DeltaCare® Limitations and Exclusions
The benefits are subject to the following limitations:
- Prophylaxis limited to two treatments in any 12 consecutive months
- Full upper and/or lower dentures are not to exceed one in any five-year period
- Partial dentures are not to be replaced within any five-year period unless due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible
- Denture relines limited to one per denture during any 12 consecutive months
- Periodontal treatments (root planing/subgingival curettage) are limited to five quadrants during any 12 consecutive months
- Bitewing x-rays limited to not more than one series of four films in any six-month period
- Full mouth x-rays limited to one set every 24 consecutive months
- Sealants are limited to noncarious, nonrestored permanent first and second molars only to age 14
The following services are not covered by the Flagship prepaid dental plan:
- General anesthesia and the services of a special anesthesiologist
- Cosmetic dental car;
- Dental conditions arising out of and due to the enrollee's employment or for which Worker's Compensation is payable. Services which 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 subdivisions
- Treatment required by reason of war
- Dental services performed in a hospital and related hospital fees
- Treatment of fractures or dislocations
- Loss or theft of fixed and removable prosthetics (crowns, bridges, full or partial dentures)
- Dental expenses incurred in connection with any dental procedures started after termination of eligibility of coverage
- Any service that is not specifically listed as a covered expense
- Dental expenses incurred in connection with any dental procedure started prior to the enrollee's eligibility. Example: Teeth prepared for crowns, root canals in progress, orthodontic treatment
- Congenital malformations
- Cysts and malignancies
- Dispensing of drugs not normally supplied in a dental office
- 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
- Cases which in the professional judgment of the attending dentist a satisfactory result cannot be obtained or where the prognosis is poor or guarded
- Dental services received from any dental office other than the assigned dental office unless expressly authorized in writing by DeltaCare or as cited under "Out-of-Area Emergency Treatment"
- Prophylactic removal of impactions (asymptomatic nonpathological)
- "Specialist consultations" for noncovered benefits
- Implant placement or removal, appliances placed on or services associated with implants
Orthodontic Limitations and Exclusions
The program provides coverage for orthodontic treatment plans provided through DeltaCare panel orthodontists. The start-up fees and the cost to the enrollee for the treatment plan are listed in the Description of Benefits and Copayments (Schedule A) subject to the following:
- Orthodontic treatment must be provided by a DeltaCare orthodontist
- Plan benefits cover 24 months of usual and customary orthodontic treatment
- Should an enrollee's coverage be cancelled or terminated for any reason, and at the time of cancellation or termination be receiving any orthodontic treatment, the enrollee and not DeltaCare will be responsible for the payment of balance due for treatment provided after cancellation or termination. In such a case, the enrollee's payment shall be based on a maximum of $2,300 for dependent children to age 19 and $2,500 for covered full-time students and adults. The amount will be prorated over the number of months to completion of the treatment and will be payable by the enrollee on such terms and conditions as are arranged between the enrollee and the orthodontist. Start-up fees are included in these amounts.
- Start-up fees cover the initial examination, diagnosis, consultation and the retention phase of treatment of up to two years maximum. This includes initial construction, placement and adjustments to retainers and office visits for a maximum period of two years
- If treatment is not required or the enrollee chooses not to start treatment after the diagnosis and consultation has been completed by the orthodontist, the enrollee will be charged a consultation fee of $25 in addition to diagnostic record fees
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