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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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(j) Delta Dental will pay the applicable percentage of the Dentist's Fee for a standard cast <br />chrome or acrylic partial denture or a standard complete denture, (A "standard" <br />complete or partial denture is defined as a removable prosthetic appliance provided to <br />replace missing natural, permanent teeth and which Is constructed using accepted and <br />conventional procedures and materials.) <br />(k) If an Enrollee selects a more expensive plan of treatment than Is customarily provided, <br />or specialized techniques, an allowance will be made for the least expensive, <br />professlonally acceptable alternative treatment plan. Delta Dental will pay the <br />applicable percentage of the lesser fee and the Enrollee is responsible for the <br />remainder of the Dentist's fee, <br />For example: a crown, where an amalgam filling would restore the tooth, or a <br />precision denture, where a standard denture would suffice. <br />4.7 EXCLUSIONS - The following services are not Beneflts: <br />(a) Services for Injuries or conditions that are covered under Workers' Compensation or <br />Employer's Uabllity Laws. <br />(b) Services which are provided to the Enrollee by any, Federal or State Government <br />Agency or are provided without cost to the Enrollee by any municipality, county or <br />other political subdivision, except as provided In California Health and Safety Code <br />Section 1373(a). <br />(c) Services with respect to congenital (hereditary) or developmental (following birth) <br />malformations or cosmetic surgery or dentistry for purely cosmetic reasons, Including <br />but not limited to: cleft palate, upper or lower jaw malformations, enamel hypoplasia <br />(lack of development), fluorosis (a type of discoloration of the teeth) and anodontia <br />(congenitally missing teeth). <br />(d) Services for restoring tooth structure lost from wear (abrasion, erosion, attrltlon, or <br />abfractlon), for rebuilding or maintaining chewing surfaces due to teeth out of <br />alignment or occlusion, or for stabilizing the teeth. Such services include but are not <br />limited to equilibration and periodontal splinting, <br />(e) Prosthodontic services or any Single Procedure started prior to the date the person <br />became eligible for such services under this Contract. <br />(f) Prescribed or applied therapeutic drugs, premedication or analgesia. <br />(g) Experimental procedures. <br />(h) All hospital costs and any additional fees charged by the Dentist for hospital <br />treatment. <br />(1) Charges for anesthesia, other than general anesthesia or LV. sedation administered by <br />a licensed Dentist In connection with covered oral Surgery services and select <br />Endodontic and Periodontic procedures. <br />(j) Extra -oral grafts (grafting of tissues from outside the mouth to oral tissue). <br />(k) Diagnosis or treatment by any method of any condition related to the <br />temporomandibular (jaw) joint or associated musculature, nerves and other tissues. <br />(1) Replacements of existing restorations for any purpose other than active tooth decay. <br />25d-61 <br />
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