Out-of- In-Network Essential Health Benefit PLUS

Transcription

1 This summary f benefits, alng with the exclusins and limitatins describe the benefits f the Essential Health Benefit PPO Family Plan with EHB PLUS (fr Children). Please review clsely t understand all benefits, exclusins and limitatins. Child-ONLY* Out-f- Adult-ONLY* Out-f- In-Netwrk In-Netwrk Essential Health Benefit PLUS Netwrk** PPO Plan Netwrk** Class I/Preventive - Cleanings, Exams, Fluride, Sealants, Space Maintainers, Emergency Pain, and Radigraphs- Bitewings Class II/Basic - Radigraphs (Full Muth X- ray, Panramic Film) Restratins (Amalgams and Anterir Resins), Simple Extractins and Anesthesia (General Anesthesia and Intravenus Sedatin) Class III/Majr - Surgical Extractins, Oral Surgery, Enddntics, Peridntal Maintenance, Peridntics, Inlay, Onlays, Crwns, Crwn Repair, Bridges, Bridge Repairs, Dentures, and Denture Repair Class II, III and IV/Orthdntia (Only fr pre-authrized Medically Necessary Orthdntia) Deductible (waived fr Class I)(per persn) Out f Pcket Maximum (OOP) (per persn) Out f Pcket Maximum*** (OOP) (per family - 2+ children) 100% 100% 80% 80% 50% 50% 50% fr medically necessary rthdntics Class I/Preventive - Cleanings, Exams, Space Maintainers, Emergency Pain, and Radigraphs-Bitewings, Radigraphs (Full Muth X-ray, Panramic Film) Class II/Basic - Fluride, Sealants, Restratins (Amalgams &Anterir Resin), Simple Extractins, Surgical Extractins, Oral Surgery, Enddntics, Peridntal Maintenance, Peridntics, Anesthesia, General Anesthesia, and Intravenus Sedatin. Class III/Majr - Inlay, Onlays, Crwns, Crwn Repair, Bridges, Bridge Repairs, Dentures, and Denture Repair Class IV/Orthdntia 100% 100% 90% 80% 60% 50% $200 Deductible (waived fr Class I)(per persn) $0 $50 $350 N/A Out f Pcket Maximum (OOP) (per persn) N/A $700 N/A Out f Pcket Maximum (OOP) (per family - 2+ children) N/A Annual Maximum N/A Annual Maximum $1,500 Orth Lifetime Maximum N/A Orth Lifetime Maximum N/A Waiting Perid 24 mnths fr medically necessary rthdntics Waiting Perid N/A * This plan is available fr individuals up t age 19. * This plan is available fr individuals ages 19 and ver. **Benefits are based n the Usual and Custmary charges f the majrity f **Benefits are based n the Usual and Custmary charges f the majrity f dentists in the same gegraphic area. dentists in the same gegraphic area. ***2 family members must each meet the ut f pcket maximum in a plan year. Once fulfilled the family maximum has been met and will nt be applied t additinal family members. N/A 1 P a g e

2 CLASSES OF COVERED SERVICES AND SUPPLIES (Individuals up t Age 19) Class II: Basic Dental Services Cverage is prvided fr the dental services and supplies described in this sectin. Please nte the age and frequency limitatins that apply fr certain prcedures. All frequency limits specified are applied t the day. Fr Yur Plicy, specific Cvered Services and Supplies may fall under a Class categry ther than what is stated belw. If Yur Plicy has Class categrizatins different frm belw, it is specified n the Schedule f Benefits. Class I: Preventive Dental Services Oral Exams Limited t twice in a 12 mnth perid fr any cmbinatin f ral exams X-Rays Bitewings limited nce every 12 mnths (nt a benefit in additin t a cmplete muth series) Prphylaxis (Cleaning) Limited t nce in a 12 mnth perid Tpical Fluride Treatment Limited t twice in a 12 mnth perid Sealants Sealant applicatins are limited t 1 per 36 mnth perid, n unrestred pit and fissures f a 1 st and 2 nd permanent mlar. Space Maintainer Only fr premature lss f deciduus (baby) psterir (back) teeth. Palliative Treatment Treatment f Emergency Pain X-Rays Full x-rays cmplete series (includes bitewings) limited t nce in 60 mnths. Panramic films limited t twice in a 12 mnth perid Amalgam (silver) Restratins Multiple restratins n 1 surface will be cnsidered a single filling. Multiple restratins n different surfaces f the same tth will be cnsidered cnnected. Limited t nce in 24 mnths Resin (tth clred) Restratins Anterir (frnt) teeth ONLY Limited t nce in 24 mnths fr the same cvered amalgam (resin) restratin Resin (tth clred) Restratins Psterir (back) teeth ONLY Limited t the benefit f the crrespnding amalgam restratin Prir t placement member must be infrmed and agree t pay the cst difference Crnal remnants deciduus tth Extractin f erupted teeth r expsed rt Cnsultatin, including specialist cnsultatins, limited as fllws: Cnsidered fr payment as a separate benefit nly if n ther treatment (except x-rays) is rendered n the same date. Benefits will nt be cnsidered fr payment if the purpse f the cnsultatin is t describe the Dental Treatment Plan General anesthesia and intravenus sedatin, limited as fllws: Cnsidered fr payment as a separate benefit nly when medically necessary (as determined by the Plan) and when 2 P a g e

3 administered in the Dentist s ffice r utpatient surgical center in cnjunctin with cmplex ral surgical services which are cvered under the Plicy. Nt a benefit fr the management f fear and anxiety Oral sedatin and nitrus xide are cvered fr children thrugh the age f 13 Class III: Majr Dental Services Therapeutic pulptmy (primary tth) excluding final restratin Benefit nly fr primary (baby) teeth Rt canal therapy (anterir/bicuspid/mlar) excluding final restratin Benefit fr permanent teeth nly. Recement crwn Prefabricated stainless steel crwn (primary and permanent teeth);prefabricated resin crwn (anterir teeth nly); Prefabricated stainless steel crwn with resin windw (anterir teeth nly) If mre than ne restratin is used t restre a tth, benefit allwance will be paid fr the mst inclusive service; Prefabricated crwns per tth are benefits nce in 24 mnth perid Surgical remval f erupted teeth Remval f impacted teeth Pathlgy remval f 3 rd mlar is nt a cvered benefit. Class IV: Orthdntia Orthdntia is cvered when medically necessary and pre apprved by the plan. There is a 24 mnth waiting perid fr medically necessary rthdntia. General Exclusins Cvered Services and Supplies d nt include: 1) Treatment which: a) is nt included in the list f Cvered Services and Supplies; b) is nt Dentally Necessary; r c) is Experimental in nature. 2) Any Charges which are: a) Payable r reimbursable by r thrugh a plan r prgram f any gvernmental agency, except if the charge is related t a nnmilitary service disability and treatment is prvided by a gvernmental agency f the United States. Hwever, We will always reimburse any state r lcal medical assistance (Medicaid) agency fr Cvered Services and Supplies. b) Nt impsed against the persn r fr which the persn is nt liable. c) Reimbursable by Medicare Part A and Part B. If a persn at any time was entitled t enrll in the Medicare prgram (including Part B) but did nt d s, his r her benefits under this Plicy will be reduced by an amunt that wuld have been reimbursed by Medicare, where permitted by law. Hwever, fr persns insured under Emplyers wh ntify Us that they emply 20 r mre Emplyees during the previus business year, this exclusin will nt apply t an Actively at Wrk Emplyee and/r his r her spuse wh is age 65 r lder if the Emplyee elects cverage under this Plicy instead f cverage under Medicare. 3) Services r supplies resulting frm r in the curse f Yur r Yur Dependent s regular ccupatin fr pay r prfit fr which Yu r Yur Dependent are entitled t benefits under any Wrkers Cmpensatin Law, Emplyer s Liability Law r similar law. Yu must prmptly claim and ntify the Plan f all such benefits. 3 P a g e

4 4) Services r supplies prvided by a Dentist, Dental Hygienist, denturist r dctr wh is: a) a Clse Relative r a persn wh rdinarily resides with Yu r a Dependent; b) an Emplyee f the Emplyer; c) the Emplyer. 5) Services and supplies which may nt reasnably be expected t successfully crrect the Cvered Persn s dental cnditin fr a perid f at least three years, as determined by the Plan. 6) All services fr which a claim is submitted mre than 6 mnths after the date f service. 7) Services and supplies prvided as ne dental prcedure, and cnsidered ne prcedure based n standard dental prcedure cdes, but separated int multiple prcedure cdes fr billing purpses. The Cvered Charge fr the Services is based n the single dental prcedure cde that accurately represents the treatment perfrmed. 8) Services and supplies prvided primarily fr csmetic purpses. 9) Cvered services and supplies btained while utside f yur cvered state and/r the United States, except fr Emergency Dental Care. 10) Crrectin f cngenital cnditins r replacement f cngenitally missing permanent teeth nt cvered, regardless f the length f time the deciduus tth is retained. 11) Diagnstic casts, unless fr medically necessary rthdntia. 12) Educatinal prcedures, including but nt limited t ral hygiene, plaque cntrl r dietary instructins. 13) Persnal supplies r equipment, including but nt limited t water piks, tthbrushes, r flss hlders. 14) Restrative prcedures, rt canals and appliances which are prvided because f attritin, abrasin, ersin, wear, r fr csmetic purpses. 15) Appliances, inlays, cast restratins, crwns, r ther labratry prepared restratins used primarily fr the purpse f splinting. 16) Replacement f a lst r stlen Appliance r Prsthesis. 17) Replacement f stayplates. 18) Hspital r facility charges fr rm, supplies r emergency rm expenses, r rutine chest x-rays and medical exams prir t ral surgery. 19) Treatment fr a jaw fracture. 20) Services, supplies and appliances related t the change f vertical dimensin, restratin r maintenance f cclusin, splinting and stabilizing teeth fr peridntic reasns, bite registratin, bite analysis, attritin, ersin r abrasin, and treatment fr temprmandibular jint dysfunctin (TMJ), unless a TMJ benefit rider was included in the Plicy. 21) Therapeutic drug injectin. 22) Cmpletin f claim frms. 23) Missed dental appintments. 24) Prcelain and cast crwns 25) Crwns, inlays, cast restratins, r ther labratry prepared restratins n teeth which may be restred with an amalgam resin filling. 26) Pathlgy free third mlar extractin r remval. 27) Crwn build-up is nt cvered as a separate service. 28) Temprary tth stabilizatin, ther than cvered space maintainers, is nt cvered. 29) Oral sedatin and nitrus xide analgesia are nt cvered, except fr Children thrugh age ) Implants, and prcedures and appliances assciated with them, are nt benefits f Premier prgrams. 31) Replacement f missing teeth prir t cverage effective date. 4 P a g e

5 CLASSES OF COVERED SERVICES AND SUPPLIES (Individuals age 19 and ver) Cverage is prvided fr the dental services and supplies described in this sectin. Please nte the age and frequency limitatins that apply fr certain prcedures. All frequency limits specified are applied t the day. Fr Yur Plicy, specific Cvered Services and Supplies may fall under a Class categry ther than what is stated belw. If Yur Plicy has Class categrizatins different frm belw, it is specified n the Schedule f Benefits. Class I: Preventive Dental Services Cmprehensive exams, peridic exams, evaluatins, re-evaluatins, limited ral exams, r peridntal evaluatins. Limited t 1 per 6 mnth perid Dental prphylaxis (cleaning and scaling). Benefit limited t either 1 dental prphylaxis r 1 peridntal maintenance prcedure per 6 mnth perid, but nt bth. Tpical fluride treatment. Limited t 1 per 6 mnth perid. Palliative (emergency) treatment f dental pain Cnsidered fr payment as a separate benefit nly if n ther treatment (except x-rays) is rendered during the same visit. Sealant applicatins are limited t ne per 36 mnth perid, n unrestred pit and fissures f a 1 st and 2 nd permanent mlar. X-rays: Intraral cmplete series x-rays, including bitewings and 10 t 14 periapical x-rays, r panramic film. Limited t 1 per 60 mnth perid. Payable amunt fr the ttal f bitewing and intraral periapical x-rays is limited t the maximum allwance fr an intraral cmplete series x- rays in a calendar year. Bitewing x-rays (tw r fur films). Limited t 1 per 12 mnth perid. Payable amunt fr the ttal f bitewing and intraral periapical x-rays is limited t the maximum allwance fr an intraral cmplete series x- rays in a calendar year. Other X-rays: Intraral periapical x-rays. Payable amunt fr the ttal f bitewing and intraral periapical x-rays is limited t the maximum allwance fr an intraral cmplete series x-rays in a calendar year. Intraral cclusal x-rays, limited t 1 film per arch per 6 mnth perid. Extraral x-rays, limited t 1 film per 6 mnth perid. Other x-rays (except films related t rthdntic prcedures r temprmandibular jint dysfunctin). Class II: Basic Dental Services Amalgam and cmpsite restratins, limited as fllws: Multiple restratins n 1 surface will be cnsidered a single filling. Multiple restratins n different surfaces f the same tth will be cnsidered cnnected. Benefits fr replacement f an existing restratin will nly be cnsidered fr payment if at least 36 mnths have passed since the existing restratin was placed (except in extrardinary circumstances invlving external, vilent and accidental means r due t radiatin therapy). Additinal fillings n the same surface f a tth in less than 36 mnths, by the same ffice r same Dentist are nt cvered, except in extrardinary circumstances invlving 5 P a g e

6 external, vilent and accidental means r due t radiatin therapy. Sedative bases and liners are cnsidered part f the restrative service and are nt paid as separate prcedures. Cmpsite restratins are als limited as fllws: Mesial-lingual, distal-lingual, mesial-facial, and distalfacial restratins n anterir teeth will be cnsidered single surface restratins Acid etch is nt cvered as a separate prcedure Benefits limited t anterir teeth nly. Benefits fr cmpsite resin restratins n psterir teeth are limited t the benefit fr the crrespnding amalgam restratin. Pins, in cnjunctin with a final amalgam restratin Space maintainers, including all adjustments made within 6 mnths f installatin. Stainless steel crwns, limited t 1 per 36 mnth perid fr teeth nt restrable by an amalgam r cmpsite filling. Pulptmy (primary teeth nly). Rt canal therapy: Including all pre-perative, perative and pst-perative x- rays, bacterilgic cultures, diagnstic tests, lcal anesthesia, all irrigants, bstructin f rt canals and rutine fllw-up care Limited t 1 time n the same tth per 24 mnth perid by the same prvider. Limited t permanent teeth nly. Apicectmy/periradicular surgery (anterir, bicuspid, mlar, each additinal rt), including all preperative, perative and pstperative x-rays, bacterilgic cultures, diagnstic tests, lcal anesthesia and rutine fllw-up care. Retrgrade filling - per rt. Rt amputatin - per rt. Hemisectin, including any rt remval and an allwance fr lcal anesthesia and rutine pst-perative care des nt include a benefit fr rt canal therapy. Peridntal scaling and rt planing, limited as fllws: 4 r mre teeth per quadrant, limited t a minimum f 5mm pckets (per tth), with radigraphic evidence f bne lss, cvered 1 time per quadrant per 24 mnth perid. 1 t 3 teeth per quadrant, limited t minimum f 5mm pckets (per tth), with radigraphic evidence f bne lss, cvered 1 time per area per 24 mnth perid. Under unusual circumstances, additinal dcumentatin can be submitted t the Plan fr review. Fllwing sseus surgery rt planing is a benefit after 36 mnths in the same area. Peridntal maintenance prcedure (fllwing active treatment). Benefit limited t either 1 peridntal maintenance prcedure r 1 dental prphylaxis per 6 mnth perid, but nt bth Peridntal maintenance prcedures may be used in thse cases in which a patient has cmpleted active peridntal therapy, and cmmencing n sner than 3 mnths thereafter. The prcedure includes any examinatin fr evaluatin, curettage, rt planing and/r plishing as may be necessary. Peridntal related services as listed belw, limited t 1 time per quadrant f the muth in any 36 mnth perid with charges cmbined fr prcedures as listed belw: Gingival flap prcedures. Gingivectmy prcedures. Osseus surgery. Pedicle tissue grafts. 6 P a g e

7 Sft tissue grafts. Subepithelial tissue grafts. Bne replacement grafts. Guided tissue regeneratin. Crwn lengthening prcedures - hard tissue. The mst inclusive prcedure will be cnsidered fr payment when 2 r mre surgical prcedures are perfrmed. Oral surgery services as listed belw, including an allwance fr lcal anesthesia and rutine pst-perative care: Simple extractins Surgical extractins, including extractin f third mlars with pathlgy (wisdm teeth) Alveplasty Vestibulplasty Remval f exstses (including tri) maxilla r mandible Frenulectmy (frenectmy r frentmy) Excisin f hyperplasic tissue per arch Tth re-implantatin and/r stabilizatin f accidentally avulsed r displaced tth and/r alvelus, limited t permanent teeth nly. Rt remval expsed rts. Bipsy Incisin and drainage The mst inclusive prcedure will be cnsidered fr payment when 2 r mre surgical prcedures are perfrmed. General anesthesia and intravenus sedatin, limited as fllws: Cnsidered fr payment as a separate benefit nly when medically necessary (as determined by the Plan) and when administered in the Dentist s ffice r utpatient surgical center in cnjunctin with cmplex ral surgical services which are cvered under the Plicy. Nt a benefit fr the management f fear and anxiety; Oral sedatin is nt a cvered benefit. Cnsultatin, including specialist cnsultatins, limited as fllws: Cnsidered fr payment as a separate benefit nly if n ther treatment (except x-rays) is rendered n the same date. Benefits will nt be cnsidered fr payment if the purpse f the cnsultatin is t describe the Dental Treatment Plan. Class III: Majr Dental Services Inlays and nlays (metallic), limited as fllws: Cvered nly when the tth cannt be restred by an amalgam r cmpsite filling. Cvered nly if mre than 5 years have elapsed since last placement. Build-up prcedure is cnsidered cvered and is inclusive in the fee. Benefits are based n the date f cementatin. Prcelain restratins n anterir teeth, limited as fllws: Cvered nly when the tth cannt be restred by an amalgam r cmpsite filling. Cvered nly if mre than 5 years have elapsed since last placement. Limited t permanent teeth. Prcelain restratins n verretained primary teeth are nt cvered. Build-up prcedure is cnsidered cvered and is inclusive in the fee. Benefits are based n the date f cementatin. Cast crwns, limited as fllws: Cvered nly when the tth cannt be restred by an amalgam r cmpsite filling. 7 P a g e

8 Cvered nly if mre than 5 years have elapsed since last placement. Limited t permanent teeth. Cast crwns n ver-retained primary teeth are nt cvered. Crwns n third mlars are cvered when adjacent first r secnd mlars are missing and the tth is in functin with an ppsing natural tth. Build-up prcedure is cnsidered cvered and inclusive in the fee. Benefits are based n the date f cementatin. Crwn lengthening is limited t a single site when cntiguus teeth are invlved. Re-cementing inlays, crwns and bridgesis limited t 3 per tth, 12 mnths after last cementatin. Pst and cre: Cvered nly fr enddntically- treated teeth, which require crwns. 1 pst and cre is cvered per tth. Full dentures, limited as fllws: Limited t 1 full denture per arch. Replacement cvered nly if 5 years have elapsed since last replacement AND the full denture cannt be made serviceable (please refer t the Denture r Bridge Replacement/Additin prvisin under Exclusins and Limitatins fr exceptins). Services include any adjustments r relines which are perfrmed within 12 mnth f initial insertin. We will nt pay additinal benefits fr persnalized dentures r verdentures r assciated treatment. Benefits fr dentures are based n the date f delivery. Partial dentures, including any clasps and rests and all teeth, limited as fllws: Limited t 1 partial denture per arch. Replacement cvered nly if 5 years have elapsed since last placement AND the partial denture cannt be made serviceable (please refer t the denture r bridge replacement/additin prvisin under exclusins and limitatins fr exceptins). Services include any adjustments r relines which are perfrmed within 12 mnths f initial insertin. There are n benefits fr precisin r semi-precisin attachments. Benefits fr partial dentures are based n the date f delivery. Denture adjustments are limited t: 1 time in any 12 mnth perid; and Adjustments made mre than 12 mnths after the insertin f the denture. Repairs t full r partial dentures, bridges, and crwns are limited t repairs r adjustments perfrmed up t 3 times after the initial insertin. Rebasing dentures are limited t 1 time per 12 mnth perid. Relining dentures is a cvered benefit 12 mnths after initial insertin f the denture. Limited t 1 time per 12 mnth perid Tissue cnditining is limited t 1 time in a 12 mnth perid. Fixed bridges (including Maryland bridges) are limited as fllws: Benefits fr the replacement f an existing fixed bridge are payable nly if the existing bridge: Is mre than 5 years ld (see the Denture r Bridge Replacement/Additin prvisin under Exclusins and Limitatins fr exceptins); and Cannt be made serviceable. A fixed bridge replacing the extracted prtin f a hemisected tth is nt cvered. 8 P a g e

9 Placement and replacement f a cantilever bridge n psterir teeth will nt be cvered. Benefits fr bridges are based n the date f cementatin. Re-cementing bridges is limited t repairs r adjustment perfrmed mre than 12 mnths after the initial insertin. vilent and accidental means. The injury must have ccurred while insured under this Plicy, and the appliance cannt be made serviceable. Hwever, the fllwing exceptins will apply: EXCLUSIONS AND LIMITATIONS Treatment Outside f the Cvered Service Area Treatment utside f the United States is nt cvered, unless the treatment is fr emergency care. Cverage fr emergency services is limited t a reimbursement amunt f $ Please refer t yur Certificate f Insurance fr additinal infrmatin regarding emergency care. Missing Teeth Limitatin Initial placement f a full denture, partial denture r fixed bridge will nt be cvered by the Plan t replace teeth that were missing prir t the effective date f cverage fr Yu r Yur Dependents. Hwever, expenses fr the replacement f teeth that were missing prir t the effective date will nly be cnsidered fr cverage, if the tth was extracted within 12 mnths f the effective date f the Plicy and while Yu r Yur Dependent were cvered under a Prir Plan. Denture r Bridge Replacement/Additin Benefits fr the replacement f an existing partial denture that is less than 5 years ld will be cvered if there is a Dentally Necessary extractin f an additinal Functining Natural Tth that cannt be added t the existing partial denture. Benefits fr the replacement f an existing fixed bridge that is less than 5 years ld will be payable if there is a Dentally Necessary extractin f an additinal Functining Natural Tth, and the extracted tth was nt an abutment t an existing bridge. Replacement f a lst bridge is nt a Cvered Benefit. A bridge t replace extracted rts when the majrity f the natural crwn is missing is nt a Cvered Benefit. Replacement f an extracted tth will nt be cnsidered a Cvered Benefit if the tth was an abutment f an existing Prsthesis that is less than 5 years ld. Replacement f an existing partial denture, full denture, crwn r bridge with mre cstly units/different type f units is limited t the crrespnding benefit fr the existing unit being replaced. Replacement f a full denture, partial denture, r fixed bridge is cvered when: 5 years have elapsed since last replacement f the denture r bridge; OR The denture r bridge was damaged while in the Cvered Persn s muth when an injury was suffered invlving external, Implants Implants, and prcedures and appliances assciated with them, are nt cvered. 9 P a g e

10 General Exclusins Cvered Services and Supplies d nt include: 1. Treatment which is: a. nt included in the list f Cvered Services and Supplies; b. nt Dentally Necessary; r c. Experimental in nature. 2. Any Charges which are: a. Payable r reimbursable by r thrugh a plan r prgram f any gvernmental agency, except if the charge is related t a nn-military service disability and treatment is prvided by a gvernmental agency f the United States. Hwever, the Plan will always reimburse any state r lcal medical assistance (Medicaid) agency fr Cvered Services and Supplies. b. Nt impsed against the persn r fr which the persn is nt liable. c. Reimbursable by Medicare Part A and Part B. If a persn at any time was entitled t enrll in the Medicare prgram (including Part B) but did nt d s, his r her benefits under this Plicy will be reduced by an amunt that wuld have been reimbursed by Medicare, where permitted by law. Hwever, fr persns insured under Emplyers wh ntify the Plan that they emply 20 r mre Emplyees during the previus business year, this exclusin will nt apply t an Actively at Wrk Emplyee and/r his r her spuse wh is age 65 r lder if the Emplyee elects cverage under this Plicy instead f cverage under Medicare. 3. Services r supplies resulting frm r in the curse f Yur regular ccupatin fr pay r prfit fr which Yu r Yur Dependent are entitled t benefits under any Wrkers Cmpensatin Law, Emplyer s Liability Law r similar law. Yu must prmptly claim and ntify the Plan f all such benefits. 4. Services r supplies prvided by a Dentist, Dental Hygienist, denturist r dctr wh is: a. a Clse Relative r a persn wh rdinarily resides with Yu r a Dependent; b. an Emplyee f the Emplyer; c. the Emplyer. 5. Services and supplies which may nt reasnably be expected t successfully crrect the Cvered Persn s dental cnditin fr a perid f at least 3 years, as determined by the Plan. 6. All services fr which a claim is received mre than 6 mnths after the date f service. 7. Services and supplies prvided as ne dental prcedure, and cnsidered ne prcedure based n standard dental prcedure cdes, but separated int multiple prcedure cdes fr billing purpses. The Cvered Charge fr the Services is based n the single dental prcedure cde that accurately represents the treatment perfrmed. 8. Services and supplies prvided primarily fr csmetic purpses. 9. Services and supplies btained while utside f the United States, except fr Emergency Dental Care. 10. Crrectin f cngenital cnditins r replacement f cngenitally missing permanent teeth, regardless f the length f time the deciduus tth is retained. 11. Diagnstic casts. 12. Educatinal prcedures, including but nt limited t ral hygiene, plaque cntrl r dietary instructins. 13. Persnal supplies r equipment, including but nt limited t water piks, tthbrushes, r flss hlders. 14. Restrative prcedures, rt canals and appliances, which are prvided because f attritin, abrasin, ersin, abfractin, wear, r fr csmetic purpses in the absence f decay. 15. Veneers 16. Appliances, inlays, cast restratins, crwns and bridges, r ther labratry prepared restratins used primarily fr the purpse f splinting (temprary tth stabilizatin). 17. Replacement f a lst r stlen Appliance r Prsthesis. 18. Replacement f stayplates. 19. Extractin f pathlgy-free teeth, including supernumerary teeth. 10 P a g e

11 (unless fr medically necessary rthdntia) 20. Scket preservatin bne graphs 21. Hspital r facility charges fr rm, supplies r emergency rm expenses, r rutine chest x-rays and medical exams prir t ral surgery. 22. Treatment fr a jaw fracture. 23. Services, supplies and appliances related t the change f vertical dimensin, restratin r maintenance f cclusin, splinting and stabilizing teeth fr peridntic reasns, bite registratin, bite analysis, attritin, ersin r abrasin, and treatment fr temprmandibular jint dysfunctin (TMJ), unless a TMJ benefit rider was included in the Plicy. 24. Orthdntic services, supplies, appliances and Orthdntic-related services, unless an Orthdntic rider was included in the Plicy. 25. Oral sedatin and nitrus xide analgesia are nt cvered. 26. Therapeutic drug injectin. 27. Cmpletin f claim frms. 28. Missed dental appintments. 29. Replacement f missing teeth prir t cverage effective date 11 P a g e