Plan Limitations
Benefits for the following services are limited as summarized below. Please note that if you exceed the Plan limits, you will be responsible for payment for services beyond the limits. For instance, your dentist may recommend more than two cleanings per year. While more cleanings may be advisable, the Plan will only cover the cost for two annual cleanings. You will be responsible for the cost of additional cleanings.
Diagnostic and Preventive Benefits
  • Oral Examinations — Benefits are limited to two oral exams in a calendar year (January through December), while you are eligible under any Delta Dental plan.
  • Prophylaxis (cleanings) — Cleanings (including procedures that contain cleanings, such as deep cleaning or scaling) and fluoride treatments are covered only twice in a calendar year, while you are eligible under any Delta Dental plan.
  • Full Mouth X-rays — Complete mouth X-rays and Panorex films are covered only once every five years while you are eligible under any Delta Dental plan, unless your dentist shows a special need for an increased frequency and submits documentation to and receives authorization from Delta Dental. (Panorex films may be covered even if you receive a full-mouth X-ray.)
  • Supplementary Bitewing X-rays — Supplementary bitewing X-rays are covered only:
    • Twice in a calendar year for Eligible Dependents up to age 18, while they are eligible under any Delta Dental plan, or
    • Once a calendar year for adults age 18 and over, while they are eligible under any Delta Dental plan.
If you or your dentist needs to reschedule an appointment, it is your responsibility to ensure the rescheduled appointment still meets the timing limitations of the Dental Plan in order to receive applicable benefits.
Basic Care Benefits
  • Periodontal Procedures — Limited to two in a calendar year. If such procedures include prophylaxis (cleanings, including procedures that contain cleanings, such as deep cleaning or scaling), those cleanings are counted towards the annual limit.
  • Sealants — Pit and fissure sealants are limited to Eligible Dependents under age 16 (permanent first molars through age 8 and second molars through age 15) using standard procedures as determined by Delta Dental. Sealant benefits include the application of sealants only to permanent posterior molar teeth with no decay, with no restorations and with occlusal surface intact. Sealant benefits do not include the repair or replacement of a sealant on any tooth within two years (24 months) of its application.
Major Care Benefits
  • Crowns, Inlays, Onlays and Cast Restorations — If you receive any such restoration while a member of a Company-sponsored Dental Plan or any other plan provided through Delta Dental, a restoration for the same tooth can only be replaced after five years, unless Delta determines that replacement is required because the restoration is unsatisfactory or the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissues since the replacement of the restoration.
  • Prosthodontic Benefits — The Dental Plan will pay the applicable percentage of the dentist's filed fee for standard cast chrome or acrylic complete or partial dentures (removable prosthetic appliances provided to replace missing natural, permanent teeth which are constructed using accepted conventional procedures and materials). Benefits for prosthodontic appliances are paid by Delta only once every five years, unless Delta determines that there is such 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 plan will be made if it is unsatisfactory and cannot be made satisfactory.
  • Implants — For implants (materials implanted into or on bone or soft tissue) or the removal of implants, you pay 15% (subject to the annual maximum benefit of $2,500). What is covered for implants includes the placement of the implant, abutment, and prosthetic device. Before work begins, you should have your dentist file a "Predetermination" with Delta Dental to review whether the proposed treatment is a covered benefit.
Orthodontic Benefits
  • Covered expenses for Delta Dentists are limited to the lesser of the usual, reasonable and customary fee or the fee actually charged.
  • Orthodontic services which are begun before a member's coverage date are not covered.
  • Periodic payments for orthodontics paid by the Dental Plan shall terminate on the next payment due date after the earliest of the following:
    • the date the employee's participation in the Dental Plan terminates;
    • the first day of the month following the month in which a dependent ceases to meet the definition of a dependent as stated in the Dental Plan;
    • the date treatment is terminated for any reason prior to completion of the treatment plan; or
    • the date the Dental Plan terminates.
  • Repair or replacement of an orthodontic appliance furnished in whole or in part is not covered.
  • X-rays and extraction procedures related to orthodontics are not covered under orthodontic benefits, but may be covered under other benefits as stated in the Dental Plan.
Other Limitations
  • Alternative Treatment — If you choose an alternative treatment that costs more than the usual, reasonable and customary fee of the standard treatment, you will be responsible for the difference in cost in addition to your annual deductible and appropriate coinsurance.