Expenses Not Covered
The plan does not pay for the following expenses:
  • Services that are not necessary as determined by the standards of generally accepted dental practice
  • Treatment by other than a licensed dentist, except for prophylaxis (cleaning and scaling of teeth) and topical application of fluoride performed by a licensed dental hygienist under the supervision and direction of a licensed dentist
  • Cosmetic dentistry or dentistry to correct congenital malformations
  • Services or appliances, including crowns and bridges, for which treatment began prior to the date the person became covered under the plan
  • Prescription drugs, laboratory tests and/or exams, premedications and local anesthesia (These services may be covered under the medical plan.)
  • Hospitalization
  • General anesthesia and intravenous sedation for restorative dentistry or surgical procedures, unless a specific need is shown (e.g., on account of a child's age)
  • Preventive control programs, including home care items
  • Charges for completion of claim forms
  • Missed dental appointments
  • Appliances, surgical procedures or restorations whose primary purpose is to alter vertical dimension, restore occlusion or replace tooth structure loss resulting from attrition, abrasion or erosion
  • Inlays
  • Replacement, repair, relines or adjustments of occlusal guards (Occlusal guards are limited to one per lifetime.)
  • Lost, missing or stolen appliances of any type, and replacement or repair of orthodontic appliances
  • Services that are experimental in nature
  • Services and supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of Delta Dental coverage
  • Services to treat a dental disease, defect or injury due to an act of war, declared or undeclared
  • Services that are covered under the healthcare or prescription drug benefits provided under the Stryker Corporation Welfare Benefits Plan
  • Services or appliances for the treatment of temporomandibular joint (TMJ) disorder (Note: These services are covered under the medical plan.)
  • Services for injuries or conditions covered under Workers' Compensation or employers' liability laws
  • Services that are available from any government agency, political subdivision, community agency, foundation or similar entity
  • Services that are excluded by Delta Dental's processing policies