State of Rhode Island
Delta Dental PPO Plus PremierTM
Benefits Summary
Administered by Delta Dental of Rhode Island
Procedure Anchor Anchor Anchor Dental Frequency / Limitations
Dental Dental Plus Platinum
Plan Maximums
Annual Maximums $1,500 $2,000 $2,500
Orthodontic lifetime maximum $1,500 $2,000 $2,500
Implant lifetime maximum N/A N/A $3,500
Diagnostic
Oral Exam 100% 100% 100% Anchor Dental Plan: Once per calendar year
Anchor Dental Plus and Platinum Plans: Twice per calendar year
Bitewing x-rays 100% 100% 100% One set per plan year
Complete x-ray series or panoramic film 100% 100% 100% Once every 36 months. A panoramic film is a benefit for
individuals ages 6 and older.
Single x-rays 100% 100% 100% As required
Consultation by a specialist N/A N/A 80% Covered twice per calendar year
Preventive
Cleaning 100% 100% 100% Twice per calendar year.
Fluoride treatment – for children under age 19 100% 100% 100% Anchor Dental Plan: Once per calendar year
Anchor Dental Plus and Platinum Plans: Twice per calendar year
Sealants – for children under age 14 100% 100% 100% Once every 24 months on unrestored permanent molars
Space Maintainers 100% 100% 100% Once per lifetime for lost deciduous (baby) teeth
Minor Restorative
Fillings 100% 100% 100% Amalgam (silver) fillings; composite (white) fillings
Repairs to existing partial or complete dentures 100% 100% 100% Once per plan year
Recementing crowns or bridges 100% 100% 100% Once every 60 months
Rebasing or relining of partial or complete dentures 100% 100% 100% Once every 60 months
Major Restorative
Crowns over natural teeth, build ups, posts & cores 80% 80% 80% Replacement limited to once every 60 months
Endodontics
Root canal therapy 100% 100% 100% One procedure per tooth per lifetime.
Periodontics
Periodontal maintenance following active therapy 50% 80% 100% Twice per plan year
Root planing and scaling 50% 80% 100% Once per quadrant every 24 months
Osseous (bone) surgery 50% 80% 100% Once per quadrant every 36 months
Gingivectomies 50% 80% 100% Once per site every 36 months
Soft tissue grafts 50% 80% 100% Once per site every 60 months
Crown lengthening 50% 80% 100% Once per site every 60 months
Guided tissue regeneration & bone replacement graft 50% 80% 100% Once per site every 24 months
Prosthodontics
Bridges and crowns over implants N/A 50% 50% Replacement limited to once every 60 months
Partial and complete dentures N/A 50% 50% Replacement limited to once every 60 months
Implants and related services N/A N/A 50% Once per tooth site per lifetime. Separate $3,500 lifetime
maximum
Extractions and Oral Surgery
Extractions and other routine oral surgery 100% 100% 100% When not covered by the patient’s medical plan. Certain oral
surgery procedures do not count toward annual maximum.
Orthodontics
Elective braces and related services 50% 50% 50% Subject to a lifetime maximum. No pre-approval required.
Anchor Dental and Plus Plans: Covered only for dependents to
age 19. Platinum Plan: Covered for all members, no age limit.
Other Services
Palliative treatment (minor procedures necessary to relieve 100% 100% 100% Twice per plan year
acute pain)
General anesthesia or intravenous (I.V.) sedation for certain 100% 100% 100%
complex surgical procedures
Occlusal guards for bruxism (grinding) only N/A 100% 100% Once every 36 months
Occlusal adjustments N/A 100% 100% Twice per plan year
Pre-treatment estimate recommended Dependent coverage: Dependent children are covered up until the end of the month that they turn age 26.
State of Rhode Island
Delta Dental Exclusions & Limitations
Administered by Delta Dental of Rhode Island
Unless specifically covered by your dental plan, the following are not covered:
n Services that are not dentally necessary n Services done by someone who is not a
and appropriate according to our review licensed dentist or a licensed hygienist
guidelines. Services subject to these working as authorized by applicable law.
guidelines include, but are not limited to,
n Disorders related to the temporomandibular
root canals; crowns and related services;
joints (TMJ), including occlusal orthotic
bridges; periodontal services; orthodontics;
device and surgery.
and oral surgery. We will make a decision
whether a service is dentally necessary n Services to increase the height of teeth or
based on these guidelines. A service may restore occlusion.
not be covered under these guidelines even
n Restorations needed because of teeth
if it was recommended by a dentist. Our
grinding or due to erosion, abrasion or
guidelines can be found on our website
attrition.
at www.deltadentalri.com. You can have
your dentist send us a request for a pre- n Services done mainly to change or to
treatment estimate in advance of the improve your appearance.
service to see if the service meets our
n Splinting and other services to stabilize
guidelines.
teeth.
n Services greater than the annual maximum.
n Laboratory or bacteriological tests or
n Services received from a dental or medical reports.
department maintained by or on behalf of
n Temporary, complete dentures or
an employer, a mutual benefit association,
temporary, fixed bridges or crowns.
labor union, trustee or similar person or
group. n Prescription drugs.
n An illness or injury that Delta Dental n General anesthesia or intravenous sedation
decides is employment-related. for non-surgical extractions, diagnostic,
preventive, or minor restorative services.
n Services you would not have to pay for if
you did not have this Delta Dental coverage. n General anesthesia or intravenous sedation
given by anyone other than a dentist.
n Services or supplies that are experimental
in terms of generally accepted dental
Delta Dental can adopt and apply policies
standards.
that we deem reasonable when we approve
n Services done by a dentist who is a member the eligibility of subscribers and the
of your immediate family. appropriateness of treatment plans and
related charges.
n An illness, injury or dental condition for
which benefits are, or would have been
available, through a government program if
you did not have this Delta Dental coverage.
All claims must be filed within one year of the date of service.
Delta Dental of Rhode Island n 10 Charles Street, Providence RI 02904 n 1.800.843.3582 n deltadentalri.com
NOTICE OF NONDISCRIMINATION AND ACCESSIBILITY POLICY
Delta Dental of Rhode Island does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-843-3582.
Português (Portuguese): ATENÇÃO: Se fala português, encontramse disponíveis serviços linguísticos, grátis. Ligue para 1-800-843-3582. REV0921
