DeltaCare USA DHMO Standard Plan

Diagnostic and Preventive Benefits and Limitations:

• Oral exams but not more than twice in a calendar year
• Full mouth or panoramic x-rays but not more than once every 36 months
• Bitewing x-rays but not more than twice per calendar year
• Cleaning of teeth (oral prophylaxis) but not more than twice in a calendar year
• Topical fluoride treatment twice in a calendar year for a dependent child 19 years of age or younger

Basic Benefits and Limitations:

• Intraoral-periapical x-rays and other x-rays not specified under Diagnostic and Preventive Benefits
• Pulp vitality tests
• Diagnostic casts
• Bacteriological studies for determinations of pathological agents
• Initial placement of amalgam or composite fillings
• Replacement of an existing amalgam or composite fillings
• Sedative fillings
• Pulp capping (excluding final restoration) and therapeutic pulpotomy (excluding final restoration)
• Periodontal maintenance where periodontal treatment (including scaling, root planning and periodontal surgery such as gingivectomy, gingivoplasty, gingival curettage and osseous surgery) has been performed. Periodontal maintenance is limited to four (4) times per calendar year less the number of teeth cleanings received during such calendar year.
• Emergency palliative treatment to relieve tooth pain
• For dependent child 19 years of age or younger, sealants which are applied to non-restored, non-decayed, first and second permanent molars, once per tooth every 24 months
• For dependent children 19 years of age or younger, space maintainers

Major Benefits and Limitations:

• Prefabricated stainless steel crown or prefabricated resin crown, but not more than one per tooth within two (2) years
• Repair or re-cementing of Cast Restorations (Cast Restoration meansan inlay, onlay or crown.)
• Periodontal surgery, including gingivectomy, gingivoplasty, gingival curettage and osseous surgery, but no more than one type of surgical procedure per quadrant in any 36 month period
• Periodontal scaling and root planing but not more than once perquadrant in any 24 month period
• Initial installation of Cast Restorations
• Replacement of any Cast Restorations with the same or a different type of Cast Restoration but not more than one replacement for the same tooth within five (5) years
• Oral surgery except as mentioned elsewhere
• Pulp therapy and apexification/recalcification
• Extractions of unimpacted teeth and removal of exposed roots
• Extractions of impacted teeth
• Root canal treatment but not more than once in a 24 month period for same tooth
• Initial installation of full or removable Dentures (Denture means fixed partial dentures (bridgework), removable partial dentures and removable full dentures.)
• Addition of teeth to a partial removable Denture to replace natural teeth removed while covered dental services are in effect for the Enrollee receiving such services
• Replacement of a non-serviceable Denture if such Denture was installed more than 5 years prior to replacement
• Replacement of an immediate, temporary full Denture with a permanent full Denture if the immediate, temporary full Denture cannot be made permanent and such replacement is done within 12 months of the installation of the immediate, temporary full Denture
• Repair of Dentures
• Relinings and rebasings of existing removable Dentures if at least six (6) months have passed since the installation of the existing removable Denture and not more than once in any 36 month period
• Other removable prosthetic services not described elsewhere
• Other fixed Denture prosthetic services not described elsewhere
• Core buildup, labial veneers and post and cores, but not more than one of each service for a tooth in a period of five (5) years
• Adjustments of Dentures, if at least six (6) months have passed since the installation of the Denture
• Administration of general anesthesia and IV Sedation administered by a provider in connection with covered Oral Surgery or selected Endodontic and Periodontal surgical procedures
• Consultations, but not more than twice in a calendar year
• Injections of therapeutic drugs
• Local chemotherapeutic agents
• Fixed removable appliances for correction of harmful habits

Note on additional benefits during pregnancy – When an Enrollee is pregnant, Delta Dental will pay for additional services to help improve the oral health of the Enrollee during the pregnancy. The additional services each calendar year while the Enrollee is covered under this Contract include: one (1) additional oral exam and either one (1) additional routine cleaning or one (1) additional periodontal scaling and root planing per quadrant. Written confirmation of the pregnancy must be provided by the Enrollee or her dentist when the claim is submitted.