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DELTA DENTAL
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Last modified
3/27/2018 10:28:51 AM
Creation date
3/27/2018 10:16:23 AM
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Contracts
Company Name
DELTA DENTAL
Contract #
A-2018-021
Agency
PERSONNEL SERVICES
Council Approval Date
2/6/2018
Expiration Date
12/31/2019
Destruction Year
2024
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4.5 PROSTHODONTIC BENEFITS, Delta Dental agrees to pay 50% of the Dentist's Usual, <br />Customary and Reasonable fees or the Fee Actually Charged, whichever is less, or So% of the <br />Delta Dental PPO Dentist's Fee for the construction or repair of fixed bridges, partial or <br />complete dentures to replace missing, natural teeth; for Implant surgical placement and <br />removal; and for Implant supported prosthetics, including Implant repair and recementatlon. <br />4.6 LIMITATIONS: <br />(a) Only the first two oral examinations, including office visits for observation and <br />specialist consultations, or combination thereof, provided to an Enrollee twice In a <br />calendar year while he or she Is enrolled under any Delta Dental plan are Benefits <br />under this plan. See Note on additional Benefits during pregnancy. <br />(b) Delta Dental pays for full -mouth x-rays only after five years have elapsed since any <br />prior set of full -mouth x-rays was provided under any Delta Dental plan. <br />Delta Dental pays for a panoramic x-ray provided as an Individual service only after <br />five years have elapsed since any prior panoramic x-ray was provided under any Delta <br />Dental plan. <br />(c) Bitewing x-rays are provided on request by the Dentist, but not more than twice In a <br />calendar year for children to age 18, or once In a calendar year for adults ages 18 and <br />over, while the patient is an Enrollee under any Delta Dental plan. <br />(d) A prophylaxis (cleaning) or Single Procedure that Includes a prophylaxis is a Benefit <br />twice each calendar year under any Delta Dental plan. See note on additional Benefits <br />during pregnancy. <br />Routine prophylaxes are covered as a Diagnostic and Preventive Benefit and <br />periodontal prophylaxes are covered as a Basic Beneflt. <br />(e) Periodontal scaling and root planing is a Benefit once for each quadrant each 24 - <br />month period. See note on additional Benefits during pregnancy. <br />(f) Fluoride treatment Is a Benefit twice each calendar year under any Delta Dental plan. <br />(g) Sealant Benefits include the application of sealants only to permanent first molars <br />through age eight and second molars through age (15) if they are without caries <br />(decay) or restorations on the occlusal surface. Sealant Benefits do not include the <br />repair or replacement of a sealant on any tooth within two years of Its application. <br />(h) Crowns, Inlays, Onlays or Cast Restoration are Benefits on the same tooth only once <br />every five years while the patient Is an Enrollee under any Delta Dental plan, unless <br />Delta Dental determines that replacement Is required because the restoration Is <br />unsatisfactory as a result of poor quality of care, or because the tooth Involved has <br />experienced extensive loss or changes to tooth structure or supporting tissues since <br />the replacement of the restoration. <br />(1) Prosthodontic appliances and implants that were provided under any Delta Dental plan <br />will be replaced only after five years . have passed, except when Delta Dental <br />determines that there Is such extensive loss of remaining teeth or change in <br />supporting tissues that the existing fixed bridge, partial denture or complete denture <br />cannot be made satisfactory, Replacement of a prosthodontic appliance or Implant <br />supported prosthesis not provided under a Delta Dental plan will be covered If It Is <br />unsatisfactory and cannot be made satisfactory, Implant removal Is limited to one for <br />each tooth during the Enrollee's lifetime whether provided under a Delta Dental or any <br />other dental care plan, <br />a <br />26C-60 <br />
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