any 12-month period for members age 15 and under and once in any 24-month period age 16 and over
  • Crowns and other cast restorations once in a seven-year period
  • Crown over implant once per lifetime per tooth.
  • Maximum of four crowns in a seven-year period.
  • Dentures once in a seven-year period age 16 and over
  • IV sedation or general anesthesia only with surgical procedures. Oral anesthesia only during an in-office procedure.
  • Night guard (occlusal guard) covered at 100% once in a five-year period, up to $150 maximum
  • Porcelain crowns on back teeth are limited to the amount for a full metal crown
  • Scaling and root planing is limited to once per quadrant in any two-year period

Exclusions

  • Services for members age 19+
  • Anesthetics, analgesics, hypnosis and most medications
  • Charges above the maximum plan allowance
  • Charting (including periodontal, gnathologic)
  • Congenital or developmental malformations
  • Cosmetic services
  • Duplication and interpretation of X-rays or records
  • Experimental or investigational treatment
  • Hospital costs or other fees for facility or home care except for emergency care
  • Implants
  • Instructions or training (including plaque control and oral hygiene or dietary instruction)
  • Orthodontia (exception for treatment of cleft palate)
  • Over-the-counter night guards and athletic mouth guards are excluded
  • Rebuilding or maintaining chewing surfaces (misalignment or malocclusion) or stabilizing teeth
  • Self treatment
  • Services or supplies available under any city, county, state or federal law, except Medicaid
  • Teledentistry, translation or sign language services are not covered as separate charges
  • Temporomandibular joint syndrome (TMJ)
  • Treatment before coverage begins or after coverage ends
  • Treatment not dentally necessary
Or Dental 2022
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