In addition to the General Exclusions and Limitations listed, the Fund does not cover any loss under the Dental Expense Benefits caused by, incurred for or resulting from the following excluded charges. All charges for the following services will be your responsibility, although your payment obligation may be satisfied by insurance or some other arrangement for which you are eligible:
- Services, as determined by the Fund, for correction of congenital or developmental malformations, cosmetic surgery, or dentistry for cosmetic aesthetic reasons including repair to facings posterior to the second bicuspid position.
- Prescription drugs (except intramuscular injectable antibiotics), premedications, medicaments/solutions, and relative analgesia. Medicines or drugs that can be obtained without a Dentist’s prescription.
- General anesthesia and/or intravenous sedation for restorative dentistry (or for surgical procedures) except as provided under Class III Benefits, item (h) in Dental Service Limitations.
- Acupuncture, acupressure or hypnosis.
- Charges for hospitalization, laboratory tests and histopathological examinations.
- Treatment performed by anyone other than a Dentist, except for services performed by a licensed Dental Hygienist under the scope of his or her license.
- Services that are covered under the Major Medical or Prescription Drug Benefits.
- Fluoride rinses, self-applied fluorides or desensitizing medicaments.
- Preventive control programs (including oral hygiene instructions, caries susceptibility tests, dietary control, tobacco counseling, home care medicaments, nutritional guidance, etc.).
- A space maintainer for maintaining space due to the premature loss of the anterior primary teeth.
- Lost, missing, or stolen appliances of any type and replacement or repair of orthodontic appliances or space maintainers.
- A prefabricated crown used as a final restoration on a permanent tooth.
- Appliances, surgical procedures, and restorations for: increasing vertical dimension; altering, restoring, or maintaining occlusion; replacing tooth structure loss resulting from attrition, abrasion, or erosion; or implantology techniques or periodontal splinting, except orthodontic care for Dependent Children under age 19.
- A substructure to a single/abutment crown over an implant.
- A paste-type root canal filling on a permanent tooth.
- Occlusal guards.
- Chemical curettage.
- Services associated with overdentures.
- Acusil, flexiplast or similar partial denture.
- A metal base on a removable prosthesis.
- The replacement of teeth beyond the normal complement of teeth.
- Personalization/characterization of any service or appliance.
- Temporary appliances.
- Precision attachments.
- Implants and implant-related services.
- Appliances, restorations or services for the diagnosis or treatment of disturbances of the temporomandibular joint dysfunction (TMJ or TMD).
- Diagnostic photographs and cephalometric films, unless done for orthodontics.
- Myofunctional therapy.
- Mounted case analysis.
- The replacement or alteration of full or partial dentures or fixed bridgework, unless the charge is required due to one of the following events and if the replacement or alteration is completed within 12 months after the event:
a) An Injury requiring surgery; or
b) Oral surgery treatment involving the repositioning of muscle attachments or the
removal of a tumor, cyst, torus or redundant tissue; or
c) Replacement of full denture, unless required as the result of structural change
within the mouth and unless made more than five years after the installation of the
32. Orthodontic treatment for you and your spouse.
33. Charges for failure to keep a scheduled visit with the Dentist
34. Services, as determined by Delta Dental, for which no valid dental need can be demonstrated,
that are specialized techniques, or that are experimental or investigational in nature as
determined by the standards of generally accepted dental practice.
35. Those benefits excluded by the policies and procedures of Delta Dental including the processing
36. Services or supplies for which no charge is made, for which you are not legally obligated to pay
or for which no charge would be made in the absence of Delta Dental coverage.
37. Services or supplies received as a result of dental disease, defect or Injury due to an act of war,
declared or undeclared.
38. Services that are not within the classes of benefits that have been selected and that are not in the
39. Replacement, repair, relines or adjustments of occlusal guards.
Dental Charges Not Paid by the Fund or Delta Dental
No payment will be made by the Plan or Delta Dental for the following services. A participating Dentist cannot charge you or your Eligible Dependent for these services. All charges from non-participating Dentists for the following services will be your responsibility:
- The fee for a consultation that is part of the fee for the examination and/or diagnostic procedure(s).
- Acid etching, cement bases, cavity liners, and a base or temporary filling.
- Infection control.
- Gingivectomy as an aid to the placement of a restoration.
- The correction of occlusion, when performed with prosthetics and restorations involving occlusal surfaces.
- Diagnostic casts not done in conjunction with orthodontics. They are considered to be a part of the fee for restorative or prosthodontic procedures.
- Palliative treatment, when any other service is provided on the same date, except X-rays and tests necessary to diagnose the emergency condition.
- Postoperative radiographs, when done following any completed service or procedure.
- Periodontal charting, when done on the same day as an oral examination. An examination, when done on the same day as a periodontal prophylaxis.
- Pins and/or a preformed post, when done with a core for a crown, onlay, or inlay.
- A pulp cap, when done with a sedative filling or any other restoration. A sedative or temporary filling, when done with the opening and drainage of a tooth or another endodontic procedure. The opening and drainage of a tooth or palliative treatment, when done on the same day a root canal is initiated.
- A therapeutic apical closure on a permanent tooth, except on a tooth where the root is not fully formed.
- Retreatment of a root canal within 12 months of the original root canal treatment.
- A prophylaxis, when done on the same day as root planing. Root planing, when done on the same day as subgingival curettage.
- An occlusal adjustment, when performed on the same day as the delivery of an occlusal guard.
- Reline, rebase, or any adjustment or repair within six months of the delivery of a partial denture.
- Tissue conditioning, when performed on the same day as the delivery of a denture or the reline or rebase of a denture.
- The completion of claim forms.
- Temporary crowns.
- Local Anesthesia, except as provided under Class III Benefits, item (h) in Dental Service Limitations.