Covered dental services are limited in certain cases. All charges for the following dental services will be your responsibility. All time limitations are measured from the last date of service in any Delta Dental plan record or, at the request of your group, any dental plan record:
1. Four bitewing X-rays are payable once in any calendar year. Full mouth X-rays (which
include bitewing X-rays) are payable once in any three-year period. A panographic X-ray
(including bitewings) is considered a full mouth X-ray. Bitewing X-rays, full mouth X-rays
and Periapical X-rays are covered without limitation for Dependent Children up to age 19.
2. Prophylaxes and oral exams are payable twice in any calendar year. Two additional
periodontal prophylaxes are payable per calendar year for individuals with a documented
history of periodontal disease. Preventive fluoride treatments are covered without limitation
for Dependent Children up to age 19. Oral exams, excluding specialty and emergency
exams, are covered without limitation for Dependent Children up to age 19.
3. A space maintainer is a covered benefit for patients up to the age of 19.
4. Cast restorations (including jackets, crowns, inlays and onlays) and associated procedures
(such as core build-ups and post substructures) on the same tooth are payable once in
any five-year period.
5. A crown, inlay, or onlay is a covered benefit only for extensive loss of tooth structure due
to caries and/or fracture.
6. An individual crown over an implant is payable at the prosthodontic benefit level.
7. Porcelain, porcelain substrate, and cast restorations are not payable for Children younger
than 12 years of age.
8. A stayplate is a covered benefit only for the replacement of permanent anterior teeth
during the healing period or for missing anterior permanent teeth for Dependent Children
16 years or younger.
9. Prosthodontic (Class III) benefit limitations:
a) One complete upper and one complete lower denture are benefits once in any five-
year period for any individual.
b) A removable partial denture or fixed bridge for any individual can be covered once
in any five-year period, unless the loss of additional teeth requires the construction
of a new appliance. Fixed bridges are covered only for Participants 16 years or
c) A reline or the complete replacement of denture base material is limited to once in
any three-year period per appliance.
d) A soft reline is limited to once in any three-year period.
e) Root planing benefits are payable once per year.
10. Orthodontic (Class IV) benefit limitations:
a) Orthodontic benefits are payable until your Eligible Dependent’s 19th birthday.
b) If the treatment plan is terminated before completion of the case for any reason, the
Fund’s obligation will cease with payment to the date of termination.
c) The Dentist may terminate treatment, with written notification to Delta Dental and to
the patient, for lack of patient interest and cooperation. In those cases, the Fund’s
obligation for payment of benefits ends on the last day of the month in which the
patient was last treated.
d) An observation and adjustment is a benefit twice in a 12-month period.
e) Delta Dental will pay 50% of your initial down payment and then provide 50%
coverage for your ongoing treatment in quarterly installments until the rest of the
Fund’s orthodontic maximum benefit is reached.
f) The calendar year deductible does not apply to orthodontic benefits.
11. The Plan’s obligation for payment of benefits ends on the last day of the month in which
coverage is terminated. However, the Plan will make payment for covered services
provided on or before the last day of the month in which coverage is terminated, unless
12. When services in progress are interrupted and completed later by another Dentist, Delta
Dental will review the claim to determine the amount of payment, if any, to each Dentist.
13. Care terminated due to the death of a Participant will be paid to the limit of the Fund
maximum for the services completed or in progress.
14. Optional treatment: If the Participant chooses a more expensive service than is
customarily provided or for which the Plan or Delta Dental does not determine a valid
dental need is shown, the Plan or Delta Dental can make an allowance based on the fee
for the customarily provided service.
For example, if the Participant chooses an overdenture, the Fund will pay only the
applicable amount that it would have paid for a conventional denture.
15. Maximum Payment:
a) The maximum benefit payable in any one calendar year will be limited to the
amount specified in the Schedule of Benefits.
b) The payment for orthodontic (Class IV) benefits will be limited to the lifetime
maximum in the Schedule of Benefits.
16. The Plan and Delta Dental will not be obligated to pay for any services to which the
deductible applies until the Plan deductible amount is met.
17. Processing policies, such as periodic limitations on certain services, may limit treatment.