What's Covered
The following information is a summary of covered services. Limitations may apply to these services according to plan provisions.
The plan will pay 100% of the charges for:
- Routine exams, including office visits for observation and
specialist consultations, twice per calendar year
- Cleanings three times per calendar year
- Fluoride application for children to 19 three times per year in conjunction with cleanings
- Bitewing x-rays (adults once per year and children to 19 two per year)
- Diagnostic casts once every 24 months only if in connection with orthodontic treatment
- Sealants to permanent teeth without decay for children to 19 once every three years
Additional Benefits during Pregnancy: If you are pregnant, the plan will pay for additional services to help improve your oral health during pregnancy. The additional services each calendar year include: one additional oral examination and either one additional routine cleaning or one additional periodontal scaling and root planing per quadrant. You or your dentist must provide written confirmation of your pregnancy when the claim is submitted.
After you meet the annual deductible, the plan pays 80% of the charges for the following services:
- Amalgam fillings (multiple restorations on one surface will be treated as a single filling)
- Composite resin fillings for front teeth and the facial surface of bicuspids
- One complete set of full-mouth x-rays every 12 months
- Space maintainers for children under age 19, once per lifetime; includes all adjustments within six months of installation
- Root canal therapy
- Periodontal maintenance
- Simple extractions and oral surgery
- General anesthesia services and supplies
- Occlusal guards and adjustments
- Endodontics
After you meet the deductible, the plan pays 50% of the charges for:
- Crowns (covered once every seven years only when a filling cannot restore the tooth)
- Dentures (construction or repair of standard fixed bridges, partial dentures, and complete dentures once every seven years, unless Delta determines that damage to the remaining teeth or supporting tissue warrants a new appliance)
- Dental implants (covered once every five years, removal of implants covered once per tooth)
- Inlays and onlays
- Periodontal surgery
- Complex oral surgery and surgery for impacted teeth
Children and adults are eligible for orthodontic care coverage. The plan pays 50% of the eligible charges for covered orthodontic procedures and services that are part of an approved orthodontic treatment plan. The lifetime maximum orthodontic benefit for each covered person is $2,000.
Charges are eligible if they are for the diagnosis and correction of misaligned teeth or abnormal bite. The charge must be a covered expense under the plan.
You must notify Delta Dental in writing before any orthodontic treatment begins. Your dentist will need to provide his or her estimated treatment plan to Delta Dental for review.
The following limitations apply:
- If orthodontic treatment begins before you become eligible for coverage, Delta's payments will begin with the first payment due to the dentist following your eligibility date
- Delta's orthodontics payments will stop when the first payment is due to the dentist following either a loss of eligibility, or if treatment is ended for any reason before it is completed
- X-rays and extractions that might be necessary for orthodontic treatment are not covered by the orthodontic portion of benefits, but may be covered under the preventive and diagnostic portion of the plan
- Delta will pay the applicable percentage of the dentist's fee for a standard orthodontic treatment plan involving surgical and/or non-surgical procedures (if you select specialized orthodontic appliances or procedures for aesthetic reasons, Delta's benefit will be based on the cost of a standard orthodontic treatment plan and you will be responsible for the remainder of the dentist's fee)