2021 Tufts Health Plan Medicare Preferred Dental Option

Tufts Health Plan makes it easy to get comprehensive dental coverage for the services you need now—and the ones you may need later!
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About the Plan

The Tufts Health Plan Medicare Preferred Dental Option is provided by Dominion National, a leading administrator of dental benefits. The plan includes access to thousands of dentists across the region and for one low cost you get complete dental coverage including a $0 deductible, $0 for preventive services such as cleaning and oral exams, 20% for restorative services such as fillings and simple extractions, and 50% coinsurance for major services such as crowns, root canals, and dentures.

If you are an existing member and would like to add the 2021 Tufts Health Plan Medicare Preferred Dental Option to your plan, call 1-800-701-9000 (TTY: 711). (If you signed up for the Tufts Health Plan Medicare Preferred Dental Option in 2020, your coverage will automatically renew.)

Dental Premium
$17.00/mo
For Saver, Basic
$30.00/mo
For Value, Prime, Prime Rx+
$0
Diagnostic Deductible
$0
Preventive Deductible
$1,000
Maximum benefit per year

Why are the premiums different?

The premium is different depending on your plan selection. Tufts Medicare Preferred HMO Basic Rx and Tufts Medicare Preferred HMO Saver Rx both have embedded preventive and restorative dental benefits, therefore the premium for the additional dental coverage is lower.

What's covered?

The charts displayed below represent what the member pays for dental services such as diagnostic, preventive, restorative, oral surgery, prosthodontics, and more.

Diagnostic Services

Benefit
Saver, Basic
Value, Prime, Prime Rx+
With Dental Option
Comprehensive oral exam
Once every 36 months.
Saver, Basic
$0
Value, Prime, Prime Rx+
With Dental Option
$0
Periodic oral evaluation
Two per year.
Saver, Basic
$0
Value, Prime, Prime Rx+
With Dental Option
$0
Emergency oral evaluation problem focused exams
Once every 12 months.
Saver, Basic
50%
Value, Prime, Prime Rx+
With Dental Option
20%
Intra-oral X-ray image of the entire mouth
Panoramic image. Once every 60 months.
Saver, Basic
50%
Value, Prime, Prime Rx+
With Dental Option
20%
Intra-oral X-ray image of the entire mouth
Full mouth series. Once every 60 months.
Saver, Basic
50%
Value, Prime, Prime Rx+
With Dental Option
20%
Intra-oral bitewing X-ray images
X-rays of the crowns of the teeth. Completed when oral conditions indicate need. Two per year.
Saver, Basic
$0
Value, Prime, Prime Rx+
With Dental Option
$0
Single tooth X-ray images; as needed
As needed.
Saver, Basic
50%
Value, Prime, Prime Rx+
With Dental Option
20%

Preventive Services

Benefit
Saver, Basic
Value, Prime, Prime Rx+
With Dental Option
Prophylaxis routine cleaning, scaling, and polishing of teeth
Two per year.
Saver, Basic
$0
Value, Prime, Prime Rx+
With Dental Option
$0
Periodontal cleaning
Once every 6 months following active periodontal therapy, not to be combined with regular cleanings.
Saver, Basic
50%
Value, Prime, Prime Rx+
With Dental Option
20%

Restorative Services

Benefit
Saver, Basic
Value, Prime, Prime Rx+
With Dental Option
Silver fillings and white fillings (front teeth)
Once every 24 months per surface per tooth.
Saver, Basic
50%
Value, Prime, Prime Rx+
With Dental Option
20%
White fillings (back teeth)
Covered only for single surfaces. Once every 24 months per surface, per tooth; multi-surfaces will be processed as a silver filling, and the patient is responsible up to the contracted fee.
Saver, Basic
50%
Value, Prime, Prime Rx+
With Dental Option
20%
Inlays
Once per tooth per 84 months.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%
Protective restorations
Once per tooth.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%

Oral Surgery

Benefit
Saver, Basic
Value, Prime, Prime Rx+
With Dental Option
Simple extractions
Once per tooth.
Saver, Basic
50%
Value, Prime, Prime Rx+
With Dental Option
20%
Surgical extractions
Once per tooth.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%

Periodontics

Benefit
Saver, Basic
Value, Prime, Prime Rx+
With Dental Option
Periodontal surgery
One surgical procedure per lifetime; gingivectomy or gingivoplasty and osseous surgery covered as needed.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%
Scaling and root planing
Once in 24 months, per quadrant.
Saver, Basic
50%
Value, Prime, Prime Rx+
With Dental Option
20%
Bone grafts and guided tissue regeneration
Once per lifetime.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%

Endodontics

Benefit
Saver, Basic
Value, Prime, Prime Rx+
With Dental Option
Root canal treatment
Once per tooth per lifetime.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%
Retreatment root canal therapy
Once per tooth per lifetime after 24 months of initial root canal therapy.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%
Apicoectomy
Covered as needed.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%

Prosthetic Maintenance

Benefit
Saver, Basic
Value, Prime, Prime Rx+
With Dental Option
Bridge or denture repair
Once every 24 months per bridge or denture.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%
Tissue conditioning
One treatment per denture every 84 months.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%
Adding teeth to existing partial or full dentures
Once per tooth, per denture, per 24 months.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%
Rebase or reline of dentures
Once per denture every 24 months.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%
Recement of crowns and onlays
Once per tooth per 12 months.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%

Adjunctive Services (provided in conjunction with the primary treatment)

Benefit
Saver, Basic
Value, Prime, Prime Rx+
With Dental Option
Minor treatment for pain relief
Only if no services other than exam and X-rays were performed on the same date of service.
Saver, Basic
50%
Value, Prime, Prime Rx+
With Dental Option
20%
Local anesthesia and inhalation of nitrous oxide/analgesia, anxiolysis
Local Anesthesia and inhalation of nitrous oxide/analgesia, anxiolysis are provided in conjunction with covered oral surgery or periodontal surgery and are integral to the primary treatment.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%

Prosthodontics

Benefit
Saver, Basic
Value, Prime, Prime Rx+
With Dental Option
Dentures
Complete or partial dentures: one per arch within 84 months.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%
Fixed bridges
Once per 84 months.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%
Temporary partial dentures
Once per 84 months.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%

Major Restorative

Benefit
Saver, Basic
Value, Prime, Prime Rx+
With Dental Option
Crowns and onlays-initial placement
When teeth cannot be restored with regular fillings due to fracture or decay, once within 84 months per tooth.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%
Post and core or crown buildup
When needed to retain a crown on a tooth with excessive breakdown due to caries and/or fractures. Once per tooth every 84 months.
Saver, Basic
100%
Value, Prime, Prime Rx+
With Dental Option
50%

Interested in adding the Tufts Health Plan Medicare Preferred Dental Option to your plan?

It's easy to add the Tufts Health Plan Medicare Preferred Dental Option to your plan. Just call 1-800-701-9000 (TTY: 711) and one of our Medicare Experts can answer any questions you have and enroll you in just a few minutes.

The Tufts Health Plan Medicare Preferred Dental Option is in addition to your medical coverage with Tufts Health Plan Medicare Preferred. It is not automatically included. To add the Dental Option to your plan, call 1-800-701-9000. The plan is administered by Dominion Dental Services, Inc., which operates under the trade name Dominion National. Services must be performed by providers in the Dominion PPO Network. Please refer to your Evidence of Coverage for more information.