No payment will be made by the Plan 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:
- Amalgam and resin restorations are payable once within a 24-month period, regardless of the number or combination of restorations placed on a surface.
- Cores and other substructures are covered benefits only when needed to retain a crown on a tooth with excessive breakdown due to caries and fractures.
- Recementation of a crown, onlay, inlay, space maintainer, or bridge within six months of the seating date or within 12 months of payment for a recementation.
- Retention pins are benefits once in a 24-month period. Only one substructure per tooth is a covered benefit.
- Benefits for periodontal surgery, including subgingival curettage, is payable once in any three-year period.
- A complete occlusal adjustment is a covered benefit once in a five-year period. The fee for a complete occlusal adjustment includes all adjustments that are necessary for a five-year period. A limited occlusal adjustment is not a covered benefit more than three times in a five-year period. The fee for a limited occlusal adjustment includes all adjustments that are necessary for a six-month period.
- Tissue conditioning is not a covered benefit more than twice per arch in 36 months.
- The allowance for a denture repair (including reline or rebase) will not exceed half the fee for a new denture.
- More than one root planing per year.