Looking At Eligible And Ineligible Expenses

Eligible Expenses From A To Z
The plan covers a wide range of services, including those described below. If you want to know whether a particular service is covered, contact the Administrative Office or Delta Dental.

Once you satisfy the deductible, the plan will pay the appropriate coinsurance (based on the negotiated rate for in-network services or based on R&C charges for non-network services) for necessary treatment under the generally accepted standards of dental practice.

BASIC BENEFITS
Basic benefits include:

• Adjunctive general services (e.g., general anesthesia; office visit for observation; office visit after regularly scheduled hours; therapeutic drug injection; treatment of post-surgical complications/unusual circumstances; and limited occlusal adjustment);
• Endodontics (treatment of the tooth pulp);
• Oral surgery (extractions and certain other surgical procedures, including pre- and post-operative care); and
• Restorative services (amalgam, silicate or composite/resin restorations/fillings for treatment of carious lesions/visible destruction of hard tooth structure resulting from the process of dental decay).

CROWNS, JACKETS, INLAYS, ONLAYS AND CAST RESTORATION BENEFITS
Benefits for the above services are provided only if the dental care is provided to treat cavities that cannot be restored with amalgam, silicate or direct composite/resin restorations.

DIAGNOSTIC AND PREVENTIVE BENEFITS
Diagnostic and preventive benefits include:

• Diagnostic work (e.g., oral examinations, including initial examinations, periodic examinations and emergency examinations; X-rays; diagnostic casts; examination of biopsied tissue; palliative/emergency treatment of dental pain; and specialist consultation);
• Preventive care (e.g., prophylaxis/cleaning; fluoride treatment; and space maintainers); and
• Sealants for covered children up to age 14 (topically applied acrylic, plastic or composite material used to seal developmental grooves and pits in teeth for the purpose of preventing dental decay).

IMPLANT BENEFITS
These include prosthetic appliances placed into or on bone of the maxillar or mandible (upper or lower jaw) to retain or support dental prostheses, including endosseous, transosseous, subperiosteal, and endodontic implants; implant connecting bars; implant repairs; and implant removal.

ORTHODONTIC BENEFITS
These include procedures using appliances or surgery to straighten or realign teeth that otherwise would not function properly. These benefits are available only for covered children up to age 19.

PROSTHODONTIC BENEFITS
These include construction or repair of fixed bridges, partial dentures and complete dentures, which is covered if provided to repair missing natural teeth; occlusal orthotic devices; removable metal overlay stabilizing appliances; and occlusal guards.

Plan Limitations
The following limitations apply to your dental coverage:

• Bitewing X-rays are provided on request by the dentist, but no more than once in a six-month period.
• Implants are covered once every five years.
• Crowns, jackets, inlays, onlays and cast restorations are cove red on the same tooth once every five years, unless Delta Dental determines that replacement is required because the restoration is unsatisfactory as the result of poor quality of care, or because the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissues since the replacement of the restoration.
• Full-mouth debridement (gross scale) is limited to one treatment in a lifetime
• Periodontal treatments (root planing/subgingival curettage) are limited to four quadrants during any 24 consecutive months.
• The plan will pay the applicable percentage of the dentist's fee for a standard partial or complete denture, up to a maximum fee allowance. This fee allowance is the fee that would satisfy the majority of Delta Dental dentists. A standard partial or complete denture is one made from accepted materials and by conventional methods. The maximum fee allowance is revised periodically, as dental fees change. If your dentist's accepted fee on file with Delta Dental for a partial or complete denture is higher than this maximum allowance, you'll be required to pay that portion of his/her fee that exceeds Delta Dental's allowance in addition to your portion of the allowance.
• The plan's payments for orthodontic treatment will stop when the first payment is due to the dentist following either a loss of eligibility or the termination of treatment for any reason before it is completed.
• Full mouth X-rays are covered only once in a three-year period.
• If orthodontic treatment is begun before you become eligible for coverage, the plan's payments will begin with the first payment due to the dentist following your eligibility date.
• If you select a more expensive treatment plan than is customarily provided, or specialized techniques, an allowance will be made for the least expensive professionally acceptable alternative treatment plan. The plan will pay the applicable percentage of the lesser fee for the customary or standard treatment, and you'll be responsible for the remainder of the dentist's fee.
• Only the first two oral examinations in a 12-month period are covered.
• Orthodontic payment is limited to treatment of covered children up to age 19.
• Prosthodontic appliances are covered once every five years, unless Delta Dental determines that there has been such an extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory. Replacement of a prosthodontic appliance not provided under a Delta Dental plan will be made if it is unsatisfactory and cannot be made satisfactory.
• Replacement implants are covered only following a five - year period after installation of an original implant provided under any Delta Dental plan.
• Sealant benefits are limited to covered children up to age 14. Sealant benefits include the application of sealants only to permanent posterior molars without caries (decay), without restorations and with the occlusal surface intact. Sealant benefits don't include the repair or replacement of a sealant on a tooth within three years of its application.
• Three cleanings or procedures that include a cleaning or combination thereof are covered every 12 months.
• X-rays and extractions that might be necessary for orthodontic treatment are not covered by orthodontic benefits, but may be covered under diagnostic and preventive or basic benefits.

Ineligible Expenses From A To Z
The plan covers a wide range of dental services, but there are some services that are not covered. It's important for you to know what these services are before you visit your dentist.

The plan doesn't cover the following services:

• Anesthesia, except for general anesthesia given by a dentist for covered oral surgery procedures;
• Charges by any hospital or other surgical or treatment facility and any additional fees charged by the dentist for treatment in any such facility;
• Charges for replacement or repair of an orthodontic appliance paid in part or in full by the plan;
• Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joints or associated muscles, nerves or tissues;
• Experimental procedures;
• Grafting of tissues from outside the mouth to tissues inside the mouth ("extraoral grafts");
• Intravenous sedation and complete occlusal adjustment;
• Prescribed drugs or applied therapeutic drugs, premedication or analgesia;
• Replacement of existing restoration for any purpose other than restoring active tooth decay or fracture of the restoration;
• Services for cosmetic purposes or for conditions that are the result of here ditaryor developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel;
• Services for injuries covered by Workers' Compensation or employer's liability laws;
• Services for restoring tooth structure lost from wear (e.g., abrasion, erosion, attrition or abfraction), for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. Examples of such treatment are equilibration and periodontal splinting; and
• Services that are provided by any federal or state government agency or that are provided without cost by any municipality, county or other political subdivision, except Medi-Cal benefits.