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Plan Exclusions
No payment will be made for an expense incurred for or in connection with:
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charges for any duplicate devices or appliances, including prosthetics;
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charges for completion of claim forms, sterilization supplies, or failure
to keep a dental appointment;
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charges for oral hygiene, a plaque control program or dietary instruction;
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charges for overdentures, including root canal therapy and supportive
restorations;
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charges for replacing a lost, missing, or stolen device or appliance,
including prosthetics;
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charges for services that are experimental;
- cosmetic services.
These services are always considered cosmetic:
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veneers, facings, or similar properties of
crowns or pontics placed on or replacing
teeth in back of the second bicuspid; and
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personalization or characterization of
dentures;
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dental care for a congenital or developmental malformation, unless the
service is an orthodontic service as provided for orthognathic surgery
described under Covered Orthodontic Services on page 10 for a covered
dependent child;
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dental service not furnished by a dentist, except the scaling or cleaning
of teeth or topical application of fluoride may be performed by a licensed
dental hygienist if the treatment is rendered under the supervision and
guidance of a dentist;
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dental services or supplies:
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to the extent that they are in excess of the
usual and customary charges or applicable
fee schedules;
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that are not necessary or customary according to accepted dental standards, or that are not recommended or approved
by the attending dentist;
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except as otherwise specifically covered under the Plan, appliances,
restorations, or procedures for Temporomandibular Joint (TMJ) Dysfunctional
Syndrome, including the following:
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altering vertical dimension;
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restoring or maintaining occlusion;
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splinting;
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replacing tooth structure lost from abrasion
or attrition;
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expenses covered under any Workers' Compensation or Occupational
Disease Law;
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expenses for dental services or supplies provided by a member of your immediate
family;
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expenses for dental services performed two years prior to filing a claim;
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expenses incurred for dental services begun prior to enrollment in this
Plan;
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implants;
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injury to sound, natural teeth. This may be covered under your
medical plan;
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military service for any country or organization, including
service with military forces as a civilian whose duties do not
include combat;
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oral biopsies of tissue found in the mouth other than a tooth biopsy;
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orthodontic services for other than a dependent child under the age of 19 years;
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prescription drugs;
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procedure for teeth removed prior to the faculty or staff member's
enrollment in the University Dental Plan;
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services of a dentist employed by any government, unless a charge:
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must be paid by the faculty or staff member; or
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was incurred in a Veterans Administration hospital for non-service
connected disability;
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services or supplies from a government-owned or operated hospital, unless a charge:
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must be paid by the faculty or staff member;
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was incurred while the faculty or staff member was confined
in a military hospital; or
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was incurred in a Veteran's Administration
hospital for a non-service connected disability;
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war or act of war, or rebellion.
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