The Office of Human Resources

Delta Dental DPPO High Plan Summary

Group 004623-9901

Calendar Year Maximum: $1,500 per person.
Deductible: $25 per individual / $100 per family.
  • Deductible waived for Diagnostic and Preventive categories.
  • Deductible waived for periodontal cleanings. 
  • Deductibles met in the fourth quarter are carried forward to the following calendar year.
Category / Procedure Qualifications In Net-work Out of Network
Comprehensive Evaluation Once every 60 months. 100% 100%
Periodic Oral Exam Twice per calendar year. 100% 100%
Panoramic or Full Mouth X-rays Once every 60 months. 100% 100%
Bitewing X-rays Twice per calendar year. 100% 100%
Single Tooth X-rays As needed. 100% 100%
Teeth Cleaning Twice per calendar year. 100% 100%
Fluoride Treatments Twice per calendar year for members under age 19. 100% 100%
Space Maintainers Required due to the premature loss of teeth. For members under age 14 and not for the replacement of
primary or permanent anterior teeth.
100% 100%
Sealants Unrestored permanent molars, every 4 years per tooth for members through age 15. Sealants also covered
for members age 16 up to age 19 with a recent cavity and are at risk for decay.
100% 100%
Silver Fillings Once every 24 months per surface per tooth. 80% 80%
White Fillings Once every 24 months per surface per tooth. 80% 80%
Inlays Once every 60 months per tooth, inlays are processed as a silver filling and the patient is responsible for
the difference between the silver filling and the Delta Dental negotiated fee for an inlay, where permitted by state law. In other states, the patient may be responsible for paying up to the provider’s full submitted
charge for an inlay.
80% 80%
Protective Restorations Once per tooth. 80% 80%
Stainless Steel Crowns Once every 24 months per tooth (on primary teeth only). 80% 80%
Oral Surgery
Extractions Once per tooth. 80% 80%
General Anesthesia General Anesthesia and IV sedation allowed with covered surgical impacted teeth only (up to one hour). 80% 80%
Periodontics (on natural teeth only)
Periodontal Surgery One surgical procedure per quadrant in 36 months. 80% 80%
Scaling and Root Planing  Once in 24 months, per quadrant.  No more than 2 quadrants per date of service. 80% 80%
Periodontal Cleaning 4 per calendar year following active periodontal treatment. Not to be combined with preventive cleanings.  100% 100%
Bone Grafts/GTR No more than 2 teeth per quadrant per 36 months on natural teeth. 80% 80%
Root Canal Treatment Once per tooth. 80% 80%
Root Canal Retreatment Once per tooth after 24 months have elapsed from initial treatment  80% 80%
Vital Pulpotomy Limited to deciduous teeth. 80% 80%
Prosthetic Maintenance 
Bridge or Denture Repair Once per bridge/denture per 12 months, after 24 months of initial insertion. 80% 80%
Crown or Onlay Repair Once per tooth per 12 months after 24 months of initial placement 80% 80%
Rebase or Reline of Dentures Once per denture within 36 months. 80% 80%
Recement of Crowns &
Onlays, Bridges
Once per crown, onlay or bridge. 80% 80%
Emergency Dental Care 
Palliative Treatment Three occurrences in 12 months. 80% 80%
Dentures Once within 60 months (age 16 and older). 60% 60%
Fixed Bridges Once within 60 months (age 16 and older). 60% 60%
Implants Once per 60 months per Implant. (Pre-estimate recommended). 60% 60%
Implant Abutments Once per implant only when surgical implant is benefitted. 60% 60%
Major Restorative 
Crowns or Onlay When teeth cannot be restored with regular fillings. Once within 60 months per tooth (age 12 and older). 60% 60%
Cast Posts/Buildups Once per tooth per 60 months only benefitted to retain a crown. 60% 60%