Type C – Major Services

1. Cast Restorations – Crowns and onlays are benefits for the treatment of visible decay and fractures of hard tooth structure when teeth are so badly damaged that they cannot be restored with amalgam or composite restorations.
2. Prosthodonics – Procedures for construction of fixed bridges, partial or complete dentures and repair of fixed bridges.
3. Complete or Partial Denture Reline – Chair side or laboratory procedure to improve the fit of the appliance to the tissue (gums).
4. Complete or Partial Denture Rebase – Laboratory replacement of the acrylic base of the appliance.

Limitations and Exclusions on Major Benefits

1. Replacement of crowns or cast restorations received in the previous five years is not a benefit. Payment for cast restorations shall include charges for preparations of tooth and gingiva, crown build-up, impression, temporary restoration and any re-cementation by the same dentist within a 12-month period.
2. A cast restoration on a tooth that can be restored with an amalgam or composite restoration is not a benefit.
3. Procedures for purely cosmetic reasons are not benefits.
4. Porcelain, gold or veneer crowns for Children under 12 years of age are not a benefit.
5. Replacement of any fixed bridges, or partial or complete dentures, that the member received in the previous five years is not a benefit.
6. Payment for a complete or partial denture shall include charges for any necessary adjustment within a six-month period. Payment for a reline or rebase of a partial or complete denture is limited to once in a three-year period and includes all adjustments required for six months after delivery.
7. Payment for standard dentures is limited to the maximum allowable fee for a standard partial or complete denture. A standard denture means a removable appliance to replace missing natural, permanent teeth. A standard denture is made by conventional means from acceptable materials. If a denture is constructed by specialized techniques and the fee is higher than the fee allowable for a standard denture, the patient is responsible for the difference.
8. Payment for implants (artificial materials implanted into or on bone or gums) or their removal is not a benefit. However, an allowance for a standard complete or partial denture toward the cost of replacing multiple missing teeth will be made. For single tooth implants, Delta Dental will make an allowance for a crown but not for the placement of the implant.
9. Payment for fixed bridges or cast partials for Children under 16 years of age is not a benefit.
10. A posterior bridge where a partial denture is constructed in the same arch is not a covered benefit.
11. Temporary partial dentures are a benefit only when upper anterior teeth are missing.

Type D – Orthodontic Services
Delta Dental will pay benefits for procedures using appliances to treat poor alignment of teeth and/or jaws. Such poor alignment must significantly interfere with function to be a benefit.

Limitations and Exclusions on Orthodontic Benefits

1. Orthodontic benefits are limited to Eligible Dependent Children to age 24.
2. Delta Dental shall make regular payments for orthodontic benefits.
3. If orthodontic treatment began prior to enrolling in this plan, Delta Dental will begin benefits with the first payment due the orthodontist after the subscriber or covered Eligible Dependent becomes eligible.
4. Benefits end with the next payment due the dentist after loss of eligibility or immediately if treatment stops.
5. Benefits are not paid to repair or replace any orthodontic appliance received.
6. Orthodontic benefits do not pay for extractions or other surgical procedures. However, these additional services may be covered under Preventive and Diagnostic or Basic Benefits.