5. Full upper and/or lower dentures are not to exceed one each in any five year period from initial placement. The patient is entitled to a new upper or lower denture only if the existing denture is more than five years old and cannot be made satisfactory by either reline or repair. Fillings and Crowns 6. Crowns will be covered only if there is not enough retention and resistance form left in the tooth to hold a filling. For example, the buccal or lingual walls are either fractured or decayed to the extent that they will not hold a filling. 7. In most plans a full cast predominantly metal crown (D2791) is the covered benefit on molar teeth. In these plans all other crowns (high noble, noble, porcelain, porcelain fused to metal) on molar teeth are considered optional treatment. When optional treatment is performed, the patient must pay the difference in cost between the dentist’s DDWA filed fees for the covered benefit and the DDWA filed fee for the optional treatment (not to exceed $200.00), plus any co-payment for the covered benefit. In some plans all crown types are a covered benefit on molar teeth and there is no optional treatment. Always consult the patients benefit plan. The patient must be permitted the option of the cast metal crown as a benefit if desired. 8. The DeltaCare program provides amalgam (posterior) and resin-based (anterior) restorations for treatment of caries. If the tooth can be restored with such materials, any other restoration such as a crown or jacket is considered optional, and if provided, the patient must pay the difference in cost between the dentist’s DDWA filed fees for the covered benefit and optional treatment, plus any co- payment for the covered benefit. 9. A restoration is a covered benefit only when required for restorative reasons (radiographic evidence of decay or missing tooth structure). Restorations placed for any other purposes including, but not limited to cosmetics, abrasion, erosion, restoring or altering vertical dimension, or the anticipation of future fractures, are not covered benefits. 10. Composite resin restorations in posterior teeth are a covered benefit once in a two-year period. 11. Anterior porcelain crowns, porcelain fused to metal or plastic processed to metal type crowns are not a benefit for children under 16 years of age. An allowance will be made for an acrylic crown. If performed, the patient must pay the difference in cost between the dentist’s DDWA filed fees for the covered benefit and optional treatment, plus any co-payment for the covered benefit. 12. A crown placed on a specific tooth is allowable only once in a five year period from initial placement. 13. A crown used as an abutment to a partial denture for purposes of re-contouring, repositioning or to provide additional retention is not covered unless the tooth is decayed to the extent that a crown would be required to restore the tooth whether or not a partial denture is required. Fixed Bridges 14. A fixed bridge to replace ONE missing permanent anterior tooth is covered for patients 16 or older. Such treatment will be covered if the patient’s oral health and general condition permits. 15. Fixed bridges for patients under the age of 16 are optional to a partial denture. 16. A fixed bridge to replace more than one permanent anterior tooth or any number of permanent posterior teeth is optional to a removable partial denture. The patient must pay the difference in cost between the dentist’s filed fee for the covered benefit (a removable partial denture) and the optional treatment (a fixed bridge), plus any co-payment for the covered benefit. 17. Fixed bridges are not a benefit when provided in connection with a partial denture on the same arch. A fixed bridge is not a covered benefit once a removable partial denture has been delivered in the same arch. 2024-01-03100-BB 22 DCL 20240101