Exclusions and Limitations:

Exclusions
No payment will be made by Delta Dental and all charges for the following services will be the responsibility of the Subscriber:

1. Services for injuries or conditions payable under Workers' Compensation or Employer's Liability laws. Benefits or services that are available from any government agency, political subdivision, community agency, foundation or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX Social Security Act, that is, Medicaid.
   
   
2. Services, as determined by Delta Dental, for correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons.
   
   
3. Services or appliances started before an individual became eligible under this Plan.
   
   
4. Prescription drugs, premedications and relative analgesia. General anesthesia and/or intravenous sedation for restorative dentistry or for surgical procedures, unless medically necessary. Charges for hospitalization, laboratory tests, and examinations.
   
   
5. Preventive control programs including home care items.
   
   
6. Charges for failure to keep a scheduled visit with the Dentist.
   
   
7. Replacement, repair, relines, or adjustments of occlusal guards.
   
   
8. Charges for completion of forms. A participating Dentist may not make these charges to a Subscriber/Eligible Dependent.
   
   
9. Inlays.
   
   
10. Lost, missing or stolen appliances of any type and replacement or repair of orthodontic appliances.
    
    
11. Services for which no valid dental need can be demonstrated, that are specialized techniques, or that are experimental in nature as determined by the standards of generally accepted dental practice.
    
    
12. Appliances, surgical procedures, and restorations for increasing vertical dimension; for restoring occlusion; for replacing tooth structure loss resulting from attrition, abrasion, or erosion. If orthodontic benefits have been selected, this exclusion will not apply to those benefits as limited by the terms and conditions of the Plan.
    
    
13. Treatment by other than a Dentist, except for services performed by a licensed dental hygienist under the scope of his or her license.
    
    
14. Those benefits excluded by the policies and procedures of Delta Dental including the Processing Policies.
    
    
15. Services or supplies for which no charge is made, for which the patient is not legally obligated to pay, or for which no charge would be made in the absence of Delta Dental coverage.
    
    
16. Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared.
    
    
17. Services that are covered under a hospital, surgical/medical, or prescription drug program.
    
    
18. Appliances, restorations, or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ).
    
    
19. Services that are not within the classes of benefits that have been selected and are not in the contract.

Limitations
The benefits for the following services are limited as follows, unless specified in the Summary of Dental Plan Benefits. All time limitations are measured from the last date of service in any Delta Dental Plan record or, at the request of your group, any dental plan record.

1. Prophylaxes and oral exams are payable twice in a contract period.
   
   
2. Bitewing x-rays are payable once in a contract period. Full mouth X-rays (which include bitewing x-rays) are payable once in any five-year period. A panographic X-ray (including bitewings) is considered a full mouth X-ray.
   
   
3. Amalgam and resin restorations are payable once within a 24-month period, regardless of the number or combination of restorations placed on a surface.
   
   
4. Cast restorations (including jackets, crowns, onlays) and associated procedures (such as cores and post substructures) on the same tooth are payable once in any five-year period.
   
   
5. Porcelain, porcelain substrate, and cast restorations are not payable for children less than 12 years of age.
   
   
6. Optional treatment: If you select a more expensive service than is customarily provided or for which Delta Dental does not determine a valid dental need is shown, Delta Dental can make an allowance based on the fee for the customarily provided service.
   
   HELPFUL HINT: "Silver" fillings are covered under the dental plans; however, if the employee or dentist opt to use a "white" filling, the dentist may charge the employee the difference in cost - that is the cost not covered by insurance. The employee is responsible for the difference.
   
   For example, if a tooth can be satisfactorily restored with amalgam (silver filling) and you choose to have the tooth restored with a more costly material or an inlay, the Plan will pay only the amount that it would have paid to restore the tooth with amalgam. You are responsible for the difference in cost.
   
   
7. Benefits for root planing are payable once in any two-year period. Periodontal surgery, including subgingival curettage, is payable once in any three-year period.
   
   
8. Prosthodontic (Class III) benefit limitations:
   
   
   1. One complete upper and one complete lower denture are benefits once in any five-year period for any individual.
      
      
   2. A partial denture, fixed bridge, or removable bridge for any individual can be covered once in any five-year period unless the loss of additional teeth requires the construction of a new appliance.
      
      
   3. Fixed bridges and removable cast partials are not payable for people less than 16 years of age.
      
      
   4. A reline or the complete replacement of denture base material is limited to once in any three-year period per appliance.
      
      
9. Preventive fluoride treatments are payable for children until their 19th birthday.
   
   HELPFUL HINT: Make sure that you understand what services are covered by insurance and what services you may have to pay part or all of the service cost.
   
   
10. Orthodontic (Class IV) benefit limitations:
    
    
    1. Orthodontic benefits are payable at any age of a Subscriber/Eligible Dependent.
       
       
    2. If the treatment plan is terminated before completion of the case for any reason, Delta Dental's obligation will cease with payment to the date of termination.
       
       
    3. The Dentist may terminate treatment, with written notification to Delta Dental and to the patient, for lack of patient interest and cooperation. In those cases, Delta Dental's obligation for payment of benefits ends on the last day of the month in which the patient was last treated.
       
       
    4. Any charge for the replacement or repair of an orthodontic appliance furnished under any Delta Dental Plan will not be paid by Delta Dental and will be the responsibility of the patient.
       
       
11. Delta Dental's obligation for payment of benefits ends on the last day of the month in which coverage is terminated.
    
    
12. When services in progress are interrupted and completed later by another Dentist, Delta Dental will review the claim to determine the amount of payment, if any, to each Dentist.
    
    
13. Care terminated due to the death of a Subscriber or Eligible Dependent will be paid to the limit of Delta Dental's liability for the services completed or in progress.
    
    
14. Maximum Payment:
    
    
    1. The maximum benefit payable in any one-benefit year will be limited to the amount specified in the Benefit Feature Sheet.
       
       
    2. Delta Dental's payment for orthodontic (Class IV) benefits will be limited to the lifetime maximum per person specified in the Benefit Feature Sheet.
       
       
15. There is a $25 annual deductible on Class II and Class III services. Delta Dental will not be obligated to pay for, in whole or in part, any service to which the deductible applies until the Plan deductible amount is met.
    
    
16. Sealants are payable once per tooth per lifetime and only for the occlusal surface of first and second permanent molars for patient up to age 19.
    
    
17. Processing Policies may limit treatment.