Limitations and Exclusions

1. Periodic Oral Evaluation—Once every six months. Includes periodontal screening and oral cancer evaluation.
2. Cleanings—Once every six months. (Months begin with first treatment.)
3. Periodontal Cleanings—Once every three months following active periodontal treatment, not to be combined with preventive cleanings.
4. Bitewing X Rays—based on need, up to one series of four films in any six-month period.
5. Full Mouth X Rays—are limited to one set every sixty (60) consecutive months when indicated.
6. Topical Fluoride Treatment—limited to one treatment per six months for members under age 19.
7. 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.
8. Sealants—Once per tooth per 48 months on the occlusal surface of permanent first and second molars for patients up to age 16. Sealants are also covered for patients age 16 to 19 on molars for those who have had a recent cavity and are at risk for decay.
9. Chlorhexidine Mouthrinse—This is a covered benefit only when administered and dispensed in the dentist’s office following scaling and root planing.
10. Fluoride Toothpaste—This is a covered benefit only when administered and dispensed in the dentist’s office following periodontal surgery.

1. General anesthesia and the services of a special anesthesiologist.
2. Cosmetic dental care.
3. Dental conditions arising out of and due to enrollee’s employment or for which Worker’s Compensation is payable. Services that are provided to the enrollee by state government or agency thereof, or are provided without cost to the enrollee by any municipality, county, or other subdivision.
4. Treatment required by reason of war.
5. Dental services performed in a hospital and related hospital fees.
6. Treatment of fractures and dislocations.
7. Loss or theft of fixed and removable prosthetics (crowns, bridges, full or partial dentures).
8. Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage.
9. Any service that is not specifically listed.
10. Congenital malformation.
11. Cysts and malignancies.
12. Dispensing of drugs not normally supplied in a dental office.
13. Accidental injury. Accidental injury is defined as damage to the hard and soft tissues of the oral cavity resulting from forces external to the mouth. Damages to the hard and soft tissues of the oral cavity from normal masticatory (chewing) function will be covered at the normal schedule of benefits.
14. Cases which in the professional judgment of the attending dentist determines a satisfactory result cannot be obtained or where the prognosis is poor or guarded.
15. Prophylactic removal of impactions (asymptomatic nonpathological).
16. Specialist consultations for noncovered benefits.
17. Dental expenses incurred in connection with any dental procedure started prior to the enrollee’s eligibility with the Delta Dental PPO Value Plan program. Example: teeth prepared for crowns, root canals in progress, orthodontic treatment.
18. Orthodontics (braces).