Here is a summary of the plan for you and your covered dependents (if any). The information listed here is not a guarantee of payment. Payment is based on the Delta Dental allowance for each procedure. To be covered, services must be dentally necessary and in accordance with Delta Dental’s treatment guidelines. All services must be performed in a dental office.
Indicates Pre-Treatment is Estimate recommended. |
| |
Procedure |
Covered At |
Waiting Period |
Frequency/Limitations |
| Diagnostic |
| |
Oral exam |
100% |
None |
Once per policy year |
| |
Bitewing x-rays |
100% |
None |
One set per policy year |
| |
Complete x-ray series or panoramic film |
100% |
None |
Once every 60 months |
| |
Single x-rays |
100% |
None |
As required |
| Preventive |
| |
Cleaning |
100% |
None |
Once every 6 months |
| |
Fluoride treatment |
100% |
None |
For children under age 19 once per policy year |
| |
Sealants |
80% |
None |
For children under age 14, once every 24 months on unrestored permanent molars |
| |
Space maintainers |
80% |
None |
Once every 60 months for lost deciduous (baby) teeth |
| Restorative |
| |
Amalgam (silver) fillings |
80% |
None |
Composite (white) fillings on front teeth only. For composite fillings on back teeth, the plan pays up to what would have been paid for an amalgam filling. Patient is responsible for the balance up to the dentist's charge. |
| |
Recementing crowns or bridges |
80% |
None |
|
 |
Crowns over natural teeth, build ups, posts and cores |
50% |
12 months |
Replacement limited to once every 60 months |
| Endodontics |
| |
Root canal therapy |
80% |
None |
|
| Periodontics |
| |
Periodontal maintenance following active therapy |
80% |
None |
Two per policy year |
 |
Root planing and scaling |
80% |
None |
Once per quadrant every 24 months |
 |
Osseous (bone) surgery |
50% |
12 months |
Once per quadrant every 24 months |
 |
Gingivectomies |
50% |
12 months |
Once per site every 24 months |
 |
Soft tissue grafts |
50% |
12 months |
Once per site every 60 months |
 |
Crown lengthening |
50% |
12 months |
Once per site every 60 months |
| Prosthodontics |
| |
Repairs to existing partial or complete dentures |
80% |
None |
Once per policy year |
| |
Rebasing or relining of partial or complete dentures |
80% |
None |
Once every 60 months |
| Extractions and Oral Surgery |
| |
Extractions and other routine oral surgery when not covered by a patient's medical plan |
80% |
None |
|
| Other Services |
| |
Palliative treatment (minor procedures necessary to relieve acute pain) |
80% |
None |
Twice per policy year |
| |
General anesthesia or intravenous (I.V.) sedation for certain complex surgical procedures |
80% |
None |
|
| |