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This plan does not cover the following services, treatments and supplies:

  • Services or supplies for which the enrollee, absent this coverage, would normally incur no charge, such as care rendered by a dentist to a member of his immediate family or the immediate family of his spouse;
  • Services or supplies for which coverage is available under workers' compensation or employers' liability laws;
  • Services or supplies performed for cosmetic purposes or to correct congenital malformations, except newborns with congenital dental defects;
  • Services that require multiple visits, which commenced prior to the Membership Effective Date or prior to the expiration of a waiting period, if applicable (including prosthetics and orthodontic care);
  • Services or supplies related to temporomandibular joint (TMJ) dysfunction (this involves the jaw hinge joint connecting the upper and lower jaws);
  • Services or supplies not specifically stated as covered dental services (including hospital or prescription drug charges);
  • Replacement of dentures and other dental appliances which are lost or stolen;
  • Diseases contracted or injuries or conditions sustained as a result of any act of war;
  • Denture adjustments for the first six months after the dentures are initially received. Separate fees may not be charged by participating dentists;
  • Complete occlusal adjustments, crowns for occlusal correction, athletic mouthguards, nightguards, bruxism appliances, and bite therapy appliances;
  • Tooth preparation, temporary crowns, bases, impressions, and anesthesia or other services which are part of the complete dental procedure. These services are considered components of and included in the fee for the complete procedure. Separate fees may not be charged by participating dentists;
  • Analgesia, including Nitrous Oxide, duplication of radiographs, temporary appliances;
  • Services or supplies covered under a terminal liability, extension of benefits, or similar provision, of a program being replaced by this program;
  • Services or supplies rendered by a dental or medical department maintained by or on behalf of a group, a mutual benefit association, union, trustee or similar person or group;
  • Services or supplies provided or paid for by or under any governmental agency or program or law, except charges which the person is legally obligated to pay (this exclusion extends to any benefits provided under the U.S. Social Security Act, as amended);
  • Services rendered beyond the scope of a dentist’s or service provider’s license, or experimental or investigational services/supplies;
  • Services or supplies that a dentist determines for any reason, in his professional judgment, should not be provided;
  • Instructions in dental hygiene, dietary planning, or plaque control;
  • Missed appointments or claim form completion;
  • Infection control, including sterilization of supplies and equipment;
  • Orthodontics; and
  • Services incurred prior to satisfying any applicable waiting period or Late Entrant Penalty.

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