View the limitations, exceptions and reductions for your EHB-Certified or non-EHB Delta Dental plan below. 

Note: EHB-Certified plans include the pediatric dental benefit as required by the Affordable Care Act (ACA).

• EHB-Certified Plans (QINVD-100-Delta-2022-NC)

  Delta Dental will make no payment for the following services or supplies, unless otherwise specified in the Summary of Dental Plan Benefits, and all charges for the following services or supplies will be the responsibility of the Insured: 

  1. Services or supplies for the treatment of an occupational injury or sickness which are payable under the North Carolina Workers’ Compensation Act only to the extent such services or supplies are the liability of the employee, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ Compensation Act. NOTE: This provision does not apply to any programs provided under Medicaid or Medicare.
  2. Services or supplies, as determined by Delta Dental, for correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons. This exclusion does not apply to any newborn, adopted, or foster child who becomes covered under this Policy after the Effective Date.
  3. Cosmetic surgery or dentistry for aesthetic reasons, as determined by Delta Dental. This exclusion does not apply to any newborn, adopted, or foster child who becomes covered under this Policy after the Effective Date.
  4. Charges for services or appliances incurred prior to the date the person became covered under this Policy.
  5. Prescription drugs (except intramuscular injectable antibiotics), premedication, medicaments/ solutions and relative analgesia.
  6. General anesthesia and intravenous sedation, unless medically necessary.
  7. Charges for hospitalization, laboratory tests, histopathological examinations and miscellaneous tests.
  8. Charges for failure to keep a scheduled visit with the dentist.
  9. Services or supplies, as determined by Delta Dental, for which no valid dental need can be demonstrated.
  10. Services or supplies, as determined by Delta Dental, that are investigational in nature including services or supplies required to treat complications from investigational procedures.
  11. Services or supplies, as determined by Delta Dental, which are specialized techniques.
  12. Services or supplies, as determined by Delta Dental, which are not provided in accordance with generally accepted standards of dental practice.
  13. Treatment by other than a dentist, except for services performed by a licensed dental hygienist under the supervision of a licensed dentist or other licensed dental professional, may be covered only and solely determined by Delta Dental.
  14. Services or supplies excluded by the policies and procedures of Delta Dental, including the Processing Policies.
  15. Services or supplies for which no charge is made, for which the patient is not legally obligated to pay, or for which no charge would be made in the absence of Delta Dental coverage.
  16. Services or supplies received due to an act of war, declared or undeclared. This exclusion does not apply to acts of terrorism.
  17. Services or supplies not within the categories of benefits that have been selected and that are not covered under the terms of the Policy.
  18. Fluoride rinses, self-applied fluorides or desensitizing medicaments.
  19. Preventive control programs (including oral hygiene instruction, caries susceptibility tests, dietary control, tobacco counseling, home care medicaments, etc.).
  20. Lost, missing or stolen appliances of any type and replacement or repair of orthodontic appliances or space maintainers.
  21. Cosmetic dentistry, (except that when a child covered from the moment of birth or placement in the adoptive or foster home requires dental care associated with congenital defects and anomalies, those defects or anomalies will be covered to the same extent an otherwise Covered Service is provided by this Policy) including repairs to facings posterior to the second bicuspid position.
  22. Veneers.
  23. Prefabricated crowns used as final restorations on permanent teeth for people over age 15.
  24. Appliances, surgical procedures and restorations for increasing vertical dimension; for altering, restoring, or maintaining occlusion; for replacing tooth structure loss resulting from attrition, abrasion, abfraction, or erosion; or for periodontal splinting. This exception will not apply to medically necessary orthodontic services for individuals under age 19 as limited by the terms and conditions of the Policy.
  25. Paste-type root canal fillings on permanent teeth.
  26. Replacement, repair, relines, or adjustments of occlusal guards.
  27. Chemical curettage.
  28. Services associated with overdentures.
  29. Metal bases on removable prostheses for people age 19 and over.
  30. The replacement of teeth beyond the normal complement of teeth.
  31. Personalization or characterization of any service or appliance.
  32. Temporary crowns used for temporization during crown or bridge fabrication.
  33. Posterior bridges in conjunction with partial dentures in the same arch.
  34. Precision attachments and stress breakers.
  35. Bone replacement grafts and specialized implant surgical techniques.
  36. Radiographic/surgical implant index for people age 19 and over.
  37. Appliances, restorations or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ).
  38. Non-medically necessary orthodontic services for children under age 19, and any orthodontic services for people age 19 and over.
  39. Diagnostic photographs and cephalometric films for people age 19 and over, unless done for orthodontics and orthodontics are a Covered Service.
  40. Myofunctional therapy.
  41. Mounted case analyses.
  42. Implants for individuals age 19 and over.
  43. Any and all taxes applicable to the services.
  44. Interim caries arresting medicament.
  45. Sealants, for individuals 19 years of age and older.
  46. Implant/abutment supported interim fixed denture for edentulous arch.
  47. Biologic materials to aid in soft and osseous tissue regeneration when submitted on the same day as soft tissue grafting, guided tissue regeneration and periodontal or implant bone grafting.

   

  Delta Dental will make no payment for the following services or supplies. Participating dentists may not charge eligible people for these services supplies. All charges from nonparticipating dentists for the following services or supplies are your responsibility:

  1. The completion of forms or submission of claims.
  2. Consultations, patient screening or patient assessment when performed in conjunction with examinations or evaluations.
  3. Local anesthesia.
  4. Acid etching, cement bases, cavity liners, and bases or temporary fillings.
  5. Infection control.
  6. Temporary, interim or provisional crowns.
  7. Gingivectomy as an aid to the placement of a restoration.
  8. The correction of occlusion, when performed with prosthetics and restorations involving occlusal surfaces.
  9. Diagnostic casts, when performed in conjunction with restorative or prosthodontic procedures.
  10. Palliative treatment, when any other service is provided on the same date except X-rays and tests necessary to diagnose the emergency condition.
  11. Post-operative X-rays, when done following any completed service or procedure.
  12. Periodontal charting.
  13. Pins and preformed posts, when done with core buildups for crowns, onlays or inlays.
  14. A pulp cap, when done with a sedative filling or any other restoration. A sedative or temporary filling, when done with pulpal debridement for the relief of acute pain prior to conventional root canal therapy or another endodontic procedure. The opening and drainage of a tooth or palliative treatment, when done by the same dentist or dental office on the same day as completed root canal treatment.
  15. A pulpotomy on a permanent tooth, except on a tooth with an open apex.
  16. A therapeutic apical closure on a permanent tooth, except on a tooth where the root is not fully formed.
  17. Retreatment of a root canal by the same Dentist or dental office within two years of the original root canal treatment for individuals over the age of 19.
  18. A prophylaxis or full mouth debridement, when done on the same day as periodontal maintenance or scaling in the presence of gingival inflammation.
  19. Scaling in the presence of gingival inflammation when done on the same day as periodontal maintenance.
  20. Prophylaxis, scaling in the presence of gingival inflammation, or periodontal maintenance when done within 30 days of three or four quadrants of scaling and root planing or other periodontal treatment.
  21. Full mouth debridement when done within 30 days of scaling and root planing.
  22. Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of implant services without flap entry and closure, when performed within 12 months of implant restorations, provisional implant crowns and implant or abutment supported interim dentures.
  23. Full mouth debridement, when done on the same day as a comprehensive evaluation.
  24. An occlusal adjustment, when performed on the same day as the delivery of an occlusal guard.
  25. Reline, rebase, or any adjustment or repair within six months of the delivery of a partial denture.
  26. Tissue conditioning, when performed on the same day as the delivery of a denture or the reline or rebase of a denture.
  27. Periapical and/or bitewing X-rays, when done within seven days, a clinically unreasonable period of time of performing panoramic and/or full mouth X-rays, as determined solely by Delta Dental.
  28. Teledentistry fees.
  29. Services or supplies, as determined by Delta Dental, which are not provided in accordance with generally accepted standards of dental practice.

   

  The benefits for the following services are limited as follows, unless otherwise specified in the Summary of Dental Plan Benefits. All charges for services and supplies that exceed these limits will be the responsibility of the Insured. All time limitations are measured from the applicable prior dates of service in our records in any Delta Dental plan:

  1. Bitewing X-rays are payable twice per benefit year for individuals under age 19 and once per benefit year for individuals age 19 and over.
  2. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.
  3. Any combination of teeth cleanings (prophylaxes), full mouth debridement, scaling in the presence of inflammation, and periodontal maintenance are payable twice per benefit year.
  4. Oral exams or evaluations are payable twice per benefit year, regardless of the dentist’s specialty.
  5. Patient screening is payable once per calendar year.
  6. Preventive fluoride treatments are payable twice per benefit year for individuals under age 19.
  7. Space maintainers are payable for individuals under age 19. A distal shoe space maintainer is only payable for first permanent molars to individuals under the age of 9.
  8. Sealants are payable once per tooth per three-year period on unrestored permanent molars for individuals under age 19.
  9. Preventative resin restorations are payable once per tooth per three-year period on permanent teeth for a moderate to high carries risk patient.
  10. Prefabricated stainless steel crowns are payable once per tooth per five-year period for individuals under age 15.
  11. Cast restorations (including jackets, crowns, onlays) and associated procedures (such as core buildups and post substructures) are payable once in any five-year period per tooth.
  12. Crowns, onlays and associated procedures (such as core buildups and post substructures) are payable once in any five-year period per tooth.
  13. Crowns or onlays are payable only for extensive loss of tooth structure due to caries and/or fracture (lost or mobile tooth structure).
  14. Individual crowns over implants are payable at the prosthodontic benefit level.
  15. Substructures, porcelain, porcelain substrate and cast restorations are not payable for individuals under age 12.
  16. An occlusal guard is payable once per benefit year for children from age 13 to age 19, and once per lifetime for individuals age 19 years of age and over.
  17. For individuals under age 19, an interim partial denture is payable only for the replacement of permanent anterior teeth. For people 19 years of age or older, an interim partial denture is payable only for the replacement of permanent anterior teeth during the healing period.
  18. Prosthodontic services reductions:
      1. One complete upper, one complete lower denture, and any impant used to support a denture are payable once in any five-year period.
      2. A removable partial denture, endosteal implant (other to support a denture) or fixed bridge is payable once in any five-year period unless the loss of additional teeth requires the construction of a new appliance.
      3. Fixed bridges and removable partial dentures are not payable for individuals under age 16.
      4. A reline or the complete replacement of denture base material is payable once in any three-year period per appliance.
      5. Implant removal is payable once in any five-year period per tooth or area.
      6. Removal of a broken implant retaining screw is payable once in a five-year period.
  19. Orthodontic services reductions, pursuant to your Summary Dental Plan of Benefits.
      1. Orthodontic services are payable for individuals under age 19 when deemed medically necessary.
      2. If the treatment plan terminates before completion for any reason, Delta Dental’s obligation for payment ends on the last day of the month in which the patient was last treated.
      3. Upon written notification to Delta Dental and to the patient, a dentist may terminate treatment for lack of patient interest and cooperation. In those cases, Delta Dental’s obligation for payment ends on the last day of the month in which the patient was last treated.
      4. An observation and adjustment is payable twice in a 12-month period.
  20. Delta Dental’s obligation for payment of benefits ends on the last day of coverage unless services are completed within a 30-day period measured from the date of termination. Delta Dental will make payment for Covered Services provided on or before the last day of coverage as long as we receive a claim for those services within 180 days of the date of service unless it was not reasonably possible for the claim to be filed within such time, provided such claim is submitted as soon as reasonably possible, in no event, except in the case of your legal incapacity, later than one year from the time submittal of the claim is otherwise required.
  21. When services in progress are interrupted and completed later by another dentist, we will review the claim to determine the amount of payment, if any, to each dentist.
  22. Care terminated due to the death of an eligible person will be paid to the limit of our liability for the services completed or in progress.
  23. Prefabricated crowns used as final restorations on permanent teeth are limited to individuals under the age of 19.
  24. Metal bases on removable prostheses are limited to individuals under the age of 19.
  25. Radiographic/surgical implant index are limited to individuals under the age of 19.
  26. Diagnostic photographs and cephalometric films are limited to individuals under the age of 19 unless such services were performed in conjunction with orthodontic services and orthodontics are a Covered Service.
  27. Optional treatment: If you select a more expensive service than is customarily provided, Delta Dental may make an allowance for certain services based on the fee for the customarily provided service. You are responsible for the difference in cost. In all cases, Delta Dental will make the final determination regarding optional treatment and any available allowance.
  28. Listed below are services for which Delta Dental will provide an allowance for optional treatment. Remember, you are responsible for the difference in cost for any optional treatment.
      1. Resin, porcelain fused to metal and porcelain crowns, bridge retainers, or pontics on posterior teeth—Delta Dental will pay only the applicable amount that it would pay for a full metal crown.
      2. Overdentures—Delta Dental will pay only the amount that it would pay for a conventional denture.
      3. Plastic, resin, porcelain/ceramic onlays—Delta Dental will pay only the applicable amount that it would pay for a metallic onlay.
      4. Inlays, regardless of the material used—Delta Dental will pay only the amount that it would pay for an amalgam or composite resin restoration (depending on the tooth being restored).
      5. All-porcelain/ceramic bridges—Delta Dental will pay only the applicable amount that it would pay for a conventional fixed bridge.
      6. Implant/abutment supported complete or partial dentures—Delta Dental will pay only the amount that it would pay for a conventional denture.
      7. Gold foil restorations—Delta Dental will pay only the amount that it would pay for an amalgam or composite restoration.
      8. Posterior stainless steel crowns with esthetic facings, veneers or coatings—Delta Dental will pay only the amount that it would pay for a conventional stainless steel crown.
  29. Maximum payment:
      1. The maximum benefits payable in any one benefit year will be limited to the Maximum Payment stated in the Summary of Dental Plan Benefits.
      2. Delta Dental’s payment for orthodontic services will be limited to the annual or lifetime Maximum Payment stated in the Summary of Dental Plan Benefits.
  30. If a Deductible amount is stated in the Summary of Dental Plan Benefits, Delta Dental will not pay for any services or supplies, in whole or in part, to which the Deductible applies until the Deductible amount is met.
  31. Processing Policies may otherwise limit Delta Dental’s payment for services or supplies.

   

  Delta Dental will make no payment for services or supplies that exceed the following limits. However, Delta Dental PPO dentists or Delta Dental Premier dentists may not charge eligible persons for these services or supplies when performed by the same dentist or dental office. All charges from nonparticipating dentists for services that exceed these limits will be your responsibility. All time limitations are measured from the applicable prior dates of services in our records with any of our benefit plans.

  1. Core buildups and other substructures are payable only when needed to retain a crown on a tooth with excessive breakdown due to caries and/or fractures.
  2. Root planing is payable once in any two-year period.
  3. Periodontal surgery is payable once in any three-year period.
  4. A complete occlusal adjustment is payable once in any five-year period. The fee for a complete occlusal adjustment includes all adjustments that are necessary for a five-year period. A limited occlusal adjustment is not payable more than three times in any five-year period. The fee for a limited occlusal adjustment includes all adjustments that are necessary for a six-month period.
  5. Distal shoe space maintainers are only payable for individuals under the age of 9.
  6. One caries risk assessment is allowed on the same date of service.
  7. One caries risk assessment is allowed within a 12-month period when done by the same dentist/dental office.
  8. Services or supplies, as determined by us, which are not provided in accordance with generally accepted standards of dental practice.

   

  Delta Dental will make no payment for services or supplies that exceed the following reductions for people age 19 and over. In addition, participating dentists may not charge any individual, regardless of age, for these services or supplies when performed by the same dentist or dental office. All time limitations are measured from the applicable prior dates of services in our records with any Delta Dental Plan.

  1. Amalgam and composite resin restorations are payable once within a two-year period, regardless of the number or combination of restorations placed on a surface.
  2. Recementation of a crown, onlay, inlay, space maintainer, or bridge within six months of the seating date.
  3. Retention pins are payable once in a two-year period. Only one substructure per tooth is a Covered Service.
  4. Tissue conditioning is payable twice per arch in any three-year period.
  5. The allowance for a denture repair (including reline or rebase) will not exceed half the fee for a new denture.
  6. Distal shoe space maintainers are only payable for individuals under the age of 9.
  7. One caries risk assessment is allowed on the same date of service.
  8. One caries risk assessment is allowed within a 12-month period when done by the same dentist/dental office.

• EHB-Certified Plans (QINVD-100-Delta-2023-NC)

  Delta Dental will make no payment for the following services or supplies, unless otherwise specified in the Summary of Dental Plan Benefits, and all charges for the following services or supplies will be the responsibility of the Insured: 

  1. Services or supplies for the treatment of an occupational injury or sickness which are payable under the North Carolina Workers’ Compensation Act only to the extent such services or supplies are the liability of the employee, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ Compensation Act. NOTE: This provision does not apply to any programs provided under Medicaid or Medicare.
  2. Services or supplies, as determined by Delta Dental, for correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons. This exclusion does not apply to any newborn, adopted, or foster child who becomes covered under this Policy after the Effective Date.
  3. Cosmetic surgery or dentistry for aesthetic reasons, as determined by Delta Dental. This exclusion does not apply to any newborn, adopted, or foster child who becomes covered under this Policy after the Effective Date.
  4. Charges for services or appliances incurred prior to the date the person became covered under this Policy.
  5. Prescription drugs (except intramuscular injectable antibiotics), premedication, medicaments/ solutions and relative analgesia.
  6. General anesthesia and intravenous sedation, unless medically necessary.
  7. Charges for hospitalization, laboratory tests, histopathological examinations and miscellaneous tests.
  8. Charges for failure to keep a scheduled visit with the dentist.
  9. Services or supplies, as determined by Delta Dental, for which no valid dental need can be demonstrated.
  10. Services or supplies, as determined by Delta Dental, that are investigational in nature including services or supplies required to treat complications from investigational procedures.
  11. Services or supplies, as determined by Delta Dental, which are specialized techniques.
  12. Services or supplies, as determined by Delta Dental, which are not provided in accordance with generally accepted standards of dental practice.
  13. Treatment by other than a dentist, except for services performed by a licensed dental hygienist under the supervision of a licensed dentist or other licensed dental professional, may be covered only and solely determined by Delta Dental.
  14. Services or supplies excluded by the policies and procedures of Delta Dental, including the Processing Policies.
  15. Services or supplies for which no charge is made, for which the patient is not legally obligated to pay, or for which no charge would be made in the absence of Delta Dental coverage.
  16. Services or supplies received due to an act of war, declared or undeclared. This exclusion does not apply to acts of terrorism.
  17. Services or supplies not within the categories of benefits that have been selected and that are not covered under the terms of the Policy.
  18. Fluoride rinses, self-applied fluorides or desensitizing medicaments.
  19. Preventive control programs (including oral hygiene instruction, caries susceptibility tests, dietary control, tobacco counseling, home care medicaments, etc.).
  20. Lost, missing or stolen appliances of any type and replacement or repair of orthodontic appliances or space maintainers.
  21. Cosmetic dentistry, (except that when a child covered from the moment of birth or placement in the adoptive or foster home requires dental care associated with congenital defects and anomalies, those defects or anomalies will be covered to the same extent an otherwise Covered Service is provided by this Policy) including repairs to facings posterior to the second bicuspid position.
  22. Veneers.
  23. Prefabricated crowns used as final restorations on permanent teeth for people over age 15.
  24. Appliances, surgical procedures and restorations for increasing vertical dimension; for altering, restoring, or maintaining occlusion; for replacing tooth structure loss resulting from attrition, abrasion, abfraction, or erosion; or for periodontal splinting. This exception will not apply to medically necessary orthodontic services for individuals under age 19 as limited by the terms and conditions of the Policy.
  25. Paste-type root canal fillings on permanent teeth.
  26. Replacement, repair, relines, or adjustments of occlusal guards.
  27. Chemical curettage.
  28. Services associated with overdentures.
  29. Metal bases on removable prostheses for people age 19 and over.
  30. The replacement of teeth beyond the normal complement of teeth.
  31. Personalization or characterization of any service or appliance.
  32. Temporary crowns used for temporization during crown or bridge fabrication.
  33. Posterior bridges in conjunction with partial dentures in the same arch.
  34. Precision attachments and stress breakers.
  35. Bone replacement grafts and specialized implant surgical techniques.
  36. Radiographic/surgical implant index for people age 19 and over.
  37. Appliances, restorations or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ).
  38. Non-medically necessary orthodontic services for children under age 19, and any orthodontic services for people age 19 and over.
  39. Diagnostic photographs and cephalometric films for people age 19 and over, unless done for orthodontics and orthodontics are a Covered Service.
  40. Myofunctional therapy.
  41. Mounted case analyses.
  42. Implants for individuals age 19 and over.
  43. Any and all taxes applicable to the services.
  44. Interim caries arresting medicament.
  45. Sealants, for individuals 19 years of age and older.
  46. Implant/abutment supported interim fixed denture for edentulous arch.
  47. Biologic materials to aid in soft and osseous tissue regeneration when submitted on the same day as soft tissue grafting, guided tissue regeneration and periodontal or implant bone grafting.

   

  Delta Dental will make no payment for the following services or supplies. Participating dentists may not charge eligible people for these services supplies. All charges from nonparticipating dentists for the following services or supplies are your responsibility:

  1. The completion of forms or submission of claims.
  2. Consultations, patient screening or patient assessment when performed in conjunction with examinations or evaluations.
  3. Local anesthesia.
  4. Acid etching, cement bases, cavity liners, and bases or temporary fillings.
  5. Infection control.
  6. Temporary, interim or provisional crowns.
  7. Gingivectomy as an aid to the placement of a restoration.
  8. The correction of occlusion, when performed with prosthetics and restorations involving occlusal surfaces.
  9. Diagnostic casts, when performed in conjunction with restorative or prosthodontic procedures.
  10. Palliative treatment, when any other service is provided on the same date except X-rays and tests necessary to diagnose the emergency condition.
  11. Post-operative X-rays, when done following any completed service or procedure.
  12. Periodontal charting.
  13. Pins and preformed posts, when done with core buildups for crowns, onlays or inlays.
  14. A pulp cap, when done with a sedative filling or any other restoration. A sedative or temporary filling, when done with pulpal debridement for the relief of acute pain prior to conventional root canal therapy or another endodontic procedure. The opening and drainage of a tooth or palliative treatment, when done by the same dentist or dental office on the same day as completed root canal treatment.
  15. A pulpotomy on a permanent tooth, except on a tooth with an open apex.
  16. A therapeutic apical closure on a permanent tooth, except on a tooth where the root is not fully formed.
  17. Retreatment of a root canal by the same Dentist or dental office within two years of the original root canal treatment for individuals over the age of 19.
  18. A prophylaxis or full mouth debridement, when done on the same day as periodontal maintenance or scaling in the presence of gingival inflammation.
  19. Scaling in the presence of gingival inflammation when done on the same day as periodontal maintenance.
  20. Prophylaxis, scaling in the presence of gingival inflammation, or periodontal maintenance when done within 30 days of three or four quadrants of scaling and root planing or other periodontal treatment.
  21. Full mouth debridement when done within 30 days of scaling and root planing.
  22. Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of implant services without flap entry and closure, when performed within 12 months of implant restorations, provisional implant crowns and implant or abutment supported interim dentures.
  23. Full mouth debridement, when done on the same day as a comprehensive evaluation.
  24. An occlusal adjustment, when performed on the same day as the delivery of an occlusal guard.
  25. Reline, rebase, or any adjustment or repair within six months of the delivery of a partial denture.
  26. Tissue conditioning, when performed on the same day as the delivery of a denture or the reline or rebase of a denture.
  27. Periapical and/or bitewing X-rays, when done within seven days, a clinically unreasonable period of time of performing panoramic and/or full mouth X-rays, as determined solely by Delta Dental.
  28. Teledentistry fees.
  29. Services or supplies, as determined by Delta Dental, which are not provided in accordance with generally accepted standards of dental practice.

   

  The benefits for the following services are limited as follows, unless otherwise specified in the Summary of Dental Plan Benefits. All charges for services and supplies that exceed these limits will be the responsibility of the Insured. All time limitations are measured from the applicable prior dates of service in our records in any Delta Dental plan:

  1. Bitewing X-rays are payable twice per benefit year for individuals under age 19 and once per benefit year for individuals age 19 and over.
  2. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.
  3. Any combination of teeth cleanings (prophylaxes), full mouth debridement, scaling in the presence of inflammation, and periodontal maintenance are payable twice per benefit year.
  4. Oral exams or evaluations are payable twice per benefit year, regardless of the dentist’s specialty.
  5. Patient screening is payable once per calendar year.
  6. Preventive fluoride treatments are payable twice per benefit year for individuals under age 19.
  7. Space maintainers are payable for individuals under age 19. A distal shoe space maintainer is only payable for first permanent molars to individuals under the age of 9.
  8. Sealants are payable once per tooth per three-year period on unrestored permanent molars for individuals under age 19.
  9. Preventative resin restorations are payable once per tooth per three-year period on permanent teeth for a moderate to high carries risk patient.
  10. Prefabricated stainless steel crowns are payable once per tooth per five-year period for individuals under age 15.
  11. Cast restorations (including jackets, crowns, onlays) and associated procedures (such as core buildups and post substructures) are payable once in any five-year period per tooth.
  12. Crowns, onlays and associated procedures (such as core buildups and post substructures) are payable once in any five-year period per tooth.
  13. Crowns or onlays are payable only for extensive loss of tooth structure due to caries and/or fracture (lost or mobile tooth structure).
  14. Individual crowns over implants are payable at the prosthodontic benefit level.
  15. Substructures, porcelain, porcelain substrate and cast restorations are not payable for individuals under age 12.
  16. An occlusal guard is payable once per benefit year for children from age 13 to age 19, and once per lifetime for individuals age 19 years of age and over.
  17. For individuals under age 19, an interim partial denture is payable only for the replacement of permanent anterior teeth. For people 19 years of age or older, an interim partial denture is payable only for the replacement of permanent anterior teeth during the healing period.
  18. Prosthodontic services reductions:
      1. One complete upper, one complete lower denture, and any impant used to support a denture are payable once in any five-year period.
      2. A removable partial denture, endosteal implant (other to support a denture) or fixed bridge is payable once in any five-year period unless the loss of additional teeth requires the construction of a new appliance.
      3. Fixed bridges and removable partial dentures are not payable for individuals under age 16.
      4. A reline or the complete replacement of denture base material is payable once in any three-year period per appliance.
      5. Implant removal is payable once in any five-year period per tooth or area.
      6. Removal of a broken implant retaining screw is payable once in a five-year period.
  19. Orthodontic services reductions, pursuant to your Summary Dental Plan of Benefits.
      1. Orthodontic services are payable for individuals under age 19 when deemed medically necessary.
      2. If the treatment plan terminates before completion for any reason, Delta Dental’s obligation for payment ends on the last day of the month in which the patient was last treated.
      3. Upon written notification to Delta Dental and to the patient, a dentist may terminate treatment for lack of patient interest and cooperation. In those cases, Delta Dental’s obligation for payment ends on the last day of the month in which the patient was last treated.
      4. An observation and adjustment is payable twice in a 12-month period.
  20. Delta Dental’s obligation for payment of benefits ends on the last day of coverage unless services are completed within a 30-day period measured from the date of termination. Delta Dental will make payment for Covered Services provided on or before the last day of coverage as long as we receive a claim for those services within 180 days of the date of service unless it was not reasonably possible for the claim to be filed within such time, provided such claim is submitted as soon as reasonably possible, in no event, except in the case of your legal incapacity, later than one year from the time submittal of the claim is otherwise required.
  21. When services in progress are interrupted and completed later by another dentist, we will review the claim to determine the amount of payment, if any, to each dentist.
  22. Care terminated due to the death of an eligible person will be paid to the limit of our liability for the services completed or in progress.
  23. Prefabricated crowns used as final restorations on permanent teeth are limited to individuals under the age of 19.
  24. Metal bases on removable prostheses are limited to individuals under the age of 19.
  25. Radiographic/surgical implant index are limited to individuals under the age of 19.
  26. Diagnostic photographs and cephalometric films are limited to individuals under the age of 19 unless such services were performed in conjunction with orthodontic services and orthodontics are a Covered Service.
  27. Optional treatment: If you select a more expensive service than is customarily provided, Delta Dental may make an allowance for certain services based on the fee for the customarily provided service. You are responsible for the difference in cost. In all cases, Delta Dental will make the final determination regarding optional treatment and any available allowance.
  28. Listed below are services for which Delta Dental will provide an allowance for optional treatment. Remember, you are responsible for the difference in cost for any optional treatment.
      1. Resin, porcelain fused to metal and porcelain crowns, bridge retainers, or pontics on posterior teeth—Delta Dental will pay only the applicable amount that it would pay for a full metal crown.
      2. Overdentures—Delta Dental will pay only the amount that it would pay for a conventional denture.
      3. Plastic, resin, porcelain/ceramic onlays—Delta Dental will pay only the applicable amount that it would pay for a metallic onlay.
      4. Inlays, regardless of the material used—Delta Dental will pay only the amount that it would pay for an amalgam or composite resin restoration (depending on the tooth being restored).
      5. All-porcelain/ceramic bridges—Delta Dental will pay only the applicable amount that it would pay for a conventional fixed bridge.
      6. Implant/abutment supported complete or partial dentures—Delta Dental will pay only the amount that it would pay for a conventional denture.
      7. Gold foil restorations—Delta Dental will pay only the amount that it would pay for an amalgam or composite restoration.
      8. Posterior stainless steel crowns with esthetic facings, veneers or coatings—Delta Dental will pay only the amount that it would pay for a conventional stainless steel crown.
  29. Maximum payment:
      1. The maximum benefits payable in any one benefit year will be limited to the Maximum Payment stated in the Summary of Dental Plan Benefits.
      2. Delta Dental’s payment for orthodontic services will be limited to the annual or lifetime Maximum Payment stated in the Summary of Dental Plan Benefits.
  30. If a Deductible amount is stated in the Summary of Dental Plan Benefits, Delta Dental will not pay for any services or supplies, in whole or in part, to which the Deductible applies until the Deductible amount is met.
  31. Processing Policies may otherwise limit Delta Dental’s payment for services or supplies.

   

  Delta Dental will make no payment for services or supplies that exceed the following limits. However, Delta Dental PPO dentists or Delta Dental Premier dentists may not charge eligible persons for these services or supplies when performed by the same dentist or dental office. All charges from nonparticipating dentists for services that exceed these limits will be your responsibility. All time limitations are measured from the applicable prior dates of services in our records with any of our benefit plans.

  1. Core buildups and other substructures are payable only when needed to retain a crown on a tooth with excessive breakdown due to caries and/or fractures.
  2. Root planing is payable once in any two-year period.
  3. Periodontal surgery is payable once in any three-year period.
  4. A complete occlusal adjustment is payable once in any five-year period. The fee for a complete occlusal adjustment includes all adjustments that are necessary for a five-year period. A limited occlusal adjustment is not payable more than three times in any five-year period. The fee for a limited occlusal adjustment includes all adjustments that are necessary for a six-month period.
  5. Distal shoe space maintainers are only payable for individuals under the age of 9.
  6. One caries risk assessment is allowed on the same date of service.
  7. One caries risk assessment is allowed within a 12-month period when done by the same dentist/dental office.
  8. Services or supplies, as determined by us, which are not provided in accordance with generally accepted standards of dental practice.

   

  Delta Dental will make no payment for services or supplies that exceed the following reductions for people age 19 and over. In addition, participating dentists may not charge any individual, regardless of age, for these services or supplies when performed by the same dentist or dental office. All time limitations are measured from the applicable prior dates of services in our records with any Delta Dental Plan.

  1. Amalgam and composite resin restorations are payable once within a two-year period, regardless of the number or combination of restorations placed on a surface.
  2. Recementation of a crown, onlay, inlay, space maintainer, or bridge within six months of the seating date.
  3. Retention pins are payable once in a two-year period. Only one substructure per tooth is a Covered Service.
  4. Tissue conditioning is payable twice per arch in any three-year period.
  5. The allowance for a denture repair (including reline or rebase) will not exceed half the fee for a new denture.
  6. Distal shoe space maintainers are only payable for individuals under the age of 9.
  7. One caries risk assessment is allowed on the same date of service.
  8. One caries risk assessment is allowed within a 12-month period when done by the same dentist/dental office.

• Non-EHB Plans (INDV-100-Delta-2022-NC)

  Delta Dental will make no payment for the following services or supplies, unless otherwise specified in the Summary of Dental Plan Benefits, and all charges for these services will be the responsibility of the Insured:

  1. Services for injuries or conditions payable under Workers’ Compensation or Employer’s Liability laws. Services received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Medicaid or Medicare.

  2. Services or supplies, as determined by Delta Dental, for correction of congenital or developmental malformations. This exclusion does not apply to any newborn, adopted, or foster Child who becomes covered under this Policy after the Effective Date.

  3. Cosmetic surgery or dentistry for aesthetic reasons, as determined by Delta Dental. This exclusion does not apply to any newborn, adopted, or foster Child who becomes covered under this Policy after the Effective Date.

  4. Services started or appliances started before a person became eligible under this Policy.  This exclusion does not apply to orthodontic treatment in progress (if a Covered Service).

  5. Prescription drugs (except intramuscular injectable antibiotics), premedication, medicaments/ solutions, and relative analgesia.

  6. General anesthesia and intravenous sedation for (a) surgical procedures, unless medically necessary, or (b) restorative dentistry.

  7. Charges for hospitalization, laboratory tests, histopathological examinations and miscellaneous tests.

  8. Charges for failure to keep a scheduled visit with the Dentist.

  9. Services or supplies, as determined by Delta Dental, for which no valid dental need can be demonstrated.

  10. Services or supplies, as determined by Delta Dental, that are investigational in nature including services or supplies required to treat complications from investigational procedures

  11. Services or supplies, as determined by Delta Dental, which are specialized techniques.

  12. Services or supplies, as determined by Delta   Dental, which are not provided in accordance with generally accepted standards of dental practice.

  13. Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other dental professional, as determined by Delta Dental, under the scope of his or her license as permitted by applicable state law.

  14. Services or supplies excluded by the policies and procedures of Delta Dental, including the Processing Policies.

  15. Services or supplies for which no charge is made, for which the patient is not legally obligated to pay, or for which no charge would be made in the absence of Delta Dental coverage.

  16. Services or supplies received due to an act of war, declared or undeclared, or terrorism.

  17. Services or supplies covered under a hospital, surgical/medical, or prescription drug program.

  18. Services or supplies not within the categories of Benefits that have been selected and that are not covered under the terms of the Policy.

  19. Fluoride rinses, self-applied fluorides, or desensitizing medicaments.

  20. Interim caries arresting medicament.

  21. Preventive control programs (including oral hygiene instruction, caries susceptibility tests, dietary control, tobacco counseling, home care medicaments, etc.).

  22. Sealants.

  23. Space maintainers for maintaining space due to premature loss of anterior primary teeth.

  24. Lost, missing, or stolen appliances of any type, or replacement or repair of orthodontic appliances or space maintainers.

  25. Cosmetic dentistry, except that when a Child covered from the moment of birth or placement in the adoptive or foster home requires dental care associated with congenital defects and anomalies, those defects or anomalies will be covered to the same extent an otherwise Covered Service is provided by this Policy including repairs to facings posterior to the second bicuspid position.

  26. Veneers.

  27. Prefabricated crowns used as final restorations on permanent teeth.

  28. Appliances, surgical procedures, and restorations for increasing vertical dimension; for altering, restoring, or maintaining occlusion; for replacing tooth structure loss resulting from attrition, abrasion, abfraction, or erosion; or for periodontal splinting. If Orthodontic Services are Covered Services, this exclusion will not apply to Orthodontic Services as limited by the terms and conditions of the Policy.

  29. Implant/abutment supported interim fixed denture for edentulous arch.

  30. Paste-type root canal fillings on permanent teeth.

  31. Replacement, repair, relines, or adjustments of occlusal guards.

  32. Chemical curettage, for individuals 19 years of age or older.

  33. Services associated with overdentures.

  34. Metal bases on removable prostheses.

  35. The replacement of teeth beyond the normal complement of teeth.

  36. Personalization or characterization of any service or appliance.

  37. Temporary crowns used for temporization during crown or bridge fabrication.

  38. Posterior bridges in conjunction with partial dentures in the same arch.

  39. Precision attachments and stress breakers.

  40. Biologic materials to aid in soft and osseous tissue regeneration when submitted on the same day as soft tissue grafting, guided tissue regeneration and periodontal or implant bone grafting.

  41. Bone replacement grafts and specialized implant surgical techniques, including radiographic/surgical implant index.

  42. Appliances, restorations, or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ).

  43. Orthodontic services.

  44. Diagnostic photographs and cephalometric films, unless done for Orthodontics and Orthodontics are a Covered Service.

  45. Myofunctional therapy.

  46. Mounted case analyses.

  47. Any and all taxes applicable to the services.

  48. Processing policies may otherwise exclude payment by Delta Dental for services or supplies. 

  Delta Dental will make no payment for the following services. Participating Dentists may not charge Eligible Persons for these services.  All charges from Nonparticipating Dentists for the following services will be the responsibility of the Insured:

  1. The completion of forms or submission of Claims.

  2. Consultations, patient screening, or patient assessment when performed in conjunction with examinations or evaluations. 

  3. Local anesthesia.

  4. Acid etching, cement bases, cavity liners, and bases or temporary fillings.

  5. Infection control.

  6. Temporary, interim, or provisional crowns.

  7. Gingivectomy as an aid to the placement of a restoration.

  8. The correction of occlusion, when performed with prosthetics and restorations involving occlusal surfaces.

  9. Diagnostic casts, when performed in conjunction with restorative or prosthodontic procedures.

  10. Palliative treatment, when any other service is provided on the same date except X-rays and tests necessary to diagnose the emergency condition.

  11. Post-operative X-rays, when done following any completed service or procedure.

  12. Periodontal charting. 

  13. Pins and preformed posts, when done with core buildups.

  14. Any substructure when done for inlays, onlays, and veneers.

  15. A pulp cap, when done with a sedative filling or any other restoration.  A sedative or temporary filling, when done with pulpal debridement for the relief of acute pain prior to conventional root canal therapy or another endodontic procedure.  The opening and drainage of a tooth or palliative treatment, when done by the same Dentist or dental office on the same day as completed root canal treatment.

  16. A pulpotomy on a permanent tooth, except on a tooth with an open apex.

  17. A therapeutic apical closure on a permanent tooth, except on a tooth where the root is not fully formed.

  18. Retreatment of a root canal by the same Dentist or dental office within two years of the original root canal treatment.

  19. A prophylaxis or full mouth debridement, when done on the same day as periodontal maintenance or scaling in the presence of gingival inflammation.

  20. Scaling in the presence of gingival inflammation when done on the same day as periodontal maintenance.

  21. Prophylaxis, scaling in the presence of gingival inflammation, or periodontal maintenance when done within 30 days of three or four quadrants of scaling and root planing or other periodontal treatment.

  22. Full mouth debridement when done within 30 days of scaling and root planing.

  23. Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces without flap entry and closure, when performed within 12 months of implant restorations, provisional implant crowns and implant or abutment supported interim dentures.

  24. Scaling and debridement in the presence of inflammation or mucositis of a single implant when done on the same day as a prophylaxis, periodontal maintenance, full mouth debridement, periodontal scaling and root planing, periodontal surgery or debridement of a peri-implant defect.

  25. Full mouth debridement, when done on the same day as a comprehensive evaluation.

  26. A sealant, sealant repair, preventive resin restoration or interim caries arresting medicament is not payable when done on the same day as a sealant, sealant repair, preventive resin restoration or interim caries arresting medicament performed on the same tooth. 

  28. An occlusal adjustment, when performed on the same day as the delivery of an occlusal guard.

  29. Reline, rebase, or any adjustment or repair within six months of the delivery of a partial denture.

  30. Tissue conditioning, when performed on the same day as the delivery of a denture or the reline or rebase of a denture.

  31. Periapical and/or bitewing X-rays when done within a clinically unreasonable period of time of performing panoramic and/or full mouth X-rays, as determined solely by Delta Dental.

  32. Charges or fees for overhead, internet/video connections, software, hardware or other equipment necessary to deliver services, including but not limited to teledentistry services.

  The Benefits for the following services or supplies are limited as follows, unless otherwise specified in the Summary of Dental Plan Benefits. All charges for services or supplies that exceed these limitations will be your responsibility.  All time limitations are measured from the applicable prior dates of services in our records:

  1. Bitewing X-rays are payable once per Benefit Year. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.

  2. Any combination of teeth cleanings (prophylaxes, full mouth debridement, scaling in the presence of inflammation, and periodontal maintenance procedures) are limited to twice per Benefit Year. Full mouth debridement is payable once in a lifetime.

  3. Oral exams or evaluations are payable twice per Benefit Year, regardless of the Dentist’s specialty.

  4. Patient screening is payable once per Benefit Year.

  5. Preventive fluoride treatments are payable twice per Benefit Year for individuals under age 19. 

  6. Space maintainers are payable up to age 18.

  7. Cast restorations (including jackets, crowns and onlays) and associated procedures (such as core buildups and post substructures) are payable once in any five-year period per tooth.

  8. Sealants are limited to once per tooth per three-year period on unrestored permanent molars for individuals age 18 and under. 

  9. Preventative resin restorations are limited to once per tooth per three-year period on permanent teeth for a moderate to high carries risk patient.

  10. Prefabricated stainless steel crowns are limited to once per tooth per five-year period.

  11. Crowns, onlays and associated procedures (such as core buildups and post substructures) are limited to once in any five-year period per tooth.

  12. Crowns or onlays are payable only for extensive loss of tooth structure due to caries (decay) and/or fracture (lost or mobile tooth structure).

  13. Individual crowns over implants are payable at the prosthodontic benefit level once in a five year period.

  14. Substructures, porcelain, porcelain substrate and cast restorations are not payable for individuals under age 12.

  15. An occlusal guard is payable once in a lifetime.

  16. An interim partial is payable only for the replacement of permanent anterior teeth for individuals under age 17 or during the healing period for individuals age 17 and over.

  17. Biological material to aid in soft and osseous tissue regeneration are payable once per tooth in a 36 month period.

  18. Prosthodontic Services limitations:

  a. One complete upper, one complete lower denture, and any implant used to support a denture are limited to once in any five-year period.

  b. A removable partial denture, endosteal implant (other than to support a denture), or fixed bridge is payable once in any five-year period unless the loss of additional teeth requires the construction of a new appliance.

  c. Fixed bridges and removable partial dentures are not payable for individuals under age 16.

  d. A reline or the complete replacement of denture base material is payable once in any three-year period per appliance.

  e. Implant removal is payable once in any five-year period per tooth or area.

  f. Implant maintenance is payable once per Benefit Year.

  19. Orthodontic Services limitations, if covered under your Plan pursuant to your Summary of Dental Plan Benefits:

  a. If the treatment plan terminates before completion for any reason, Delta Dental’s obligation for payment ends on the last day of the month in which the patient was last treated.

  b. Upon written notification to Delta Dental and to the patient, a Dentist may terminate treatment for lack of patient interest and cooperation. In those cases, Delta Dental’s obligation for payment ends on the last day of the month in which the patient was last treated.

  c. Benefits for an observation and adjustment are limited to twice in a 12-month period.

  20. Delta Dental’s obligation for payment of Benefits ends on the last day of coverage. However, Delta Dental will make payment for Covered Services provided on or before the last day of coverage as long as Delta Dental receives a Claim for those services within one year of the date of service.

  21. When services in progress are interrupted, Delta Dental will not issue payment for any incomplete services; however, Delta Dental will calculate the Maximum Approved Fee that the dentist may charge you for such incomplete services, and those charges will be your responsibility.  In the event the interrupted services are completed later by a Dentist, Delta Dental will review the Claim to determine the amount of payment, if any, to the Dentist in accordance with Delta Dental’s policies at the time services are completed.

  22. Care terminated due to the death of an Eligible Person will be paid to the limit of Delta Dental’s liability for the services completed or in progress.

  23. Optional treatment: If you select a more expensive service than is customarily provided, Delta Dental may make an allowance for certain services based on the fee for the customarily provided service. You are responsible for the difference in cost.  In all cases, Delta Dental will make the final determination regarding optional treatment and any available allowance.

  Listed below are services for which Delta Dental will provide an allowance for optional treatment.  Remember, you are responsible for the difference in cost for any optional treatment.

  a. Plastic, resin, porcelain fused to metal, and porcelain crowns (including implant crowns), bridge retainers, or pontics on posterior teeth –Delta Dental will pay only the amount that it would pay for a full metal crown.

  b. Overdentures –Delta Dental will pay only the amount that it would pay for a conventional denture.

  c. Plastic, resin, or porcelain/ceramic onlays on posterior teeth –Delta Dental will pay only for the amount that it would pay for a metallic onlay.

  d. Inlays, regardless of the material used –Delta Dental will pay only the amount that it would pay for an amalgam or composite resin restoration.

  e. All-porcelain/ceramic bridges –Delta Dental will pay only for the amount that it would pay for a conventional fixed bridge.

  f. Implant/abutment supported complete or partial dentures –Delta Dental will pay only for the amount that it would pay for a conventional denture.

  g. Gold foil restorations –Delta Dental will pay only for the amount that it would pay for an amalgam or composite restoration.

  h. Posterior stainless steel crowns with esthetic facings, veneers or coatings –Delta Dental will pay only for the amount that it would pay for a conventional stainless steel crown.

  24.  Maximum Payment:

  a. All Benefits payable under This Plan are subject to the Maximum Payment limitations stated in your Summary of Dental Plan Benefits.

  b. Delta Dental’s payment for Orthodontic Services will be limited to the annual or lifetime Maximum Payment stated in your Summary of Dental Plan Benefits.

  25. If a Deductible amount is stated in the Summary of Dental Plan Benefits, Delta Dental will not pay for any services or supplies, in whole or in part, to which the Deductible applies until the Deductible amount is met.

  26. Processing Policies may otherwise limit by Delta Dental payment for services or supplies.

  Delta Dental will make no payment for services or supplies that exceed the following limitations. However, Participating Dentists may not charge eligible people for these services or supplies when performed by the same Dentist or dental office. All charges from Nonparticipating Dentists for services that exceed these limitations will be your responsibility.  All time limitations are measured from the applicable prior dates of services in our records.

  1. Amalgram and composite resin restorations are payable once in any two-year period, regardless of the number of combination of restorations placed on a surface.

  2. Core buildups and other substructures are payable only when needed to retain a crown on a tooth with excessive breakdown due to caries and/or fractures.

  3. Recementation of a crown, onlay, inlay, space maintainer, or bridge within six months of the seating date.

  4. Retention pins are payable once in any two-year period.  Only one substructure per tooth is a Covered Service.

  5. Root planing is limited to once in any two-year period.

  6. Periodontal surgery is limited to once in any three-year period.

  7. A complete occlusal adjustment is payable once in any five-year period. The fee for a complete occlusal adjustment includes all adjustments that are necessary for a five-year period. A limited occlusal adjustment is not payable more than three times in any five-year period. The fee for a limited occlusal adjustment includes all adjustments that are necessary for a six-month period.

  8. Tissue conditioning is payable twice per arch in any three-year period.

  9. The allowance for a denture repair (including reline or rebase) will not exceed half the fee for a new denture.

  10. Services or supplies, as determined by Delta Dental, which are not provided in accordance with generally accepted standards of dental practice.

  11. Scaling and debridement in the presence of inflammation or mucositis of a single implant is payable once per tooth in any 24-month period when performed by the same office.

  12. A sealant, sealant repair, preventive resin restoration or interim caries arresting medicament is not payable when done on the same day as restorations involving the occlusal surface when performed by the same office.

  13. A sealant, sealant repair or preventive resin restoration is not payable when performed within

  14. 24 months of a sealant, sealant repair or preventive resin restoration performed on the same tooth.

  15. Processing Policies may otherwise limit payment by Delta Dental for services or supplies. 

• Non-EHB Plans (INDV-100-Delta-2023-NC)

  Delta Dental will make no payment for the following services or supplies, unless otherwise specified in the Summary of Dental Plan Benefits, and all charges for these services will be the responsibility of the Insured:

  1. Services for injuries or conditions payable under Workers’ Compensation or Employer’s Liability laws. Services received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Medicaid or Medicare.

  2. Services or supplies, as determined by Delta Dental, for correction of congenital or developmental malformations. This exclusion does not apply to any newborn, adopted, or foster Child who becomes covered under this Policy after the Effective Date.

  3. Cosmetic surgery or dentistry for aesthetic reasons, as determined by Delta Dental. This exclusion does not apply to any newborn, adopted, or foster Child who becomes covered under this Policy after the Effective Date.

  4. Services started or appliances started before a person became eligible under this Policy.  This exclusion does not apply to orthodontic treatment in progress (if a Covered Service).

  5. Prescription drugs (except intramuscular injectable antibiotics), premedication, medicaments/ solutions, and relative analgesia.

  6. General anesthesia and intravenous sedation for (a) surgical procedures, unless medically necessary, or (b) restorative dentistry.

  7. Charges for hospitalization, laboratory tests, histopathological examinations and miscellaneous tests.

  8. Charges for failure to keep a scheduled visit with the Dentist.

  9. Services or supplies, as determined by Delta Dental, for which no valid dental need can be demonstrated.

  10. Services or supplies, as determined by Delta Dental, that are investigational in nature including services or supplies required to treat complications from investigational procedures

  11. Services or supplies, as determined by Delta Dental, which are specialized techniques.

  12. Services or supplies, as determined by Delta   Dental, which are not provided in accordance with generally accepted standards of dental practice.

  13. Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other dental professional, as determined by Delta Dental, under the scope of his or her license as permitted by applicable state law.

  14. Services or supplies excluded by the policies and procedures of Delta Dental, including the Processing Policies.

  15. Services or supplies for which no charge is made, for which the patient is not legally obligated to pay, or for which no charge would be made in the absence of Delta Dental coverage.

  16. Services or supplies received due to an act of war, declared or undeclared, or terrorism.

  17. Services or supplies covered under a hospital, surgical/medical, or prescription drug program.

  18. Services or supplies not within the categories of Benefits that have been selected and that are not covered under the terms of the Policy.

  19. Fluoride rinses, self-applied fluorides, or desensitizing medicaments.

  20. Interim caries arresting medicament.

  21. Preventive control programs (including oral hygiene instruction, caries susceptibility tests, dietary control, tobacco counseling, home care medicaments, etc.).

  22. Sealants.

  23. Space maintainers for maintaining space due to premature loss of anterior primary teeth.

  24. Lost, missing, or stolen appliances of any type, or replacement or repair of orthodontic appliances or space maintainers.

  25. Cosmetic dentistry, except that when a Child covered from the moment of birth or placement in the adoptive or foster home requires dental care associated with congenital defects and anomalies, those defects or anomalies will be covered to the same extent an otherwise Covered Service is provided by this Policy including repairs to facings posterior to the second bicuspid position.

  26. Veneers.

  27. Prefabricated crowns used as final restorations on permanent teeth.

  28. Appliances, surgical procedures, and restorations for increasing vertical dimension; for altering, restoring, or maintaining occlusion; for replacing tooth structure loss resulting from attrition, abrasion, abfraction, or erosion; or for periodontal splinting. If Orthodontic Services are Covered Services, this exclusion will not apply to Orthodontic Services as limited by the terms and conditions of the Policy.

  29. Implant/abutment supported interim fixed denture for edentulous arch.

  30. Paste-type root canal fillings on permanent teeth.

  31. Replacement, repair, relines, or adjustments of occlusal guards.

  32. Chemical curettage, for individuals 19 years of age or older.

  33. Services associated with overdentures.

  34. Metal bases on removable prostheses.

  35. The replacement of teeth beyond the normal complement of teeth.

  36. Personalization or characterization of any service or appliance.

  37. Temporary crowns used for temporization during crown or bridge fabrication.

  38. Posterior bridges in conjunction with partial dentures in the same arch.

  39. Precision attachments and stress breakers.

  40. Biologic materials to aid in soft and osseous tissue regeneration when submitted on the same day as soft tissue grafting, guided tissue regeneration and periodontal or implant bone grafting.

  41. Bone replacement grafts and specialized implant surgical techniques, including radiographic/surgical implant index.

  42. Appliances, restorations, or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ).

  43. Orthodontic services.

  44. Diagnostic photographs and cephalometric films, unless done for Orthodontics and Orthodontics are a Covered Service.

  45. Myofunctional therapy.

  46. Mounted case analyses.

  47. Any and all taxes applicable to the services.

  48. Processing policies may otherwise exclude payment by Delta Dental for services or supplies. 

  Delta Dental will make no payment for the following services. Participating Dentists may not charge Eligible Persons for these services.  All charges from Nonparticipating Dentists for the following services will be the responsibility of the Insured:

  1. The completion of forms or submission of Claims.

  2. Consultations, patient screening, or patient assessment when performed in conjunction with examinations or evaluations. 

  3. Local anesthesia.

  4. Acid etching, cement bases, cavity liners, and bases or temporary fillings.

  5. Infection control.

  6. Temporary, interim, or provisional crowns.

  7. Gingivectomy as an aid to the placement of a restoration.

  8. The correction of occlusion, when performed with prosthetics and restorations involving occlusal surfaces.

  9. Diagnostic casts, when performed in conjunction with restorative or prosthodontic procedures.

  10. Palliative treatment, when any other service is provided on the same date except X-rays and tests necessary to diagnose the emergency condition.

  11. Post-operative X-rays, when done following any completed service or procedure.

  12. Periodontal charting. 

  13. Pins and preformed posts, when done with core buildups.

  14. Any substructure when done for inlays, onlays, and veneers.

  15. A pulp cap, when done with a sedative filling or any other restoration.  A sedative or temporary filling, when done with pulpal debridement for the relief of acute pain prior to conventional root canal therapy or another endodontic procedure.  The opening and drainage of a tooth or palliative treatment, when done by the same Dentist or dental office on the same day as completed root canal treatment.

  16. A pulpotomy on a permanent tooth, except on a tooth with an open apex.

  17. A therapeutic apical closure on a permanent tooth, except on a tooth where the root is not fully formed.

  18. Retreatment of a root canal by the same Dentist or dental office within two years of the original root canal treatment.

  19. A prophylaxis or full mouth debridement, when done on the same day as periodontal maintenance or scaling in the presence of gingival inflammation.

  20. Scaling in the presence of gingival inflammation when done on the same day as periodontal maintenance.

  21. Prophylaxis, scaling in the presence of gingival inflammation, or periodontal maintenance when done within 30 days of three or four quadrants of scaling and root planing or other periodontal treatment.

  22. Full mouth debridement when done within 30 days of scaling and root planing.

  23. Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces without flap entry and closure, when performed within 12 months of implant restorations, provisional implant crowns and implant or abutment supported interim dentures.

  24. Scaling and debridement in the presence of inflammation or mucositis of a single implant when done on the same day as a prophylaxis, periodontal maintenance, full mouth debridement, periodontal scaling and root planing, periodontal surgery or debridement of a peri-implant defect.

  25. Full mouth debridement, when done on the same day as a comprehensive evaluation.

  26. A sealant, sealant repair, preventive resin restoration or interim caries arresting medicament is not payable when done on the same day as a sealant, sealant repair, preventive resin restoration or interim caries arresting medicament performed on the same tooth. 

  28. An occlusal adjustment, when performed on the same day as the delivery of an occlusal guard.

  29. Reline, rebase, or any adjustment or repair within six months of the delivery of a partial denture.

  30. Tissue conditioning, when performed on the same day as the delivery of a denture or the reline or rebase of a denture.

  31. Periapical and/or bitewing X-rays when done within a clinically unreasonable period of time of performing panoramic and/or full mouth X-rays, as determined solely by Delta Dental.

  32. Charges or fees for overhead, internet/video connections, software, hardware or other equipment necessary to deliver services, including but not limited to teledentistry services.

  The Benefits for the following services or supplies are limited as follows, unless otherwise specified in the Summary of Dental Plan Benefits. All charges for services or supplies that exceed these limitations will be your responsibility.  All time limitations are measured from the applicable prior dates of services in our records:

  1. Bitewing X-rays are payable once per Benefit Year. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.

  2. Any combination of teeth cleanings (prophylaxes, full mouth debridement, scaling in the presence of inflammation, and periodontal maintenance procedures) are limited to twice per Benefit Year. Full mouth debridement is payable once in a lifetime.

  3. Oral exams or evaluations are payable twice per Benefit Year, regardless of the Dentist’s specialty.

  4. Patient screening is payable once per Benefit Year.

  5. Preventive fluoride treatments are payable twice per Benefit Year for individuals under age 19. 

  6. Space maintainers are payable up to age 18.

  7. Cast restorations (including jackets, crowns and onlays) and associated procedures (such as core buildups and post substructures) are payable once in any five-year period per tooth.

  8. Sealants are limited to once per tooth per three-year period on unrestored permanent molars for individuals age 18 and under. 

  9. Preventative resin restorations are limited to once per tooth per three-year period on permanent teeth for a moderate to high carries risk patient.

  10. Prefabricated stainless steel crowns are limited to once per tooth per five-year period.

  11. Crowns, onlays and associated procedures (such as core buildups and post substructures) are limited to once in any five-year period per tooth.

  12. Crowns or onlays are payable only for extensive loss of tooth structure due to caries (decay) and/or fracture (lost or mobile tooth structure).

  13. Individual crowns over implants are payable at the prosthodontic benefit level once in a five year period.

  14. Substructures, porcelain, porcelain substrate and cast restorations are not payable for individuals under age 12.

  15. An occlusal guard is payable once in a lifetime.

  16. An interim partial is payable only for the replacement of permanent anterior teeth for individuals under age 17 or during the healing period for individuals age 17 and over.

  17. Biological material to aid in soft and osseous tissue regeneration are payable once per tooth in a 36 month period.

  18. Prosthodontic Services limitations:

  a. One complete upper, one complete lower denture, and any implant used to support a denture are limited to once in any five-year period.

  b. A removable partial denture, endosteal implant (other than to support a denture), or fixed bridge is payable once in any five-year period unless the loss of additional teeth requires the construction of a new appliance.

  c. Fixed bridges and removable partial dentures are not payable for individuals under age 16.

  d. A reline or the complete replacement of denture base material is payable once in any three-year period per appliance.

  e. Implant removal is payable once in any five-year period per tooth or area.

  f. Implant maintenance is payable once per Benefit Year.

  19. Orthodontic Services limitations, if covered under your Plan pursuant to your Summary of Dental Plan Benefits:

  a. If the treatment plan terminates before completion for any reason, Delta Dental’s obligation for payment ends on the last day of the month in which the patient was last treated.

  b. Upon written notification to Delta Dental and to the patient, a Dentist may terminate treatment for lack of patient interest and cooperation. In those cases, Delta Dental’s obligation for payment ends on the last day of the month in which the patient was last treated.

  c. Benefits for an observation and adjustment are limited to twice in a 12-month period.

  20. Delta Dental’s obligation for payment of Benefits ends on the last day of coverage. However, Delta Dental will make payment for Covered Services provided on or before the last day of coverage as long as Delta Dental receives a Claim for those services within one year of the date of service.

  21. When services in progress are interrupted, Delta Dental will not issue payment for any incomplete services; however, Delta Dental will calculate the Maximum Approved Fee that the dentist may charge you for such incomplete services, and those charges will be your responsibility.  In the event the interrupted services are completed later by a Dentist, Delta Dental will review the Claim to determine the amount of payment, if any, to the Dentist in accordance with Delta Dental’s policies at the time services are completed.

  22. Care terminated due to the death of an Eligible Person will be paid to the limit of Delta Dental’s liability for the services completed or in progress.

  23. Optional treatment: If you select a more expensive service than is customarily provided, Delta Dental may make an allowance for certain services based on the fee for the customarily provided service. You are responsible for the difference in cost.  In all cases, Delta Dental will make the final determination regarding optional treatment and any available allowance.

  Listed below are services for which Delta Dental will provide an allowance for optional treatment.  Remember, you are responsible for the difference in cost for any optional treatment.

  a. Plastic, resin, porcelain fused to metal, and porcelain crowns (including implant crowns), bridge retainers, or pontics on posterior teeth –Delta Dental will pay only the amount that it would pay for a full metal crown.

  b. Overdentures –Delta Dental will pay only the amount that it would pay for a conventional denture.

  c. Plastic, resin, or porcelain/ceramic onlays on posterior teeth –Delta Dental will pay only for the amount that it would pay for a metallic onlay.

  d. Inlays, regardless of the material used –Delta Dental will pay only the amount that it would pay for an amalgam or composite resin restoration.

  e. All-porcelain/ceramic bridges –Delta Dental will pay only for the amount that it would pay for a conventional fixed bridge.

  f. Implant/abutment supported complete or partial dentures –Delta Dental will pay only for the amount that it would pay for a conventional denture.

  g. Gold foil restorations –Delta Dental will pay only for the amount that it would pay for an amalgam or composite restoration.

  h. Posterior stainless steel crowns with esthetic facings, veneers or coatings –Delta Dental will pay only for the amount that it would pay for a conventional stainless steel crown.

  24.  Maximum Payment:

  a. All Benefits payable under This Plan are subject to the Maximum Payment limitations stated in your Summary of Dental Plan Benefits.

  b. Delta Dental’s payment for Orthodontic Services will be limited to the annual or lifetime Maximum Payment stated in your Summary of Dental Plan Benefits.

  25. If a Deductible amount is stated in the Summary of Dental Plan Benefits, Delta Dental will not pay for any services or supplies, in whole or in part, to which the Deductible applies until the Deductible amount is met.

  26. Processing Policies may otherwise limit by Delta Dental payment for services or supplies.

  Delta Dental will make no payment for services or supplies that exceed the following limitations. However, Participating Dentists may not charge eligible people for these services or supplies when performed by the same Dentist or dental office. All charges from Nonparticipating Dentists for services that exceed these limitations will be your responsibility.  All time limitations are measured from the applicable prior dates of services in our records.

  1. Amalgram and composite resin restorations are payable once in any two-year period, regardless of the number of combination of restorations placed on a surface.

  2. Core buildups and other substructures are payable only when needed to retain a crown on a tooth with excessive breakdown due to caries and/or fractures.

  3. Recementation of a crown, onlay, inlay, space maintainer, or bridge within six months of the seating date.

  4. Retention pins are payable once in any two-year period.  Only one substructure per tooth is a Covered Service.

  5. Root planing is limited to once in any two-year period.

  6. Periodontal surgery is limited to once in any three-year period.

  7. A complete occlusal adjustment is payable once in any five-year period. The fee for a complete occlusal adjustment includes all adjustments that are necessary for a five-year period. A limited occlusal adjustment is not payable more than three times in any five-year period. The fee for a limited occlusal adjustment includes all adjustments that are necessary for a six-month period.

  8. Tissue conditioning is payable twice per arch in any three-year period.

  9. The allowance for a denture repair (including reline or rebase) will not exceed half the fee for a new denture.

  10. Services or supplies, as determined by Delta Dental, which are not provided in accordance with generally accepted standards of dental practice.

  11. Scaling and debridement in the presence of inflammation or mucositis of a single implant is payable once per tooth in any 24-month period when performed by the same office.

  12. A sealant, sealant repair, preventive resin restoration or interim caries arresting medicament is not payable when done on the same day as restorations involving the occlusal surface when performed by the same office.

  13. A sealant, sealant repair or preventive resin restoration is not payable when performed within

  14. 24 months of a sealant, sealant repair or preventive resin restoration performed on the same tooth.

  15. Processing Policies may otherwise limit payment by Delta Dental for services or supplies.