What's Not Covered
The following expenses are not covered under the Dental PPO Plan:
- Services for injuries or conditions that are covered under Workers' Compensation or employer's liability laws.
- Services that are provided by any federal or state governmental agency or are provided without cost by any municipality, county or other political subdivision, except Medi-Cal benefits.
- Services for cosmetic purposes or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth, and teeth that are discolored or lacking enamel.
- Provisional and/or temporary restorations.
- Services for restoring tooth structure lost from wear (abrasion, erosion, attrition, or abfraction), for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. Examples of such treatment are equilibration and periodontal splinting.
- Any single procedure, bridge, denture, or other prosthodontic service which was started before the patient was covered by this plan.
- Prescribed drugs, or applied therapeutic drugs, premedication, or analgesia.
- Experimenta or investigational procedures.
- Charges by any hospital or other surgical or treatment facility and any additional fees charged by the provider for treatment in any such facility.
- Anesthesia, except for general anesthesia, given by a dentist for covered oral surgery procedures.
- Grafting tissues from outside the mouth to tissues inside the mouth ("extraoral grafts").
- Laboratory processed crowns for patients under age 12.
- Fixed bridges and removable partials for patients under age 16.
- Interim implants and endodontic endosseous implant.
- Indirectly fabricated resin-based inlays/onlays.
- Treatment by someone other than a provider or a person who by law may work under a provider's direct supervision.
- Charges incurred for oral hygiene instruction, a plaque control program, and preventive control programs, or broken appointments.
- Administrative services and ancillary materials.
- Procedures having a questionable prognosis.
- Any tax imposed (or incurred) by a government entity.
- Deductibles, amounts over plan maximums, and services that exceed benefit limitations.