25C - AGMT GROUP INSURANCE - Laserfiche WebLink

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Exclusions and Limitations Limitations 1. Cleanings (prophylaxis) and fluoride treatments are limited to twice a year unless medically necessary. 2. An additional charge will be applied for any procedure using noble or high noble metal. 3. Full -mouth X-rays: Once initially and thereafter when diagnostically necessary, 4. Periodontal maintenance procedures are a covered benefit only when listed as a covered service on your plan's Schedule of Benefits. If covered, periodontal maintenance procedures must follow active periodontal therapy, and are limited to 2 in a 12 month period. 5. Dentures (full or partial): Replacement only after three (3) years have elapsed following any prior provision of such dentures under a SafeGuard Benefit Plan. Replacements will be a benefit only if the existing denture is unsatisfactory and can not be made satisfactory as determined by the SafeGuard Selected General dentist. 6. Denture relines: Twice in one year 7. Sealants are a covered benefit only when they are listed as a covered service on your plan's Schedule of Benefits. If covered, the plan benefit applies to primary and permanent molar teeth, within four (4) years of eruption. S. There is a $75 co -payment per crown/bridge unit in addition to regular co -payments for porcelain on molars. 9. Surgical removal of wisdom teeth/third molar for orthodontic reasons only is not a covered benefit. 10. Delivery of removable prosthodontics includes up to three (3) adjustments within six (6) months of delivery date of service. 11. Surgical removal of impacted teeth is not a covered benefit unless pathology [disease] exists. 12. The co -payments listed for endodontic procedures do not include the cost of final restoration. 13. General anesthesia Is a covered benefit only when it is listed as a covered service on your plan's Schedule of Benefits, and when it is administered by the treating dentist, In conjunction with oral and periodontal surgical procedures. Orthodontic Exclusions & Limitations 1. Orthodontic treatment must be provided by a SafeGuard Selected General Dentist or contracted dentist whose practice is limited to providing Specialty Care in order for the cc -payments listed in the Schedule of Benefits to apply. 2. Plan benefits shall cover twenty-four (24) months of usual and customary orthodontic treatment and an additional twenty-four (24) months of retention. Treatment extending beyond such time periods will be subject to a per -office -visit charge of $25 dollars. 3. The following are not included as orthodontic benefits: A. Repair or replacement of lost or broken appliances; B. Retreatment of orthodontic cases; C. Treatment in progress at inception of eligibility; 0041 -D-SOB 25C-49 EL's 2.15