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SCHEDULE OF EXCLUSIONS AND LIMITATIONS
Exclusions and limitations may differ by state. Some exclusions and/or limitations may be waived depending on the
Member’s medical condition. Only American Dental Association procedure codes are covered.
EXCLUSIONS – The following services, supplies or charges are excluded:
1. Started prior to the Member’s Effective Date or after the Termination Date of coverage under the Group Policy (e.g.
multi-visit procedures such as endodontics, crowns, bridges, inlays, onlays, and dentures).
2. For house or hospital calls for dental services and for hospitalization costs (e.g. facility-use fees).
3. That are the responsibility of Workers’ Compensation or employer’s liability insurance, or for treatment of any
automobile-related injury in which the Member is entitled to payment under an automobile insurance policy. The
Company’s benefits would be in excess to the third-party benefits and therefore, the Company would have right of
recovery for any benefits paid in excess.
For Group Policies issued and delivered in Georgia, Missouri and Virginia, only services that are the responsibility of
Workers’ Compensation or employer’s liability insurance shall be excluded from this Plan.
For Group Policies issued and delivered in North Carolina, services or supplies for the treatment of an Occupational
Injury or Sickness which are paid under the North Carolina Workers’ Compensation Act are excluded only to the
extent such services or supplies are the liability of the employee according to a final adjudication under the North
Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement
agreement under the North Carolina Workers’ Compensation Act.
For Group Policies issued and delivered in Maryland, this exclusion does not apply.
4. For prescription and non-prescription drugs, vitamins or dietary supplements.
For Group Policies issued and delivered in Arizona and New Mexico, this exclusion does not apply.
5. Administration of nitrous oxide and/or IV sedation, unless specifically indicated on the Schedule of Benefits.
For Group Policies issued and delivered in Washington, this exclusion does not apply when required dental services
and procedures are performed in a dental office for covered persons under the age of seven (7) or physically or
developmentally disabled.
For Group Policies issued and delivered in New York, this exclusion does not apply if dental services are required for
sound teeth as a result of accidental injury.
6. Which are Cosmetic in nature as determined by the Company (e.g. bleaching, veneer facings, personalization or
characterization of crowns, bridges and/or dentures).
For Group Policies issued and delivered in New York, this exclusion does not apply if dental services are required for
sound teeth as a result of accidental injury.
For Group Policies issued and delivered in New Jersey, this exclusion does not apply for Cosmetic services for newly
born children of Members.
For Group Policies issued and delivered in Washington, this exclusion does not apply in the instance of congenital
abnormalities for covered newly born children from the moment of birth.
7. Elective procedures (e.g. the prophylactic extraction of third molars).
8. For congenital mouth malformations or skeletal imbalances (e.g. treatment related to cleft lip or cleft palate,
disharmony of facial bone, or required as the result of orthognathic surgery including orthodontic treatment).
For Group Policies issued and delivered in Kentucky, Minnesota and Pennsylvania, this exclusion shall not apply to
newly born children of Members including newly adoptive children, regardless of age.
For Group Policies issued and delivered in Colorado, Hawaii, Indiana, Missouri, New Jersey and Virginia, this exclusion shall
not apply to newly born children of Members.
For Group Policies issued and delivered in Florida, this exclusion shall not apply for diagnostic or surgical dental (not
medical) procedures rendered to a Member of any age.
For Group Policies issued and delivered in Washington, this exclusion shall not apply in the instance of congenital
abnormalities for covered newly born children from the moment of birth.
9. For dental implants and any related surgery, placement, restoration, prosthetics (except single implant crowns),
maintenance and removal of implants unless specifically covered under the Certificate.