Below is a listing of limitations that apply to the Dental Plan, followed by a listing of services for which no benefits are paid.

Alternate Benefits

In dentistry, there is often more than one method of treating a particular dental condition. If more than one service can be used to treat a covered person’s dental condition, the claims administrator may decide to authorize coverage only for a less costly covered service provided that both of the following terms are met:

· The service selected must be deemed by the dental profession to be an appropriate method of treatment; and

· The service selected must meet broadly accepted national standards of dental practice.

This means the following, for:

· Inlays, Onlays, Crowns and Gold Foil—If a tooth can be repaired by a less costly method than an inlay, onlay, crown or gold foil, benefits will be based on the adequate method of repair that costs the least.

· Crowns, Pontics, and Abutments—Veneer materials may be used for front teeth or bicuspids. However, benefits will be based on the adequate veneer materials that cost the least.

· Bridgework and Dentures—Benefits will be based on the adequate method of treating the dental arch that costs the least. In some cases removable dentures may serve as well as fixed bridgework. If dentures are replaced by fixed bridgework, benefits will be based on the cost of a replacement denture unless adequate results can only be achieved with fixed bridgework.

These are just a few examples of alternate benefits—there are others. That’s why it’s important you follow the plan’s predetermination of benefits process, as outlined previously. By following this process, you’ll know ahead of time how much the plan will pay for the treatment or services being recommended by your dentist.

Replacement Rule

The replacement of, addition to, or modification of existing dentures, crowns, casts or processed restorations, removable denture, fixed bridgework or other prosthetic services is covered only if one of the following terms is met:

· The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or bridgework was installed. This coverage must have been in force for the covered person when the extraction took place.

· The existing denture, crown, cast, or processed restoration, removable denture, bridgework, or other prosthetic service cannot be made serviceable, and was installed at least 10 years before its replacement.

· The existing denture is an immediate temporary one to replace one or more natural teeth extracted while the person is covered, and cannot be made permanent, and replacement by a permanent denture is required. The replacement must take place within 12 months from the date of initial installation of the immediate temporary denture.

Tooth Missing But Not Replaced

The first installation of:

· Removable dentures;

· Fixed bridgework; and

· Other prosthetic services

is covered if:

· Needed to replace one or more natural teeth that were removed while the person is covered by the Dental Plan; and

· Not an abutment to a partial denture, removable bridge or fixed bridge installed during the previous 10 years.

Exclusions and Limitations

Covered dental expenses do not include and no benefits are payable for charges for:

· Bruxing appliances.

· Claims incurred as the result of an accident, which are considered a medical expense.

· Implantology.

· Sealants for dependent children under age 6 and age 14 and over.

· Services or supplies initiated for or received by a covered person before becoming eligible for the dental expense benefits.

· Those for treatment by other than a dentist; except that scaling or cleaning of teeth and topical application of fluoride may be done by a licensed dental hygienist. In this case, the treatment must be given under the supervision and guidance of a dentist.

· Surgery, treatment, services and supplies, which are cosmetic in nature.

· Replacement of a lost, missing or stolen crown, bridge or denture and those for replacement of appliances that have been damaged due to abuse, misuse, or neglect.

· Repair or replacement of an orthodontic appliance.

· Services or supplies which are required as a result of a work related injury.

· Services or supplies received by a covered person for which no charge would have been made in the absence of dental expense benefits for that covered person.

· Services or supplies for which a covered person is not required to pay.

· Services or supplies obtained through a government hospital or covered under a government plan, except as required by federal law.

· Services or supplies which are deemed experimental in terms of generally accepted dental standards as determined by the claims administrator in its sole discretion.

· Services or supplies received as a result of dental disease, defect or injury due to an act of war or a warlike act in time of peace.

· Adjustment of a denture or bridgework which is made within 6 months of its installation.

· Any duplicate appliance or prosthetic device.

· Use of materials to prevent decay other than fluorides and sealants.

· Instruction for oral care, such as hygiene or diet.

· Periodontal splinting.

· Services or supplies to the extent that benefits are otherwise provided under a medical plan.

· Myofunctional therapy.

· Broken appointments.

· The dentist for completing dental forms.

· Services or supplies not specifically listed as covered under the Dental Plan.

· Services or supplies related to missing but unreplaced teeth at the time coverage becomes effective.

· Services received as a result of injury or sickness caused or contributed to by engaging in an illegal act or occupation; by committing or attempting to commit any crime, assault or other felonious behavior, or by participating in a riot or public disturbance unless due to a mental or physical medical condition.

· Services or supplies furnished by a family member.

· The part of an expense for care and treatment of an injury or sickness that is in excess of the reasonable and customary charge.

· Services intended for treatment of any jaw joint disorder (TMJ); except as specifically provided.

· Repair to a damaged or injured tooth that was damaged or injured when the individual was not a participant under the plan.

· Dentures, crowns, inlays, onlays, bridgework, or other appliances or services used for the purpose of splinting, to alter vertical dimension to restore occlusion, or correction attrition, abrasion, or erosion.

· Any of the following services:

○ An appliance, or modification of one, if an impression for it was made before the person became a covered person;

○ A crown, bridge, or cast or processed restoration, if a tooth was prepared for it before the person became a covered person; or

○ Root canal therapy, if the pulp chamber for it was opened before the person became a covered person.

· Space maintainers except when needed to preserve space resulting from the premature loss of deciduous teeth.

· Orthodontic treatment; except as specifically provided.

· General anesthesia and intravenous sedation; unless done in conjunction with another necessary covered service.

· A crown, cast or processed restoration unless:

○ It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material; or

○ The tooth is an abutment to a covered partial denture or fixed bridge.

· Pontics, crowns, cast or processed restorations made with high noble metals; except as specifically provided.

· Surgical removal of impacted wisdom teeth only for orthodontic reasons.

· Services needed solely in connection with non-covered services.

· Services done where there is no evidence of pathology, dysfunction, or disease other than covered preventive services.

· Services done after the termination date of coverage.

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Questions about your employee benefits or other Human Resources issues? Contact the Workplace Solutions Center at (888) 471-2271.