City of Nashua/NSD
Plan E
Outline of Coverage
Delta Dental Premier Network
Northeast Delta Dental
Read Your Dental Plan Description Carefully—This Outline of Coverage provides a very brief description of the important features of your dental benefits pian. This is not the
insurance contract, and only the actual policy provisions will control, The Dental Plan Description itself sets forth in detail the rights and obligations of both you and your insurance
company, it is therefore important that you READ YOUR Dental Pian Description CAREFULLY! Not alf time limitations and exclusions are shown herein. Benefit percentages
shown are based on the actual charges submitted up to the Maximum Allowable Charge for participating dentists, or Delta Dental’s allowance for non-participating dentists.
AFSME Public Works/Fire Option 1/COBRA & Retiree
Diagnostic / Preventive
(Coverage A)
Basic Restorative
(Coverage B)
Major Restorative
(Coverage C)
DIAGNOSTIC:
Evaluations twice in a 12-month period;
X-rays (complete series or panoramic film) once
in 3-year period
Bitewing x-rays once in a 12-month period
X-rays of individual teeth as necessary
Brush biopsy once in a 12-month period
PREVENTIVE:
Two cleanings in a 12-month period
Fluoride once in a 12-month period to age 19
Space maintainers to age 16
Sealant application to permanent molars, once in a 3-
year period per tooth, for children to age 19
Note: Expenses incurred for covered Diagnostic and
Preventive services do not accrue to your annual
maximum.
RESTORATIVE:
Amalgam (silver) fillings;
Resin(white) restorations on anterior teeth only
ORAL SURGERY:
Surgical and routine extractions
ENDODONTICS:
Root canal therapy
PERIODONTICS:
Periodontal maintenance (cleaning)
Note: Cleanings are limited to two in a I2-month period;
these may be routine (Coverage A) or periodontal
(Coverage 8), or a combination of both.
Treatment of gum disease
Clinical crown lengthening once per tooth per lifetime
DENTURE REPAIR:
Repair of a removable denture to its original condition
EMERGENCY PALLIATIVE TREATMENT
PROSTHODONTICS:
Removable and fixed partial dentures (bridge); complete
dentures
Rebase and reline (dentures)
Crowns
Onlays
implants
Occlusal Guards. Once in a five year period.
Delta Dental Pays: 100%
Delta Dental Pays: 60%
Delta Dental Pays: 50%
Contract Year Maximum: $750 per Person beginning each July Ist
Health through Oral Wellness* program included (please see reverse for details)
Rev. 4/14/2017
