Delta Dental of Missouri (DDMO) offers comprehensive dental benefits through a nationwide network of participating providers. These benefits include:
Members may visit a dentist of their choice, but out-of-pocket costs may vary depending on dentist selection. Visit Delta Dental to find a participating dentist. ID cards can be requested through DDMO.
Delta Dental encourages providers and/or members to submit a pre-determination claim to Delta Dental for review whenever a treatment plan is expected to exceed $200. Delta Dental reviews the proposed treatment plan and formally notifies the provider how services will be covered, the actual benefits that will be paid and the balance to be paid by the member.
Coordination of benefits is available if member has additional dental coverage.
The cost of dental insurance is paid by the subscriber.
|Diagnostic & Preventive||Exams1||All types||Twice per calendar year2||No deductible
|Prophylaxis1||Teeth cleaning, scaling and polishing, periodontal maintenance visits||Twice per calendar year2|
|Fluoride||For eligible dependents under age 14||Once per calendar year|
|Bitewing X-rays1||Once per calendar year|
|Sealants||Limited to caries-free occlusal surfaces of the first and second permanent molars||Once every 5 years|
|Basic & Restorative||Emergency Palliative Treatment||Minor procedures to temporarily reduce or eliminate pain||As needed||$50/person deductible3
|Space Maintainers||Replaces prematurely lost teeth, except for accidental injuries. For eligible dependents under age 14||Once every 5 years|
|Minor Restorative Services||Fillings that use amalgam, synthetic porcelain and plastic material||Once every 2 years per tooth unless accidental injury|
|Periapical X-rays||As required|
|Full-mouth X-rays||Includes panoramic film with or without other films, as well as multiple X-rays on the same date of service||One every 5 years|
|Simple Extractions||Routine removal (through use of forceps) of tooth structure, minor smoothing of socket bone, and closure||As needed|
12-month waiting period required
Waiting period is waived with proof of prior 12-month dental coverage
|Oral Surgery||Includes surgical extractions, such as the cutting of gingiva and bone when removing tooth||As needed||50/person deductible3
|Periodontics||Treatment of gum disease and bone supporting the teeth||Surgery on the same site: One every 3 years
Therapy: One every 2 years
|Endodontics||Root canal and pulpal therapy. Re-treatment of the same tooth is allowed when performed by a different dental office||One every 2 years per tooth|
|Prosthetic Devices||Bridges, dentures and partials. An alternate benefit allowance (based on cost) will be provided for a fixed bridge||Once every 7 years|
|Major Restorative Services||New or replacement crown, jacket, labial veneer, inlay or onlay. Excludes accidental injury||Once every 7 years|
|General Anesthesia||In conjunction with covered surgical procedures|
|Dentures||Repairs and relines|
|Implants||Including related bone grafts||Once every 7 years per tooth|
|Limitations||Alternative Treatments||If available, DDMO will cover the least costly treatment|
|Coverage||Coverage is limited to $1,000 per person per calendar year|
|Preauthorizations||Non-emergency procedures with a cost estimate of more than $200 may be subject to a preauthorization. This provides an advanced estimate of what the dental coverage will pay and what the member will pay|
|Transferring Care||If two or more providers are used for the same procedure, benefits will not exceed what would have been paid for one provider|
|Exclusions||Analgesic Services||Includes nitrous oxide|
|Congenital Malformations||Except newborns with congenital dental defects|
|Dentures||Excludes coverage of lost or stolen dentures, as well as adjustments for the first six months|
|Occlusal Services||Includes athletic mouthguards, nightguards, bruxism and bite therapy appliances|
|Temporomandibular joint syndrome (TMJ) Services||Involves the hinge joint connecting the upper and lower jaws|
|Third Molar Removal||When absent of symptoms|
Summary of excluded services: For a complete list, visit DDMO’s website.
How the Dental Plan Works
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