Benefit Summary
Federal Employee Voluntary Dental Plan
The information listed here is not a guarantee of payment. Payment is based on the Delta Dental allowance for eachprocedure. 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. These benefits are listed according to the level of coverage (i.e. 100%,80%).
The annual maximum is: $1,500 per member per calendar year
The annual deductible is: $0.00
The maximum lifetime cap: Unlimited
Pretreatment estimates are recommended for underlined procedures.
Plan pays 100%; Member Coinsurance 0%
- One oral exam per calendar year performed by a general dentist
- Two cleanings per calendar year
- Fluoride treatment for children under age 19 once per calendar year
- One set of bitewing x-rays per calendar year
- One complete x-ray series or panoramic film every 60 months
- Single x-rays as required
- Sealants for children under age 14, once per unrestored permanent molar every 24 months
Plan pays 80%; Member Coinsurance 20%
- Palliative treatment (minor procedures necessary to relieve acute pain) twice per calendar year
- Amalgam (silver) fillings. 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. The patient is responsible for the balance up to the dentist's charge.
- Space maintainers for lost deciduous (baby) teeth, replacement limited to once every 60 months
- Extractions and other routine oral surgery not covered by a patient's medical plan
- General anesthesia or intravenous (I.V.) sedation for certain complex surgical procedures
- Root canal therapy
- Repairs to existing partial or complete dentures once per calendar year
- Recementing crowns or bridges
- Rebasing or relining of partial or complete dentures; once every 60 months
- Periodontal maintenance following active therapy - two per year
- Root planing and scaling once per quadrant every 24 months
Plan pays 50%; Member Coinsurance 50%
- Crowns over natural teeth, build ups, posts and cores - replacement limited to once every 60 months
- Osseous (bone) surgery once per quadrant every 24 months
- Gingivectomies once per site every 24 months
- Soft tissue grafts once per site every 60 months
- Crown lengthening once per site every 60 months
- Bridges, build ups, posts and cores - replacement limited to once every 60 months
- Partial and Complete dentures - replacement limited to once every 60 months
- Guided tissue regeneration and bone replacement graft; once per site every 24 months
- Surgical placement of endosteal implant, abutment and crown; once per tooth per lifetime
Orthodontics:
Plan pays 50%; Member Coinsurance 50%; a 12-month waiting period applies
- Braces and related services for dependent children under the age of 19
Lifetime maximum (orthodontics only) is $1,200.00
Dependent coverage - Dependent children who are full-time students over age 19 are covered as long as they stay inschool or up until the end of the year that they turn age 23.
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