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SCHEDULE B
LIMITATIONS OF BENEFITS |
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- A full mouth x-ray series (including any combination of periapicals or bitewings with a panoramic film) or a series of seven or more vertical bitewings is limited to one series every 24 months.
- Bitewing x-rays are limited to not more than one series of four films in any six month period.
- Diagnostic casts are limited to aid in diagnosis by the Contract Dentist for covered benefits.
- Prophylaxis or periodontal maintenance is limited to one procedure each six month period.
- Amalgams and composites are benefits for the removal of decay, for minor repairs of tooth structure or to replace a lost or failing restoration.
- The placement of a crown, inlay or onlay is a benefit when there is insufficient tooth structure to support a filling. Replacement of an existing crown, inlay or onlay that is non-functional or non-restorable is a benefit when the existing restoration is five+ years old.
- A covered metallic inlay, onlay, and indirectly fabricated post and core using base or noble metal is available for listed Copayment(s). If the Enrollee elects to have high noble metal used instead, the maximum additional cost of this material upgrade is $100.00 per tooth.
- For molars, a covered inlay, onlay, crown, or unit of fixed partial denture (bridge) is metallic without porcelain or other tooth-colored material. If you elect to have porcelain, porcelain-fused-to-metal, resin or resin-with-metal used instead, the maximum additional cost for this tooth-colored material upgrade is $150.00 per molar
- If you also choose a porcelain margin for a covered porcelain-fused to metal crown, the maximum additional cost for this laboratory upgrade is $75.00.
- Coverage for the placement of a fixed partial denture ("bridge") is limited to:
- The initial placement of a bridge when all the following conditions are present:
- a single permanent tooth requires prosthetic replacement.
- the abutment teeth can adequately support and retain a new bridge.
- the missing tooth cannot be replaced by adding a prosthetic tooth to a serviceable existing removable partial denture.
- no other missing teeth in the same arch require prosthetic replacement with a new removable partial denture; and (for a bridge replacing a posterior tooth) one or more of the abutment teeth meet Limitation #7.
- The replacement of an existing bridge that is not serviceable due to decay, fracture or other non-cosmetic defect, if:
- the existing bridge is at least five years old; and
- the same abutment teeth can adequately support and retain a new bridge; and
- no other missing teeth in the same arch require prosthetic replacement.
- Coverage for a new removable partial or complete denture is limited to:
- The initial placement of removable partial or complete denture in an arch when:
- one or more permanent teeth require prosthetic replacement; and
- the missing tooth/teeth cannot be replaced by adding a prosthetic tooth to a serviceable existing removable partial denture; and
- (for partial dentures only) there are suitable abutment teeth to retain and support a removable partial denture.
- The replacement of an existing removable partial or complete denture with non-cosmetic defect(s) that cause the denture to be non-serviceable if:
- the existing removable denture is at least five years old; and
- the existing removable denture cannot be made serviceable by adjustment, repair, relining or rebasing.
- A direct or indirect pulp cap is a benefit only on a vital permanent tooth with an open apex or a vital primary tooth.
- A therapeutic pulpotomy on a permanent tooth is limited to palliative treatment when the Contract Dentist is not performing root canal therapy.
- Periodontal scaling and root-planing are limited to four quadrants during any 12 month period.
- Full mouth debridement (gross scale) is limited to one treatment in any 12 month period.
- Relines, tissue conditioning and rebases are limited to one per denture during any 12 consecutive months.
- Interim partial dentures (stayplates), in conjunction with fixed or removable appliances, are limited to the replacement of extracted anterior teeth for adults during a healing period when the teeth cannot be added to an existing partial denture.
- Excision of the frenum is a benefit only when it causes limited mobility of the tongue, a large diastema between teeth, or it interferes with a prosthetic appliance.
- Soft tissue management programs are limited to periodontal pocket charting, root planing, scaling, curettage, oral hygiene instruction, periodontal maintenance and/or prophylaxis. If you decline non-covered services within a soft tissue management program, it does not eliminate or alter other covered benefits.
- A new removable partial, complete or immediate denture includes after delivery adjustments and tissue conditioning at no additional cost for the first six months after placement if you continue to be eligible and the service is provided at the Contract Dentist's facility where the denture was originally delivered.
- An Optional procedure is defined as any alternative procedure presented by the Contract Dentist that satisfies the same dental need as a covered procedure, is chosen by you, and is subject to the limitations and exclusions of the Program. The applicable charge to you is the difference between the Contract Dentist's "'filed fee" for the Optional procedure and the covered procedure. Optional treatment does not apply when alternative choices are benefits.
"Filed fees" means the Contract Dentist's fees on file with Delta Dental. Questions regarding these fees should be directed to the Customer Service department at (800) 422-4234. |
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