For Basic and Premiere Plans: Treatment, care, services or supplies for which benefits are not specifically provided for in the Policy | Charges exceeding the maximum
benefit amount, if any | Attempted suicide or any intentionally self-inflicted injury | Directly or indirectly engaging in illegal activity| Treatment of disturbances of the
temporomandibular joint (TMJ) | A service not furnished by a dentist, unless by a dental hygienist under the dentist’s supervision and x-rays are ordered by the dentist | Plaque
control, completion of claim forms; broken appointments, prescription or take-home fluoride, or diagnostic photographs | Oral/facial images, including intra- and extra-oral
images | Pulp vitality tests | Chairside, labial veneers (laminates) | Regional block anesthesia | Hospital, house or extended care facility calls | Office visits for the purpose of
observation, during or after regularly scheduled hours | Office visits outside of regularly scheduled hours | Enamel microabrasions | Services not completed by the end of the
month in which coverage terminates | Procedures that are begun, but not completed | Those services for which there would be no charge in the absence of insurance or for any
service or treatment provided without charge | Services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring
while on full-time active duty in the armed forces of any country or combination of countries | Care or treatment of a condition for which benefits are payable under any Workers’
Compensation Act or similar law | Orthodontic procedures | Covered expenses for which an insured person is not legally obligated to pay | Experimental/Investigational treatment
For Basic Plan Only: Cosmetic procedures
For Premiere Plan Only: Cosmetic procedures, unless due to an injury or for congenital/developmental malformation. Facing on crowns, or pontics, posterior to the second
bicuspid is considered cosmetic | The replacement of full and partial dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function | Implants;
replacement of lost or stolen appliances; replacement of orthodontic retainers; athletic mouth-guards; precision or semi-precision attachments; denture duplication; or splinting
| Replacement of any prosthetic appliance, crown, inlay, or onlay restoration, or fixed bridge within 5 years of the date of the last replacement, unless due to an injury | Post
removals unless in conjunction with endodontic therapy | Intentional re-implantation, including necessary splinting | Surgical procedure for isolation of tooth with rubber dam |
Canal preparation and fitting of performed dowel or post | An initial placement of a partial or full removable denture or fixed bridgework if it involves the replacement of one or
more natural teeth lost before coverage was effective under the Policy. This limitation does not apply if replacement includes a natural tooth extracted while covered under the
Policy.
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