Summary Plan Description

Exclusions

  1. Analgesics such as nitrous oxide, conscious sedation and euphoric drugs or injections.
  2. Prescription drugs.
  3. Consultations, office visits and study models.
  4. Caries susceptibility/risk tests.
  5. Plaque control program (oral hygiene instructions, dietary instruction and home fluoride kits).
  6. Overhang removal or re-contouring of restoration.
  7. 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; or materials placed in tooth extraction sockets for the purpose of generating osseous filling.
  8. Duplicate dentures; personalized dentures; maintenance or cleaning of a prosthetic appliance, except for implant maintenance; temporary crowns, or copings.
  9. Hospitalization charges or any additional fees charged by the dentist for hospital treatment.
  10. Broken appointments.
  11. Behavior management.
  12. TMJ services or supplies.
  13. Dentistry for cosmetic reasons or bleaching of teeth.
  14. Crowns or restorations for anything other than decay or fracture.
  15. Charges for intravenous sedation or general anesthesia when billed in conjunction with any services other than covered oral surgery procedures. General anesthesia is not a covered benefit except when medically necessary for children through age six, or for a physically or developmentally disabled person and only when in conjunction with covered dental procedures.
  16. Charges for the replacement of a lost, missing or stolen prosthetic device, unless time limitations have been met.