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Return to Northeast Delta Dental Benefit    Download PDF

See Frequently Asked Questions for more information about coverage, deductibles and more.

See Table of Allowances for information on what Delta allows for various procedures.

Maine Public Employee Retiree Dental Program - 6125 6126 6127

Monthly Premiums:

1 Person: $ 34.22
2 People: $ 62.37
Three or More: $ 97.41

Coverage

Type Diagnostic & Preventative
Coverage A		 Basic Restorative
Coverage B		 Major Restorative
Coverage C
Covered Services DIAGNOSTIC:

Evaluations twice per calendar year

X-RAYS:
Complete series or panoramic film once in a 3 year period, bitewing X-rays once each 12 month period, X-rays of individual teeth as necessary

PREVENTIVE:
Cleanings twice per calendar year
Fluoride once in a 12 month period to age 19
Space maintainers to age 16
Sealant application to permanent molars once in a lifetime per tooth, for children to age 15

RESTORATIVE:
Amalgam fillings
composite (white) fillings (anterior teeth only)

ORAL SURGERY:
Surgical and routine extractions

PERIODONTICS:
Treatment of gum disease
Periodontal cleaning (maintenance procedures) twice per calendar year

DENTURE REPAIR:
Repair of removable denture to its original condition

EMERGENCY PALLIATIVE TREATMENT

PROSTHODONTICS:
Removable and fixed partial dentures, bridges, complete dentures
Rebase and reline
Crowns
Onlays
Waiting Period None 6 Months 6 Months
Deductible None Contract year deductible (Feb. 1 through Jan. 31): $25 per person, up to a maximum of $75 per family
MAXIMUM Coverage A, B and C combined contract year maximum is $1,500 per person
Delta Dental of Maine will cover eligible services provided by licensed denturists in the State of Maine for eligible subscribers of Delta Dental of Maine. The dentist must be duly licensed by the State of Maine in the practice of denturism. Claims submitted by a licensed denturist must be accompanied by a copy of certificate of good oral health that has been issued for a patient by a licensed denturist.
Your Northeast Delta Dental program includes all of the above coverage categories. This chart is provided for summary purposes only. Please refer to your benefit booklet for complete benefit information. In the event of a conflict or discrepancy between this chart and either the group contract or the benefit booklet, the group contract or benefit book will prevail.