Delta Dental DPPO Low Plan Summary
Group 004623-9902
Delta Dental DPPO Low Plan Summary PDF
Calendar Year Maximum: $750 per person
Deductible: $50 per individual / $150 per family. The deductible is waived for diagnostic and preventive categories and periodontal cleanings. Deductibles met in the fourth quarter are carried forward to the following calendar year.
Diagnostic
| Category / Procedure | Qualifications | In Network | 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% |
Preventive
| Category / Procedure | Qualifications | In Network | Out of Network |
|---|---|---|---|
| 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% |
Restorative
| Category / Procedure | Qualifications | In Network | Out of Network |
|---|---|---|---|
| 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
| Category / Procedure | Qualifications | In Network | Out of Network |
|---|---|---|---|
| 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)
| Category / Procedure | Qualifications | In Network | Out of Network |
|---|---|---|---|
| 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% |
Endodontics
| Category / Procedure | Qualifications | In Network | Out of Network |
|---|---|---|---|
| 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
| Category / Procedure | Qualifications | In Network | Out of Network |
|---|---|---|---|
| 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
| Category / Procedure | Qualifications | In Network | Out of Network |
|---|---|---|---|
| Palliative Treatment | Three occurrences in 12 months. | 80% | 80% |
Prosthodontics
| Category / Procedure | Qualifications | In Network | Out of Network |
|---|---|---|---|
| Dentures | Once within 60 months (age 16 and older). | 30% | 30% |
| Fixed Bridges | Once within 60 months (age 16 and older). | 30% | 30% |
| Implants | Once per 60 months per Implant. (Pre-estimate recommended). | 30% | 30% |
| Implant Abutments | Once per implant only when surgical implant is benefitted. | 30% | 30% |
Major Restorative
| Category / Procedure | Qualifications | In Network | Out of Network |
|---|---|---|---|
| Crowns or Onlay | When teeth cannot be restored with regular fillings. Once within 60 months per tooth (age 12 and older). | 30% | 30% |
| Cast Posts/Buildups | Once per tooth per 60 months only benefitted to retain a crown. | 30% | 30% |
Dependent Eligibility Eligible dependents up to the end of the month in which they turn age 26.
*Non-participating dentists may balance bill. Subscribers are responsible for the difference between the non-participating maximum plan allowance and the full fee charged by the dentist.