MSMA Group Dental Plans
Dental Home
Class 2 Procedures
Class 3 Procedures
Class 4 Procedures
Plan 2 $25 Individual Deductible ($75 Maximum per family)
Plan 3 $50 Individual Deductible ($150 Maximum per family) Orthodontia not covered
Plan 4 $25 Individual Deductible ($75 Maximum per family) Orthodontia not covered
Plans 1 and 2 cover procedures listed below under Classes 1, 2, 3 and 4. Plans 3 and 4 cover procedures listed below under Classes 1, 2 and 3.
Contact MSMA customer service with questions.
All plans have a maximum of $1200 in benefits paid per family member for Class 1, 2 and 3 services
Class 1 Procedures - Diagnostic and Preventive (Partial Listing)
- Clinical oral examinations - - 1 every 6 consecutive months.
- Intra-oral x-rays -- complete series (including bitewings)-- limit 1 series in a 36 consecutive month period.
- Bitewing -- limit to one service in any 6 consecutive month period.
- Dental prophylaxis -- not more than 1 in any 6 consecutive month period
- Fluoride treatments -- for individuals under 19 years of age -- limit to one in any 12 consecutive month period.
Coverage
Plan 1
Payment 100%
Plan 2 Payment 100%
Plan 3 Payment 100%
Plan 4 Payment 100%
Class 2 Procedures - Basic (Partial Listing)
Fillings
-- Amalgam, silicate, acrylic or plastic
Root canal therapy
Periodontal scaling and root planing
If more than one periodontal
surgical procedure is performed per quadrant, only the most
inclusive is considered a dental procedure.
Adjustment of
dentures
Replace broken
tooth on complete or partial denture.
Extraction of Wisdom Teeth
Emergency Treatment
Anesthesia
Coverage
Plan 1 - Plan pays 80%
after a $50 deductible is met
Plan 2 - Plan pays 80% after a $25 deductible is met
Plan 3 - Plan pays 80% after a $50 deductible is met
Plan 4 - Plan pays 80% after a $25 deductible is met
Class 3 Procedures - Major (Partial Listing)
Crowns, bridges,
dentures, implants. (Upon Review)
Complete and
partial dentures (includes 6 months of post-installation
care)
Coverage
Plan 1 - Plan pays 50%
after a $50 deductible is met
Plan 2 - Plan pays 50% after a $25 deductible is met
Plan 3 - Plan pays 50% after a $50 deductible is met
Plan 4 - Plan pays 50% after a $25 deductible is met
Class 4 Procedures - Orthodontic Coverage (Partial Listing)
Orthodontic
benefits are limited to dependent children under the age of 19. The
maximum lifetime benefit is $1000.
Comprehensive
orthodontic treatment preliminary study including cephalometric
radiographs, diagnostic casts and treatment plans.
Appliances for
tooth guidance.
Eligible orthodontic treatment is payable at 50%, and payments will begin once the bands are placed. Periodic payments will be made for eligible orthodontic services, provided eligible dependent remains in active treatment.
Coverage
Plan 1 - Plan pays 50%
Plan 2 - Plan pays 50%
Plan 3 - No Coverage
Plan 4 - No Coverage
$1000 lifetime maximum coverage for Orthodontia.