Rates

Rates

Rates

DENTAL INSURANCE: EXCLUSIONS

We will not pay Dental Insurance benefits for charges incurred for:

1. services which are not Dentally Necessary, or those which do not meet generally accepted standards of care for treating the particular dental condition;

2. services for which You would not be required to pay in the absence of Dental Insurance; 

3. services or supplies received by You or Your Dependent before the Dental Insurance starts for that person;

4. services which are neither performed nor prescribed by a Dentist, except for those services of a licensed Dental Hygienist which are supervised and billed by a Dentist, and which are for: 

  • scaling and polishing of teeth; or 
  • fluoride treatments;

5. services which are primarily cosmetic, unless required for the treatment or correction of a congenital defect of a newborn Child; 

6. services or appliances which restore or alter occlusion or vertical dimension;

7. restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease; 

8. restorations or appliances used for the purpose of periodontal splinting; 

9. counseling or instruction about oral hygiene, plaque control, nutrition and tobacco; 

10. personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss;

11. decoration or inscription of any tooth, device, appliance, crown or other dental work;

12. missed appointments;

13. services:

  • covered under any workers’ compensation or occupational disease law;
  • covered under any employer liability law;
  • for which the Employer of the person receiving such services is required to pay; or
  • received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital; 

14. services covered under other coverage provided by the Policyholder;

15. temporary or provisional restorations;

16. temporary or provisional appliances; 

17. prescription drugs; 

18. services for which the submitted documentation indicates a poor prognosis;

19. the following, when charged by the Dentist on a separate basis:

  • claim form completion;
  • infection control, such as gloves, masks, and sterilization of supplies; or 
  • local anesthesia, non-intravenous conscious sedation or analgesia, such as nitrous oxide;

20. dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food;

21. caries susceptibility tests; 

22. appliances or treatment for bruxism (grinding teeth);

23. precision attachments associated with fixed and removable prostheses, except when the precision attachment is related to implant prosthetics;

24. adjustment of a Denture made within 6 months after installation by the same Dentist who installed it; 

25. duplicate prosthetic devices or appliances;

26. replacement of a lost or stolen appliance, Cast Restoration or Denture;

27. replacement of an orthodontic device; 

28. diagnosis and treatment of temporomandibular joint disorders and cone beam imaging associated with the treatment of temporomandibular joint disorders; 

29. intra and extraoral photographic images; 

30.  adult prophylaxis for Dependents under age 14.