Covered Diagnostic & Preventive Expenses (Class I)
The Plan will pay 100% in-network, and 80% out of network of the maximum allowable fee or the actual charge, whichever is less, with no deductible for expenses considered preventive services
according to all provisions, requirements, and limitations of the Plan.
Diagnostic
● Diagnostic evaluation for routine or emergency purposes
● X-rays
● Study models
Detail of Covered Benefits, with Limitations
● Routine examination (periodic oral evaluation) is covered twice in a benefit period.
● Comprehensive or detailed and extensive oral evaluation is covered once in the patient’s lifetime by the same dentist. Additional comprehensive or detailed and extensive oral evaluations by the same dentist will be allowed as periodic oral examinations.
● Limited problem-focused evaluations are covered twice in a benefit period.
● Complete series or panorex x-rays are covered once in a three-year period from the date of service. Any number or combination of X-rays billed for same date of service that equals or exceeds the allowed fee for a complete series will be paid as a complete series.
● Supplementary bitewing x-rays are covered twice in a benefit period.
Preventive
● Prophylaxis (cleaning) ● Periodontal maintenance ● Fissure sealants
● Topical application of fluoride including fluoridated varnishes
● Space maintainers
● Preventive resin restoration
Detail of Covered Benefits, with Limitations
● Any combination of prophylaxis and
periodontal maintenance is covered twice in a benefit period.
● Periodontal maintenance procedures are covered only if a patient has completed active periodontal treatment.
● Topical application of fluoride, including fluoride varnishes, is limited to two covered procedures in a benefit period through age 18. ● Application of fissure sealants will be covered
for permanent molars with no restoration on the occlusal (biting) surface once in a lifetime per tooth from the date of service through age 15. If eruption of permanent molars is delayed, sealants will be allowed if applied within 12 months of eruption with documentation from the attending Dentist.
● Space maintainers are covered once in a patient’s lifetime through age 13 for the same missing tooth or teeth.
● Application of preventive resin restorations will be covered for permanent molars with no restorations on the occlusal (biting) surface. Limited to once in a three-year period per tooth from the date of service for either fissure sealant or preventive resin restoration (but not both) through age 15. If eruption of permanent molars is delayed, preventive resin restorations will be allowed if applied within 12 months of eruption with documentation from the attending dentist.
Not Covered: Plaque control program (oral hygiene instruction, dietary instruction and home fluoride kits)
Covered Restorative Expenses (Class II) If you elect either the Delta Dental PPO 2000 Plan option or the Delta Dental PPO 1500 Plan option, the Plan will pay 80% in-network and 70% out of network of the maximum allowable fee or the actual charges, whichever is less, after payment of the combined Restorative and Major deductible for expenses considered basic services according to all provisions, requirements, and limitations of the Plan.
Restorative
● Restorations (fillings) ● Stainless steel crowns
Refer to Major Expenses (Class III) for crowns, veneers or onlays
Detail of Covered Benefits, with Limitations
● Restorations (fillings) to treat carious lesions (visible destruction resulting from dental decay) or to treat a fracture resulting in significant damage to tooth structure (missing cusp) or existing restoration on the same surface(s) of the same tooth are covered once in a two-year period from the date of service.
● Restorations on a posterior tooth, (including a white filling) will receive an amalgam allowance will be made, with any difference in cost being the responsibility of the eligible person.
● An inlay (as a single tooth restoration) will be considered as elective treatment and an amalgam allowance will be made, with any difference in cost being the responsibility of the eligible person.
● Stainless steel crowns are covered once in a two-year period from the seat date.
Not Covered: Overhang removal, re-contouring or polishing of a restoration, and restorations necessary to correct vertical dimension or to alter the morphology (shape) or occlusion are not a paid covered benefit.
● Preparation of the mouth for the insertion of dentures
● Treatment of pathological conditions and traumatic injuries of the mouth
Not covered:
● Bone replacement graft for ridge preservation
● Bone grafts, of any kind, to the upper or lower jaws not associated with periodontal treatment of teeth. ● Tooth transplants.
Sedation
● General anesthesia ● Intravenous sedation
Detail of Covered Benefits, with Limitations
● Either general anesthesia or intravenous sedation (but not both) is covered when
performed on the same day when administered by a licensed dentist or other Delta Dental/ Washington Dental Service-approved licensed professional who meets the educational, credentialing and privileging guidelines established by the Dental Quality Assurance Commission of the state of Washington or as determined by the state in which the services are delivered. Predeterminations are required. ● General anesthesia is covered in conjunction
with certain covered endodontic, periodontic and oral surgery procedures, as determined by Delta Dental/Washington Dental Service or when medically necessary, for children through age six or a physically or developmentally disabled person, when in conjunction with Diagnostic & Preventive, Restorative, Major, and Orthodontic covered dental procedures. Pre-determinations are required.
certain conditions of oral health. It is strongly recommended that you have your dentist submit a predetermination of benefits to determine if the treatment will be covered. A predetermination is not a guarantee of payment.
● Surgical and nonsurgical procedures for treatment of the tissues supporting the teeth, including
● Periodontal scaling/root planing ● Gingivectomy
● Limited adjustments to occlusion (eight teeth or fewer)
Refer to Preventive for periodontal maintenance benefits
Detail of Covered Benefits, with Limitations
● Periodontal scaling/root planing for 4 teeth per quad is covered once in a two-year period from the date of service.
● Gingivectomy or gingioplasty for 4 teeth per quad is covered once in a three-year period from date of service.
● Limited adjustments to occlusion are covered once in a 12-month period from date of service. ● Periodontal maintenance procedures are
covered twice in a benefit period, and only if a patient has completed active periodontal treatment.
● Under certain conditions of oral health, any combination of prophylaxis or periodontal maintenance may be covered up to a total of four times in a benefit period.
Endodontics
● Procedures for pulpal and root canal treatment, services, including
● Pulp exposure treatment ● Pulpotomy
Detail of Covered Benefits, with Limitations
● Root canal treatment on the same tooth is covered only once in a two-year period from the date of service.
● Re-treatment of the same tooth is allowed when performed by a different dental office
Not covered: Bleaching of teeth
Covered Major Expenses (Class III)
If you elect dental coverage, the Plan will pay 50% of the maximum allowable fee or the actual charges, whichever is less after payment of the combined Restorative and Major deductible for expenses considered major services according to all provisions, requirements, and limitations of the Plan.
Restorative
● Crowns, veneers or onlays ● Crown buildups
● Post and core on endodontically treated teeth
Detail of Covered Benefits, with Limitations
● Crowns or onlays for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay) or fracture resulting in significant loss of tooth structure (missing cusp), when teeth cannot reasonably be restored with filling materials such as amalgam or resin-based composites.
● Crowns or onlays on the same teeth are covered only once in a five-year period. ● If a tooth can be restored with a filling material such as amalgam or filled resin, an allowance will be made for such a procedure toward the cost of any other type of restoration that may be provided. Delta Dental/Washington Dental Service will allow the appropriate amount for an amalgam restoration (posterior tooth) or composite restoration (anterior tooth) toward the cost of processed filled resin or processed composite restorations.
● A crown buildup or a post and core are covered once in a five-year period on the same tooth from the date of service.
● Under certain conditions of oral health, services covered are occlusal guard (nightguard) (once in three years), repair and relines of occlusal guard (nightguard) more than six months after the initial placement. Note: These benefits are available only under certain conditions of oral health. It is strongly recommended that you have your dentist submit a predetermination of benefits to determine if the treatment will be covered.
Not covered: Crowns in conjunction with overdentures.
Prosthodontics
● Dentures
● Fixed partial dentures (fixed bridges) ● Inlays when used as a retainer for a fixed
partial denture (fixed bridge) ● Removable partial dentures
● Adjustment or repair of an existing prosthetic appliance
● Surgical placement or removal of implants or attachments to implants
Detail of Covered Benefits, with Limitations
● Surgical placement or removal of implants or attachments to implants.
● Initial installation of dentures.
● Dentures, fixed partial dentures (fixed bridges), removable partial dentures, and the adjustment or repair of an existing prosthetic device. ● Replacement of an existing prosthetic appliance
is covered only once every five years and only then if it is unserviceable and cannot be made serviceable.
● Replacement of implants and superstructures is covered only after five years have elapsed from any prior provision of the implant.
or overdenture toward the cost of any other procedure that may be provided, such as personalized restorations or specialized treatment is allowed.
● Root canal treatment performed in
conjunction with overdentures is limited to two teeth per arch and is paid at the Major expense payment level.
● Temporary/interim dentures - the amount of a reline toward the cost of an interim partial or full denture. After placement of the permanent prosthesis, an initial reline will be a benefit after six months.
● Partial dentures - if a more elaborate or precision device is used to restore the case, the cost of a cast chrome and acrylic partial denture will be allowed toward the cost of any other procedure provided.
Covered Orthodontic Expenses – Delta Dental PPO 2000 Plan
The Plan will pay 50% of the maximum allowable fee or the actual charges, whichever is less up to the lifetime orthodontic maximum, after payment of the $50 lifetime orthodontic deductible for expenses related to orthodontic services according to all provisions, requirements, and limitations of the Plan.
Orthodontia benefits are paid according to a schedule; not as a single sum. Not more than $1,000 of the maximum, or one-half of WDS’s total responsibility shall be payable at the time of initial banding. Subsequent payments of the plan benefits will be made quarterly following the initial banding as long as you, and your child if the child is the patient, are covered under this option. It is strongly suggested that an orthodontic treatment plan be submitted to, and a predetermination be made by, WDS prior to commencement of treatment. A predetermination
is not a guarantee of payment. Additionally, payment for orthodontic benefits is based upon
not covered.
Detail of Covered Benefits, with Limitations
● Treatment of malalignment of teeth and/ or jaws. Orthodontic records: exams (initial, periodic, comprehensive, detailed and extensive), X-rays (intraoral, extraoral,
diagnostic radiographs, panoramic), diagnostic photographs, diagnostic casts (study models) or cephalometric films.
● Payment is limited to:
● Completion, or through when the patient is no longer covered under the Delta Dental PPO 2000 Plan, whichever occurs first ● Treatment received after coverage begins
(claims must be submitted to WDS within 180 days of the treatment date). For
orthodontia claims, the initial banding date is the treatment date.
● Treatment that began prior to the start of coverage will be prorated:
● Payment is made based on the balance remaining after the down payment and charges prior to the date of coverage are deducted.
● WDS will issue payments based on the Plan’s responsibility for the length of the treatment. The payments are issued providing the employee is eligible and the dependent is in compliance with the age limitation.
Not covered: charges for replacement or repair of an appliance; services considered inappropriate and unnecessary, as determined by WDS.
Maximum Payments
Delta Dental PPO 2000 Plan: The maximum plan
payment for all services is $2,000 per calendar year for you and each eligible family member. In addition, there is a $2,000 lifetime Orthodontic benefit.
Delta Dental PPO 1500 Plan: The maximum plan
payment for all services is $1,500 per calendar year for you and each eligible family member.