Summary Plan Description

Procedures and Limitations

Dental Procedure Limitations
Oral exams Covered twice in a calendar year
Bitewing x-rays Covered twice in a calendar year
Full mouth and panoramic x-rays Covered once in a five-year period
Fluoride and fluoride varnish Covered twice in a calendar year. No age limit.
Space maintainers Covered through age 17
Crowns, veneers and onlays Covered once in a seven-year period
Post core and build up Covered once in a seven-year period
Major/complete occlusal adjustment Covered once per lifetime for patients with advanced periodontal disease
Dentures, bridges and partials Covered once in a seven-year period
Denture relines and bases Covered once in a 12-month period
Sealants Covered once per tooth in a 24-month period. No age limit.
Restorations (fillings) Covered once per tooth every two years
Stainless steel crowns Covered once per tooth in a 24-month period
Root canal treatment Covered once per tooth in a 24-month period
Prescription-strength fluoride toothpaste Covered following certain periodontal procedures administered in dental office
Antimicrobial mouth rinse (dispensed by dental office) Covered once per periodontal course of treatment and also covered for women during pregnancy without a periodontal procedure
Periodontal scaling and root planing Covered once per quadrant every three-year period
Prophylaxis (cleaning) and periodontal maintenance Either prophylaxis or periodontal maintenance is covered twice in a calendar year. Patients at risk of advanced periodontal disease qualify for up to four treatments per year.
Site-specific therapy Covered twice per calendar year
Payment requirements for crowns, veneers and onlays Delta Dental pays on seat/completion date
Temporary crowns, bridgework, fillings Delta Dental allows
Occlusal guard Covered once every three-year period. For perio and bruxism.
Extension of benefits Delta will pay for procedures that require multiple appointments (i.e. crowns, root canals, etc.). Must be started while still eligible and completed within 21 days after loss of coverage.

In some cases, there may be two or more treatment options that meet the standard of care for dental needs covered by the plan. In such instances, the plan will pay the lowest scheduled fee. The balance of the treatment cost remains the patient's responsibility.