Four Plan Options

Certain services listed above have frequencies and limitations.

Exclusions and Limitations. For a complete list of exclusions and limitations, refer to your contract. Common non-covered services (exclusions) include the following: services which are available from any Federal or State government agency, or similar entity; services for injuries compensable under an automobile policy or worker’s compensation or similar employer coverage; cosmetic services (unless stated otherwise); services started prior to coverage; services that are not completed; administrative fees such as missed appointments; temporary services and procedures; duplicate dentures; prescription drugs, premedications and relative analgesia, including hospital, healthcare facility or medical emergency room charges; laboratory charges; anesthesia for restorative dentistry; preventive control programs; injuries or disease intentionally self-inflicted or occurring during or as a result of participation in riots or civil disobedience of any form, acts of war, or criminal activity; appliances or restorations to restore occlusion, splinting, equilibration, or replace tooth structure lost by attrition; restorations in conjunction with overdenture; services provided outside of the United States or Canada; dental implants (except for the Platinum plan); services related to TMJ; and services, supplies or treatments not specifically listed as covered in the member’s contract. Common limitations include: the least costly professionally accepted treatment to achieve reasonable functionality; costs of procedures necessary to prevent or eliminate oral disease and for appliances or restorations to replace missing teeth as allowed by the plan; frequency and combined service limitations related to restorations, individual crowns, prosthetic appliances, and periodontal procedures as identified within the contract; and other frequency, age or contractual limitations as specified. Additionally, for implant procedures, benefits are allowed for a bilateral partial if teeth are missing in both quadrants of the same arch. See Benefit Booklet for additional details on exclusions and limitations.