Individual & Family Plans


 

Plan Exlusions

The following exclusions are not benefits.

Allergies
You are not covered for restorations or procedures due to allergies or allergic reaction to dental treatment materials such as allergies to metals or mercury.

Anesthesia or analgesia
You are not covered for local anesthesia or nitrous oxide (relative analgesia) when billed separately from the related procedure. This exclusion does not apply to general anesthesia or intravenous sedation administered in connection with covered oral surgery.

Appliances, restorations, or procedures for:

  • increasing vertical dimension;
  • restoring occlusion;
  • correcting harmful habits;
  • replacing tooth structure lost by attrition, abrasion, erosion and abfractions;
  • correcting congenital or developmental malformations;
  • temporary dental procedures;
  • splints, unless necessary as a result of accidental injury.

Athletic mouth guards
You are not covered for the construction or repair of any athletic mouth guard.

Broken or missed appointments
You are not covered for any charges for failure to keep a scheduled visit with your dental provider.

Cleaning of prosthetic appliance
Your plan does not cover the cost of cleaning removable partials or dentures.

Completion of form
Your plan does not cover any charges to complete forms.

Complete occlusal adjustment
You are not covered for services or supplies used for revision or alteration of the functional relationships between upper and lower teeth.

Complications of a non-covered procedure
You are not covered for complications of a non-covered procedure.

Consultation charges
The charge for a practitioner’s opinion or advice given in-person, by phone or other electronic means is not a covered service.

Controlled release device (antimicrobial agents)
The use of localized delivery of antimicrobial agents as part of the overall management of periodontal disease is not a covered benefit.

Correction of occlusion
You are not covered for the correction of occlusion when performed with prosthetics and restorations involving occlusal surfaces.

Cosmetic in nature
You are not covered for services or supplies which have the primary purpose of improving the appearance of your teeth, rather than restoring or improving dental form or function or the treatment of dental disease.

Crowns not meant to restore form and function
You are not covered for crowns that are not meant to restore form and function of a tooth, including crowns placed for the primary purpose of periodontal splinting, cosmetics, altering vertical dimension, restoring your bite (occlusion), or restoring a tooth due to allergies, wear, (attrition, abrasion, erosion and abfractions). Crowns placed on anterior teeth for endodontic purposes only are not a benefit. Crowns placed prior to actual failure of the tooth is not a benefit. Crowns placed for fracture lines (craze lines) are not a benefit.

Dental procedures that are:

  • Provided by other than a dentist or licensed hygienist employed by a dentist.
  • To treat injuries or diseases caused by riots or any form of civil disobedience.
  • To treat injuries sustained while committing a criminal act.
  • To treat injuries intentionally inflicted.
  • In cases for which, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained.

Desensitization materials
You are not covered for desensitization materials or their application.

Drugs
You are not covered for prescription, non-prescription drugs, medicines or therapeutic drug injections.

Duplicate dentures
Your plan does not cover any charges for the duplication of dentures.

Duplication of dental records
Your plan does not cover any charges for the duplication of dental records.

Effective date
You are not covered for services or supplies received before the effective date of coverage.

Experimental or investigative
You are not covered for services or supplies that are considered experimental, investigative or have a poor prognosis. Peer reviewed outcomes data from clinical trial, Food and Drug Administration regulatory status, and established governmental and professional guidelines will be used in this determination.

Government programs
You are not covered for services or supplies when you are entitled to claim benefits from governmental programs (except Medicaid).

Health or medical plan
Services for which a benefit is provided by a health or medical plan.

Incomplete services
You are not covered for dental services that have not been completed.

Infection control
You are not covered for separate charges for “infection control,” which includes the costs for services and supplies associated with sterilization procedures. Participating dentists incorporate these costs into their normal fees and will not charge an additional fee for “infection control.”

Lost or stolen appliances
You are not covered for services or supplies required to replace a lost or stolen dental appliance or charges for duplicate dentures.

Medical services or supplies
You are not covered for services or supplies which are medical in nature or covered under a medical plan. These may include but are not limited to dental services performed in a hospital, surgical treatment centers, treatment of fractures and dislocations, treatment of cysts and malignancies, and accidental injuries or treatment rendered other than by a licensed dentist.

Military service
You are not covered for services or supplies received while you are on active status in the military services.

Night guard/occlusal guards
Your plan does not cover appliances for bruxism, grinding or clenching of teeth.

Non-standard dental treatment and procedures
There is no coverage for services or supplies, as determined by Delta Dental, which are not provided in accordance with generally accepted standards of dental practice.

Orthodontic appliances repair or replacement
Your plan does not cover repair or replacement of any orthodontic appliance.

Payment responsibility
You are not covered for services or supplies when someone else has the legal obligation to pay for your care.

Periodontal appliances
You are not covered for services or supplies for periodontal appliances (bite guards) to reduce bite (occlusal) trauma due to tooth grinding or jaw clenching.

Periodontal splinting
You are not covered for services or supplies used for the primary purpose of reducing tooth mobility, including but not limited to crown/bridge restorations.

Prevention control programs
Preventive control programs including but not limited to oral hygiene instructions, caries susceptibility tests, dietary control, tobacco counseling, and home care medicaments are not a covered benefit.

Provisional (temporary) crowns, bridges, dentures, partials or implants
You are not covered for services or supplies for provisional (temporary) crowns, bridges, dentures, partials or implants.

Pulp caps (Direct or Indirect)
You are not covered for any pulp cap procedures.

Sealants for primary teeth, wisdom teeth, or restored teeth
You are not covered for sealants for primary teeth, wisdom teeth, or teeth that have already been treated with an occlusal restoration. Coverage only applies to 1st and 2nd permanent molars, non-decayed, non-restored up to age 16. This is a once in a lifetime benefit per eligible tooth.

Services provided in other than an office setting
You are not covered for services provided in other than a dental office setting. This includes, but is not limited to, any hospital or surgical/treatment facility.

Specialized services
You are not covered for specialized, personalized, elective materials and techniques or technology which are not reasonably necessary for the diagnosis or treatment of dental disease or dysfunction. Specialized services represent enhancements to other services and are considered optional. Includes, but not limited to, copings and precision attachments.

Taxes
Provider tax, state sales tax, or medical tax is not a covered benefit.

Temporary or interim procedures
You are not covered for temporary or interim procedures.

Temporomandibular joint (TMJ) dysfunction
You are not covered for expenses incurred for diagnostic x-rays, appliances, restorations or surgery in connection with temporomandibular joint (TMJ) dysfunction or myofunctional therapy.

Termination
Whether or not we have approved a treatment plan, you are not covered for treatment received after your termination date.

Tooth colored fillings
Composite/resin restorations are allowed on the front teeth (anterior teeth) only. When composite/resin restorations are done on the back teeth (posterior teeth) they are considered optional services. Coverage will be made for a corresponding silver (amalgam) restoration.

Treatment by other than a licensed dentist
You are not covered for services or treatment performed by anyone other than a licensed dentist or a licensed hygienist employed by the dentist.

Waiting period
You are not covered for any service started during a waiting period.