Dental Health Services Dental Plan Limitations and Exclusion: Summary of Dental exclusions: This is a very brief overview. Please refer to the evidence of coverage before purchasing this dental plan.  The following services are not covered by this dental plan:
A. Services that are not consistent with professionally recognized standards of practice.
B. Services related to implants or attachments to implants.
C. Cosmetic services, for appearance only, unless specifically listed.
D. Myofunctional therapy-procedures for training, treating or developing muscles in and around the jaw or mouth including T.M.J. and related diseases, except for occlusal guard.
E. Treatment for malignancies, neoplasms (tumors) and cysts as well as hereditary, congenital and/or developmental malformations.
F. Dispensing of drugs not normally supplied in a dental office.
G. Hospitalization charges, dental procedures or services rendered while patient is hospitalized.
H. Procedures, appliances or restorations (other than fillings) that are necessary for full mouth rehabilitation, to increase arch vertical dimension, or crown/bridgework requiring more than 10 crowns/pontics. Replacement or stabilization of tooth structure lost through attrition, abrasion or erosion.

Procedures performed by a prosthodontist.
I. Fixed bridges for patients under the age of sixteen, in the presence of nonsupportive periodontal tissue, when edentulous spaces are bilateral in the same arch, when replacement of more than four teeth in an arch, replacement of missing third molars, or when the prognosis is poor.
J. General anesthesia, including intravenous and inhalation sedation.
K. Dental procedures that cannot be performed in the dental office due to the general health and/or physical limitations of the member.
L. Expenses incurred for dental procedures initiated prior to member’s eligibility with Dental Health Services, or after termination of eligibility.
M. Services that are reimbursed by a third party (such as the medical portion of an insurance/health plan or any other third party indemnification).
N. Extractions of non-pathologic, asymptomatic teeth, including extractions and/or surgical procedures for orthodontic reasons.
O. Setting of a fracture or dislocation, surgical procedures related to cleft palate, micrognathia or macrognathia, and surgical grafting procedures.
P. Coordination of benefits with another prepaid managed care dental plan.
Q. Orthodontic treatment of a case in progress and/or retreatment of orthodontic cases.
R. Cephalometric x-rays, tracings, photographs and orthodontic study models.
S. Replacement of lost or broken orthodontic appliances.
T. Changes in orthodontic treatment necessitated by an accident of any kind.
U. Malocclusions so severe or mutilated which are not amenable to ideal orthodontic therapy.
V. Services not specifically covered on the Schedule of Covered Services and Copayments.

Dental limitations: Restrictions on benefits are applied to the following services
A. Treatment of dental emergencies is limited to treatment that will alleviate acute symptoms and does not cover definitive restorative treatment including, but not limited to root canal treatment and crowns.
B. Optional services: when the patient selects a plan of treatment that is considered optional or unnecessary by the attending dentist, the additional cost is the responsibility of the patient.
C. Routine teeth cleaning (prophylaxis) is limited to once every six months and full mouth x-rays are limited to one set every three years if needed.
D. Sealants are only a benefit for permanent posterior teeth of children under the age of eighteen.
E. Covered specialist referrals must be pre-approved by Dental Health Services.
F. Periodontal surgical procedures are limited to four quadrants every two years.
G. There are additional charges for precious/noble metals (gold).
H. Replacement will be made of any existing appliance (denture, etc.) only if it is unsatisfactory and cannot be made satisfactory. Prosthetic appliances will be replaced only after five years have elapsed from the time of delivery. Lost or stolen removable appliances are the responsibility of the enrollee.
I. Relines are limited to once per twelve months, per appliance.
J. Single unit inlays and crowns are a benefit as provided above only when the teeth cannot be adequately restored with other restorative materials.
K. The maximum benefit for all contracted specialty care, excluding orthodontics, is $1,000 per member, per contract year.

Orthodontic exclusions: The following services are not covered by this dental plan
A. Retreatment of orthodontic cases.
B. Treatment of a case in progress at inception of eligibility.
C. Surgical procedures (including extraction of teeth) incidental orthodontic treatment.
D. Surgical procedures related to cleft palate, micrognathia or macrognathia.
E. Treatment related to temporomandibular joint (TMJ) disturbances and/or hormonal imbalances.
F. Any dental procedure considered within the field of general dentistry,including but not limited to: myofunctional therapy; general anesthetics, including intravenous and inhalation sedation; dental services of any nature performed in a hospital.
G. Orthodontic treatment of a case in progress and/or retreatment of orthodontic cases
H. Cephalometric x-rays, tracings, photographs and orthodontic study models.
I. Replacement of lost or broken orthodontic appliances
J. Changes in treatment necessitated by an accident of any kind.
K. Services which are compensable under worker’s compensation or employer liability laws.
L. Malocclusions so severe or mutilated they are not amenable to ideal orthodontic therapy.

Orthodontic limitations: The following are subject to additional charges
A. Full banded treatments are based on a 24-month standard treatment plan. Additional treatment, or treatment that extends beyond that time may be subject to additional charges. If the contract between the enrollee and Dental Health Services is terminated, service is subject to a pro-rated fee based on current market value for the balance of orthodontic treatment. If the member should terminate coverage, they are no longer eligible for the enrollee orthodontic rate. Should the contract between Dental Health Services and the orthodontist terminate, any Dental Health Services members in treatment would not be subject to proration. Please call your Member Service Specialist at 800.63.SMILE for a referral to the nearest participating orthodontist.

Health plan benefits and coverage matrix: THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Deductibles: None
Lifetime maximums: None.
Professional services – exam & preventive services: No charge for most services.
Full mouth x-rays limited to every three years. Prophylaxis (cleanings) limited to every six months. Sealants limited to permanent teeth to age 18.
Professional services – restorative, crowns, endodontics and oral surgery services: Copayments for fillings, caps, root canals and extractions vary by procedure in the enclosed Schedule.
Professional services – periodontic services: Copayments for gum treatments vary by procedure in the enclosed Schedule. Surgical procedures are limited to four quads every two years.
Professional services – dentures and partial dentures: Copayments vary by procedure and appear in the enclosed Schedule. Replacements limited to every five years. Relines limited to every 12 months.
Professional services – specialty services: Copayments vary by procedure and appear in the enclosed Schedule of Covered Services and Copayments. There is a $1,000 maximum benefit per member, per contract year, excluding orthodontics. See Services when performed by a Dental Health Services specialist.
Outpatient office visits: $4 per visit
Hospitalization services: Not covered
Prescription drug coverage: Not covered
Emergency health services: Not covered
Ambulance services: Not covered
Durable medical equipment: Not covered
Mental health services: Not covered
Chemical dependency services: Not covered
Home health services: Not covered
This dental plan does not provide general anesthesia. Members requiring