Limitations & Exclusions

All benefits provided are subject to limitations and exclusions. Complete details are available in the Delta Dental of MO Membership Certificate which governs provisions of your benefit plan. A summary is listed in the following paragraphs.

1. Alternative Treatment Plans
2. Prosthetics
3. Coverage Limitations
4. Exclusions

Alternative Treatment Plans
When there are alternate plans of treatment, coverage is provided for the applicable percentage of the least costly, professionally satisfactory, course of treatment. This includes, but is not limited to, services such as composite resin fillings on molar teeth, in which case the benefits are based on the cost of the amalgam (silver) filling. This also includes fixed bridges and implants, in which case the benefits will be based on the cost of a removable partial denture or fixed bridge.

If you receive care from more than one dentist for the same procedure, benefits will not exceed what would have been paid for one dentist for that procedure (including, but not limited to, prosthetics and root canal therapy).

If you transfer care from one dentist to another during the course of treatment or if more than one dentist renders services for one dental procedure, the program pays no more than the amount it would have paid if only one dentist had rendered the service.

Coverage Limitations

• Oral examinations, including those by a specialist, are limited to twice per calendar year.
• Prophylaxes (teeth cleaning), including periodontal prophylaxes, are limited to twice per calendar year. Two additional cleanings allowed per calendar year for patients that are pregnant, diabetic, have a suppressed immune system or have a history of periodontal therapy. To be eligible for the additional cleaning benefits, you must submit a completed Self-Report form. If periodontal therapy has already been reported on your claims, the Self-Report form is not necessary.
• Topical application of fluoride is limited to once per calendar year for children up to age 14.
• Space maintainers are limited to once in five years for children up to age 14.
• Bitewing radiographs (x-rays) are limited to one set per calendar year and full-mouth radiographs (x-rays) are limited to once in a five year period.
• Dental benefits for an initial or replacement crown, jacket, labial veneer, inlay or onlay on or for a particular tooth will only be provided once in seven years, unless the damage to that tooth was caused by an accidental injury not related to the normal function of a tooth or teeth.
• If an existing bridge or denture cannot be made satisfactory, a replacement will be covered only once in seven years.

Exclusions
(Dental Services Not Covered)

• Services for which the participant, absent this coverage, would normally incur no charge, such as care rendered by a dentist to a member of his immediate family or the immediate family of his spouse.
• Services for which coverage is available under Workers’ Compensation or Employers’ Liability Laws.
• Services performed for cosmetic purposes or to correct congenital malformations except for newborns with congenital dental defects.
• Charges for services that require multiple visits, which commenced prior to the membership effective date (including, but not limited to, prosthetics and orthodontic care.)
• Services or supplies related to temporomandibular joint (TMJ) dysfunction (this involves the jaw hinge joint connecting the upper and lower jaws.)
• Any services not specifically stated as Covered Services (including hospital, prescription drug charges and orthodontics.)
• Replacement of dentures and other dental appliances which are lost or stolen.
• Services rendered by a dentist beyond the scope of his license.
• Hypnosis.
• Duplicate services provided by another group dental plan.
• Diseases contracted or injuries or conditions sustained as a result of any act of war.
• Denture adjustments for the first six months after the dentures are initially received. Separate fees may not be charged by participating dentists.
• Charges for complete occlusal adjustments, crowns for occlusal correction, nightguards, bruxism appliances and bite therapy appliances.
• Tooth preparation, temporary crowns, bases, impressions and anesthesia or other services which are part of the complete dental procedure. These services are considered components of, and included in the fee for, the complete procedure. Separate fees may not be charged by participating dentists.
• Analgesia, including nitrous oxide.
• Charges covered under a terminal liability, extension of benefits, or similar provision, of a program being replaced by this program.
• Services rendered by a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trustee or similar person or group.
• Services provided or paid for by any governmental agency or under any governmental program or law, except charges which the person is legally obligated to pay (this exclusion extends to any benefits provided under the U.S. Social Security Act and its Amendments.)
• Charges for duplication of radiographs.
• Charges for temporary appliances.
• Implants and related procedures are not covered. However, an alternate benefit allowance will be provided for an implant based on the cost of a removable partial denture or fixed bridge.
• Charges for experimental or investigational services or supplies.
• Services that the dentist feels, in his or her professional judgment, should not be provided.
• Instructions in dental hygiene, dietary planning or plaque control.
• Missed appointments or completion of claim forms.
• Infection control, including sterilization of supplies and equipment.
• Removal of third molars without symptoms.