Exclusions And Limitations
Individual Plans
Plan II
COVERED SERVICES
We agree to provide Benefits to you and your Eligible Dependents under our policies and procedures and under the terms and conditions of this Policy, including, but not limited to, the categories of Covered Services, exclusions, and limitations listed below.
- Diagnostic and Preventive Services
Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include oral evaluations (examinations), prophylaxes (cleanings), bitewing X-rays and fluoride treatments. These services are subject to the following exclusions and limitations:
- Topical fluoride treatments are payable twice in any Benefit Year for Covered Persons under age 14;
- Oral examination submitted as a consultation or evaluation are payable twice in any Benefit Year, whether provided under one or more RLHICA Plans. An evaluation is not a Covered Service when done in conjunction with a consultation;
- Prophylaxes, including periodontal maintenance procedures, are payable twice in any Benefit Year;
- Bitewing X-rays are payable once in any Benefit Year;
- Space maintenance services are payable once per lifetime, per area on posterior teeth, for Covered Persons under age 14;
- We will not make payment for preventive control programs, including home care items, oral hygiene instructions, nutritional counseling, and tobacco counseling and all charges for the same will be your responsibility;
- We will not make payment for tests and laboratory examinations (including, but not limited to cytology, bacteriology or pathology) and caries susceptibility tests and all charges for the same will be your responsibility, unless otherwise indicated in the Summary of Dental Plan Benefits or in this Policy.
Brush Biopsy
Oral brush biopsy procedure and laboratory analysis used to detect oral cancer, an important tool that identifies and analyzes precancerous and cancerous cells.
Basic Services
Emergency Palliative Treatment
Emergency treatment to temporarily relieve pain is not a Covered Service when done in conjunction with any services except X-rays, tests or examinations.
Radiographs (X-rays) / Diagnostic Imaging / Diagnostic Casts
X-rays as required for routine care or as necessary for the diagnosis of a specific condition, subject to the following exclusions and limitations:
- Full mouth X-rays (which include bitewing X-rays) or a panoramic X-ray (with or without bitewing X-rays) are payable once in any 5 year period;
- A serial listing of X-rays is paid as full mouth X-rays if the total fee equals or exceeds the fee for full mouth X-rays;
- Any supplemental films with full mouth X-rays are part of the complete procedure;
- Cephalometric films, oral/facial photographic images or diagnostic casts are not payable except in conjunction with Orthodontic Services and all charges for the same will be your responsibility;
- Posterior-anterior or lateral skull and facial bone survey, sialography, temporomandibular joint films (including arthrograms) or tomographic films are not payable and all charges for the same will be your responsibility.
Minor Restorative Services
Minor restorative services to rebuild and repair natural tooth structure when damaged by disease or injury. These services include amalgam (silver) and composite resin (white) restoration (fillings), subject to the following exclusions and limitations:
- Amalgam and composite resin restorations are payable once per posterior tooth surface within a 24 month period regardless of the number or combination of restorations placed on a surface;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility.
- Retention pins are payable once in a two-year period. Only one substructure per tooth is a Covered Service.
Simple Extractions
Simple extractions including local anesthesia, suturing, if needed, and routine post-operative care.
Sealants
Sealants are payable only for the occlusal (biting) surface of first permanent molars for Covered Persons under age 9 and second permanent molars for Covered Persons under age 14. The surface must be free from decay and restorations. Sealants are a Benefit payable once in any 3 year period.
Periodontal Maintenance Following Therapy
Periodontal maintenance following active periodontal therapy procedures to treat diseases of the gums and supportive structures of the teeth along with benefits for prophylaxes, including periodontal maintenance procedures are payable twice in any Benefit Year.
Other Basic Services
After hours visits, not to exceed once per Benefit Year.
Major Services
Oral Surgery Services
Surgical extractions and dental surgery, including local anesthesia, suturing, if needed, and routine postoperative care are subject to the following exclusions and limitations:
- We will not make payment for the following services and items and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits: appliances, restorations, X-rays or other services for the diagnosis or treatment of temporomandibular disorders (“TMD”) including myofunctional therapy;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown.
Endodontic Services
The treatment of teeth with diseased or damaged nerves (for example, root canals) is subject to the following exclusions and limitations:
- Endodontic therapy, endodontic retreatment, and apicoectomy/periradicular services are payable once per tooth in any 24 month period;
- Root canal fillings on primary teeth are limited to primary teeth without succedaneous (replacement) teeth;
- We will not make payment for pulp caps and all charges for the same will be your responsibility.
- Pulpotomy is a Covered Service only for Covered Persons under the age of 21.
Maxillofacial Prosthetics
RLHICA will not make payment for maxillofacial prosthetics and all charges for the same will be your responsibility.
Periodontic Services
The treatment of diseases of the gums and supporting structures of the teeth is subject to the following exclusions and limitations:
- Full mouth debridement will be payable once in Covered Person’s lifetime;
- Scaling and root planing are payable once per area in any 24 month period;
- Periodontal surgery is payable once per area in any 3 year period;
Major Restorative Services
Major restorative services, such as crowns, are payable only for extensive loss of tooth structure due to caries (decay) or fracture. These services are subject to the following further exclusions and limitations:
- Indirect restorations including porcelain/ceramic substrate, porcelain/resin processed to metal and cast metal restorations (including crowns and onlays) and associated procedures such as cores and post and core substructures on the same posterior tooth are payable once in any 7 year period;
- Substructures and indirect restorations, including porcelain/ceramic substrate, porcelain/resin processed to metal, and cast restorations are not payable for Covered Persons under age 12 and all charges for the same will be your responsibility. Cores are payable only when necessary to retain a crown or a tooth with extensive breakdown due to decay or fracture;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Inlays, regardless of the material used: we will pay only the applicable amount that it would have paid for a resin-based composite restoration. You will be responsible for any additional charges;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility;
- Veneers are not a Covered Service and all charges for the same will be your responsibility.
Prosthodontic Services
Services and appliances that replace missing natural teeth (such as fixed bridges, endosteal implants, partial dentures, and complete dentures) are subject to the following exclusions and limitations:
- One complete upper and one complete lower denture is payable once in any 7 year period for any individual;
- A partial denture, fixed bridge, or removable bridge and any associated services are payable once in any 7 year period;
- Fixed bridges, endosteal implants and removable partial dentures are not payable for Covered Persons under age 16 and all charges for the same will be your responsibility;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Services for tissue conditioning are payable twice per denture unit in any 3 year period.
- Endosteal implants are allowed once per tooth, per lifetime. We will not make payment if the implant is placed within 7 years following prosthodontic or major restorative services involving that tooth and all charges for the same will be your responsibility;
- We will not make payment for specialized implant surgical techniques, bone replacement grafts, removal of an implant, implant maintenance procedures, or implant repairs and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing or stolen appliances of any type; temporary, provisional, or interim prosthodontic appliances; precision or semi-precision attachments, copings or myofunctional therapy.
- We will not make payment for (a) procedures to replace a missing tooth or teeth that were lost prior to the date that a Covered Person was covered under this Policy; or (b) the replacement of teeth beyond the normal complement of teeth; or (c) services associated with overdentures; or (d) posterior bridges in conjunction with partial dentures in the same arch, and all charges for the same will be your responsibility.
Relines and Repairs
Relines and repairs to fixed bridges, partial dentures, and complete dentures. A reline or a complete replacement of denture base material is limited to once in any 3 year period per appliance.
Other Major Services
- An occlusal guard is payable once in a Covered Person’s lifetime;
- Limited occlusal adjustments are limited to 1 in a 5 year period;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: repair, relines, or adjustments of occlusal guards.
Orthodontics
Orthodontic Services
No person will be eligible for Orthodontic Services under this Policy unless Orthodontic Services are provided for in the Summary of Dental Plan Benefits. Services, treatment, and procedures to correct malposed teeth (for example, braces), are subject to the following exclusions and limitations:
- Our payment for Orthodontic Services will be limited to the lifetime Maximum Payment specified in the Summary of Dental Plan Benefits;
- Orthodontic Services are payable until the end of the calendar year in which the Covered Person attains the age of 19, unless otherwise specified in the Summary of Dental Plan Benefits;
- Our payment for orthodontic retention services (removal of appliances, construction and placement of retainer) is included in its payment of overall Orthodontic Services. If a Dentist bills these services separately, payment will be denied.
- If the treatment plan is terminated before completion of the case for any reason, our obligation will cease with payment up to the date of termination;
- The Dentist may terminate treatment, with written notification to us and to the patient, for lack of patient interest and cooperation. In those cases, our obligation for payment ends on the last day of the month in which the patient was last treated;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing, or stolen appliances of any type or replacement or repair of an orthodontic appliance.
EXCLUSIONS
In addition to the exclusions listed above in the Benefits Section, we will not make payment for the following services, items or supplies and all charges for the same will be your responsibility, unless otherwise specified in the Summary of Dental Plan Benefits:
- Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;
- Services or appliances started prior to the effective date of a Covered Person’s coverage under this Policy, excluding orthodontic treatment in progress (if a Covered Service);
- Charges for failure to keep a scheduled visit with the Dentist;
- Charges for completion of forms or submission of claims;
- Services, items or supplies for which no valid dental need can be demonstrated, as determined by us;
- Services, items or supplies that are specialized techniques, as determined by us;
- Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by us;
- Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;
- Services, items or supplies excluded by our policies and procedures;
- Services, items or supplies, as determined by us, which are not provided in accordance with accepted standards of dental practice;
- Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of our coverage;
- Services, items or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared;
- Services, items or supplies that are generally covered under a hospital, surgical/medical, or prescription drug program;
- Services, items or supplies that are not within the categories of Covered Services as shown in the Summary of Dental Plan Benefits;
- Prescription drugs, non-prescription drugs, premedications, fluoride rinses and self-applied fluorides, localized delivery of antimicrobial or chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustment, enamel microabrasions, odontoplasty, or bleaching;
- Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by us;
- Any appliance, restoration or surgical procedure used to: (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; and (d) splint or stabilize teeth for periodontal reasons;
- Local anesthesia;
- Gingivectomy as an aid to the placement of a restoration.
LIMITATIONS
In addition to the limitations listed above in the Benefits Section, the following limitations apply under this Policy, unless otherwise specified in the Summary of Dental Plan Benefits:
- Our obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this Policy;
- When services in progress are interrupted and completed later by another Dentist, we will review the claim to determine the amount of payment, if any, to each Dentist;
- Care terminated due to the death of a Covered Person will be paid to the limit of our liability for the services completed or in progress;
- The Maximum Payment will be limited to the amount specified in the Summary of Dental Plan Benefits;
- If a Deductible amount is specified in the Summary of Dental Plan Benefits, we will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies, until the Deductible amount is met.
Plan III
COVERED SERVICES
We agree to provide Benefits to you and your Eligible Dependents under our policies and procedures and under the terms and conditions of this Policy, including, but not limited to, the categories of Covered Services, exclusions, and limitations listed below.
Diagnostic and Preventive Services
Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include oral evaluations (examinations), prophylaxes (cleanings), bitewing X-rays and fluoride treatments. These services are subject to the following exclusions and limitations:
- Topical fluoride treatments are payable twice in any Benefit Year for Covered Persons under age 14;
- Oral examination submitted as a consultation or evaluation are payable twice in any Benefit Year, whether provided under one or more RLHICA Plans. An evaluation is not a Covered Service when done in conjunction with a consultation;
- Prophylaxes, including periodontal maintenance procedures, are payable twice in any Benefit Year;
- Bitewing X-rays are payable once in any Benefit Year;
- Space maintenance services are payable once per lifetime, per area on posterior teeth, for Covered Persons under age 14;
- We will not make payment for preventive control programs, including home care items, oral hygiene instructions, nutritional counseling, and tobacco counseling and all charges for the same will be your responsibility;
- We will not make payment for tests and laboratory examinations (including, but not limited to cytology, bacteriology or pathology) and caries susceptibility tests and all charges for the same will be your responsibility, unless otherwise indicated in the Summary of Dental Plan Benefits or in this Policy.
Brush Biopsy
Oral brush biopsy procedure and laboratory analysis used to detect oral cancer, an important tool that identifies and analyzes precancerous and cancerous cells.
Basic Services
Emergency Palliative Treatment
Emergency treatment to temporarily relieve pain is not a Covered Service when done in conjunction with any services except X-rays, tests or examinations.
Radiographs (X-rays) / Diagnostic Imaging / Diagnostic Casts
X-rays as required for routine care or as necessary for the diagnosis of a specific condition, subject to the following exclusions and limitations:
- Full mouth X-rays (which include bitewing X-rays) or a panoramic X-ray (with or without bitewing X-rays) are payable once in any 5 year period;
- A serial listing of X-rays is paid as full mouth X-rays if the total fee equals or exceeds the fee for full mouth X-rays;
- Any supplemental films with full mouth X-rays are part of the complete procedure;
- Cephalometric films, oral/facial photographic images or diagnostic casts are not payable except in conjunction with Orthodontic Services and all charges for the same will be your responsibility;
- Posterior-anterior or lateral skull and facial bone survey, sialography, temporomandibular joint films (including arthrograms) or tomographic films are not payable and all charges for the same will be your responsibility.
Minor Restorative Services
Minor restorative services to rebuild and repair natural tooth structure when damaged by disease or injury. These services include amalgam (silver) and composite resin (white) restoration (fillings), subject to the following exclusions and limitations:
- Amalgam and composite resin restorations are payable once per posterior tooth surface within a 24 month period regardless of the number or combination of restorations placed on a surface;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility.
- Retention pins are payable once in a two-year period. Only one substructure per tooth is a Covered Service.
Simple Extractions
Simple extractions including local anesthesia, suturing, if needed, and routine post-operative care.
Sealants
Sealants are payable only for the occlusal (biting) surface of first permanent molars for Covered Persons under age 9 and second permanent molars for Covered Persons under age 14. The surface must be free from decay and restorations. Sealants are a Benefit payable once in any 3 year period.
Periodontal Maintenance Following Therapy
Periodontal maintenance following active periodontal therapy procedures to treat diseases of the gums and supportive structures of the teeth along with benefits for prophylaxes, including periodontal maintenance procedures are payable twice in any Benefit Year.
Other Basic Services
After hours visits, not to exceed once per Benefit Year.
Major Services
Oral Surgery Services
Surgical extractions and dental surgery, including local anesthesia, suturing, if needed, and routine postoperative care are subject to the following exclusions and limitations:
- We will not make payment for the following services and items and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits: appliances, restorations, X-rays or other services for the diagnosis or treatment of temporomandibular disorders (“TMD”) including myofunctional therapy;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown.
Endodontic Services
The treatment of teeth with diseased or damaged nerves (for example, root canals) is subject to the following exclusions and limitations:
- Endodontic therapy, endodontic retreatment, and apicoectomy/periradicular services are payable once per tooth in any 24 month period;
- Root canal fillings on primary teeth are limited to primary teeth without succedaneous (replacement) teeth;
- We will not make payment for pulp caps and all charges for the same will be your responsibility.
- Pulpotomy is a Covered Service only for Covered Persons under the age of 21.
Maxillofacial Prosthetics
RLHICA will not make payment for maxillofacial prosthetics and all charges for the same will be your responsibility.
Periodontic Services
The treatment of diseases of the gums and supporting structures of the teeth is subject to the following exclusions and limitations:
- Full mouth debridement will be payable once in Covered Person’s lifetime;
- Scaling and root planing are payable once per area in any 24 month period;
- Periodontal surgery is payable once per area in any 3 year period;
Major Restorative Services
Major restorative services, such as crowns, are payable only for extensive loss of tooth structure due to caries (decay) or fracture. These services are subject to the following further exclusions and limitations:
- Indirect restorations including porcelain/ceramic substrate, porcelain/resin processed to metal and cast metal restorations (including crowns and onlays) and associated procedures such as cores and post and core substructures on the same posterior tooth are payable once in any 7 year period;
- Substructures and indirect restorations, including porcelain/ceramic substrate, porcelain/resin processed to metal, and cast restorations are not payable for Covered Persons under age 12 and all charges for the same will be your responsibility. Cores are payable only when necessary to retain a crown or a tooth with extensive breakdown due to decay or fracture;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Inlays, regardless of the material used: we will pay only the applicable amount that it would have paid for a resin-based composite restoration. You will be responsible for any additional charges;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility;
- Veneers are not a Covered Service and all charges for the same will be your responsibility.
Prosthodontic Services
Services and appliances that replace missing natural teeth (such as fixed bridges, endosteal implants, partial dentures, and complete dentures) are subject to the following exclusions and limitations:
- One complete upper and one complete lower denture is payable once in any 7 year period for any individual;
- A partial denture, fixed bridge, or removable bridge and any associated services are payable once in any 7 year period;
- Fixed bridges, endosteal implants and removable partial dentures are not payable for Covered Persons under age 16 and all charges for the same will be your responsibility;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Services for tissue conditioning are payable twice per denture unit in any 3 year period.
- Endosteal implants are allowed once per tooth, per lifetime. We will not make payment if the implant is placed within 7 years following prosthodontic or major restorative services involving that tooth and all charges for the same will be your responsibility;
- We will not make payment for specialized implant surgical techniques, bone replacement grafts, removal of an implant, implant maintenance procedures, or implant repairs and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing or stolen appliances of any type; temporary, provisional, or interim prosthodontic appliances; precision or semi-precision attachments, copings or myofunctional therapy.
- We will not make payment for (a) procedures to replace a missing tooth or teeth that were lost prior to the date that a Covered Person was covered under this Policy; or (b) the replacement of teeth beyond the normal complement of teeth; or (c) services associated with overdentures; or (d) posterior bridges in conjunction with partial dentures in the same arch, and all charges for the same will be your responsibility.
Relines and Repairs
Relines and repairs to fixed bridges, partial dentures, and complete dentures. A reline or a complete replacement of denture base material is limited to once in any 3 year period per appliance.
Other Major Services
- An occlusal guard is payable once in a Covered Person’s lifetime;
- Limited occlusal adjustments are limited to 1 in a 5 year period;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: repair, relines, or adjustments of occlusal guards.
Orthodontics
Orthodontic Services
No person will be eligible for Orthodontic Services under this Policy unless Orthodontic Services are provided for in the Summary of Dental Plan Benefits. Services, treatment, and procedures to correct malposed teeth (for example, braces), are subject to the following exclusions and limitations:
- Our payment for Orthodontic Services will be limited to the lifetime Maximum Payment specified in the Summary of Dental Plan Benefits;
- Orthodontic Services are payable until the end of the calendar year in which the Covered Person attains the age of 19, unless otherwise specified in the Summary of Dental Plan Benefits;
- Our payment for orthodontic retention services (removal of appliances, construction and placement of retainer) is included in its payment of overall Orthodontic Services. If a Dentist bills these services separately, payment will be denied.
- If the treatment plan is terminated before completion of the case for any reason, our obligation will cease with payment up to the date of termination;
- The Dentist may terminate treatment, with written notification to us and to the patient, for lack of patient interest and cooperation. In those cases, our obligation for payment ends on the last day of the month in which the patient was last treated;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing, or stolen appliances of any type or replacement or repair of an orthodontic appliance.
EXCLUSIONS
In addition to the exclusions listed above in the Benefits Section, we will not make payment for the following services, items or supplies and all charges for the same will be your responsibility, unless otherwise specified in the Summary of Dental Plan Benefits:
- Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;
- Services or appliances started prior to the effective date of a Covered Person’s coverage under this Policy, excluding orthodontic treatment in progress (if a Covered Service);
- Charges for failure to keep a scheduled visit with the Dentist;
- Charges for completion of forms or submission of claims;
- Services, items or supplies for which no valid dental need can be demonstrated, as determined by us;
- Services, items or supplies that are specialized techniques, as determined by us;
- Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by us;
- Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;
- Services, items or supplies excluded by our policies and procedures;
- Services, items or supplies, as determined by us, which are not provided in accordance with accepted standards of dental practice;
- Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of our coverage;
- Services, items or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared;
- Services, items or supplies that are generally covered under a hospital, surgical/medical, or prescription drug program;
- Services, items or supplies that are not within the categories of Covered Services as shown in the Summary of Dental Plan Benefits;
- Prescription drugs, non-prescription drugs, premedications, fluoride rinses and self-applied fluorides, localized delivery of antimicrobial or chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustment, enamel microabrasions, odontoplasty, or bleaching;
- Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by us;
- Any appliance, restoration or surgical procedure used to: (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; and (d) splint or stabilize teeth for periodontal reasons;
- Local anesthesia;
- Gingivectomy as an aid to the placement of a restoration.
LIMITATIONS
In addition to the limitations listed above in the Benefits Section, the following limitations apply under this Policy, unless otherwise specified in the Summary of Dental Plan Benefits:
- Our obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this Policy;
- When services in progress are interrupted and completed later by another Dentist, we will review the claim to determine the amount of payment, if any, to each Dentist;
- Care terminated due to the death of a Covered Person will be paid to the limit of our liability for the services completed or in progress;
- The Maximum Payment will be limited to the amount specified in the Summary of Dental Plan Benefits;
- If a Deductible amount is specified in the Summary of Dental Plan Benefits, we will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies, until the Deductible amount is met.
MAX CHOICE
COVERED SERVICES
We agree to provide Benefits to you and your Eligible Dependents under our policies and procedures and under the terms and conditions of this plan, including, but not limited to, the categories of Covered Services, exclusions, and limitations listed below.
Diagnostic and Preventive Services
Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include oral evaluations (examinations) and prophylaxes (cleanings). These services are subject to the following exclusions and limitations:
- Oral examination submitted as a consultation or evaluation are payable twice in any Benefit Year, whether provided under one or more Renaissance Plans. An evaluation is not a Covered Service when done in conjunction with a consultation;
- Prophylaxes, including periodontal maintenance procedures, are payable three times in any Benefit Year;
- We will not make payment for preventive control programs, including home care items, oral hygiene instructions, nutritional counseling, and tobacco counseling and all charges for the same will be your responsibility;
- We will not make payment for tests and laboratory examinations (including, but not limited to cytology, bacteriology or pathology) and caries susceptibility tests and all charges for the same will be your responsibility, unless otherwise indicated in the Summary of Dental Plan Benefits.
- Brush Biopsy
Oral brush biopsy procedure and laboratory analysis used to detect oral cancer, an important tool that identifies and analyzes precancerous and cancerous cells.
Basic Services
Fluoride Treatment
Topical fluoride treatments are payable once in any Benefit Year for Covered Persons under age 16.
Bitewing Radiographs
Bitewing X-rays are payable once in any Benefit Year.
Emergency Palliative Treatment
Emergency treatment to temporarily relieve pain is not a Covered Service when done in conjunction with any services except X-rays, tests or examinations.
Radiographs (X-rays) / Diagnostic Imaging / Diagnostic Casts
X-rays as required for routine care or as necessary for the diagnosis of a specific condition, subject to the following exclusions and limitations:
- Full mouth X-rays (which include bitewing X-rays) or a panoramic X-ray (with or without bitewing X-rays) are payable once in any 3 year period;
- A serial listing of X-rays is paid as full mouth X-rays if the total fee equals or exceeds the fee for full mouth X-rays;
- Any supplemental films with full mouth X-rays are part of the complete procedure;
- Cephalometric films, oral/facial photographic images or diagnostic casts are not payable except in conjunction with Orthodontic Services and all charges for the same will be your responsibility;
- Posterior-anterior or lateral skull and facial bone survey, sialography, temporomandibular joint films (including arthrograms) or tomographic films are not payable and all charges for the same will be your responsibility.
Minor Restorative Services
Minor restorative services to rebuild and repair natural tooth structure when damaged by disease or injury. These services include amalgam (silver) and composite resin (white) restoration (fillings), subject to the following exclusions and limitations:
- Amalgam and composite resin restorations are payable once per posterior tooth surface within a 24 month period regardless of the number or combination of restorations placed on a surface;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility.
- Retention pins are payable once in a two-year period. Only one substructure per tooth is a Covered Service.
Sealants
Sealants are payable only for the occlusal (biting) surface of first permanent molars for Covered Persons under age 16 and second permanent molars for Covered Persons under age 16. The surface must be free from decay and restorations. Sealants are a Benefit payable once in any 3 year period.
Major Services
Simple Extractions
Simple extractions including local anesthesia, suturing, if needed, and routine post-operative care.
Space Maintenance
Space maintenance services are payable once per lifetime, per area on posterior teeth, for Covered Persons under age 16.
Periodontal Maintenance Following Therapy
Periodontal maintenance following active periodontal therapy procedures to treat diseases of the gums and supportive structures of the teeth along with benefits for prophylaxes, including periodontal maintenance procedures are payable three times in any Benefit Year.
Oral Surgery Services
Surgical extractions and dental surgery, including local anesthesia, suturing, if needed, and routine postoperative care are subject to the following exclusions and limitations:
- We will not make payment for the following services and items and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits: appliances, restorations, X-rays or other services for the diagnosis or treatment of temporomandibular disorders (“TMD”) including myofunctional therapy;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown.
Endodontic Services
The treatment of teeth with diseased or damaged nerves (for example, root canals) is subject to the following exclusions and limitations:
- Endodontic therapy, endodontic retreatment, and apicoectomy/periradicular services are payable once per tooth in any 24 month period;
- Root canal fillings on primary teeth are limited to primary teeth without succedaneous (replacement) teeth;
- We will not make payment for pulp caps and all charges for the same will be your responsibility.
Maxillofacial Prosthetics
RLHICA will not make payment for maxillofacial prosthetics and all charges for the same will be your responsibility.
Periodontic Services
The treatment of diseases of the gums and supporting structures of the teeth is subject to the following exclusions and limitations:
- Full mouth debridement will be payable once in Covered Person’s lifetime;
- Scaling and root planing are payable once per area in any 24 month period;
- Periodontal surgery is payable once per area in any 3 year period;
Major Restorative Services
Major restorative services, such as crowns, are payable only for extensive loss of tooth structure due to caries (decay) or fracture. These services are subject to the following further exclusions and limitations:
- Indirect restorations including porcelain/ceramic substrate, porcelain/resin processed to metal and cast metal restorations (including crowns and onlays) and associated procedures such as cores and post and core substructures on the same posterior tooth are payable once in any 5 year period;
- Substructures and indirect restorations, including porcelain/ceramic substrate, porcelain/resin processed to metal, and cast restorations are not payable for Covered Persons under age 12 and all charges for the same will be your responsibility. Cores are payable only when necessary to retain a crown or a tooth with extensive breakdown due to decay or fracture;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Inlays, regardless of the material used: we will pay only the applicable amount that it would have paid for a resin-based composite restoration. You will be responsible for any additional charges;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility;
- Veneers are not a Covered Service and all charges for the same will be your responsibility.
Prosthodontic Services
Services and appliances that replace missing natural teeth (such as fixed bridges, endosteal implants, partial dentures, and complete dentures) are subject to the following exclusions and limitations:
- One complete upper and one complete lower denture is payable once in any 5 year period for any individual;
- A partial denture, fixed bridge, or removable bridge and any associated services are payable once in any 5 year period;
- Fixed bridges, endosteal implants and removable partial dentures are not payable for Covered Persons under age 16 and all charges for the same will be your responsibility;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Services for tissue conditioning are payable twice per denture unit in any 3 year period.
- Endosteal implants are allowed once per tooth, per lifetime. We will not make payment if the implant is placed within 5 years following prosthodontic or major restorative services involving that tooth and all charges for the same will be your responsibility;
- We will not make payment for specialized implant surgical techniques, bone replacement grafts, removal of an implant, implant maintenance procedures, or implant repairs and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing or stolen appliances of any type; temporary, provisional, or interim prosthodontic appliances; precision or semi-precision attachments, copings or myofunctional therapy.
- We will not make payment for (a) procedures to replace a missing tooth or teeth that were lost prior to the date that a Covered Person was covered under this plan; or (b) the replacement of teeth beyond the normal complement of teeth; or (c) services associated with overdentures; or (d) posterior bridges in conjunction with partial dentures in the same arch, and all charges for the same will be your responsibility.
Relines and Repairs
Relines and repairs to fixed bridges, partial dentures, and complete dentures. A reline or a complete replacement of denture base material is limited to once in any 3 year period per appliance.
Other Major Services
- An occlusal guard is payable once in a Covered Person’s lifetime;
- Limited occlusal adjustments are limited to once in a five year period;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: repair, relines, or adjustments of occlusal guards.
Orthodontics
Orthodontic Services
No person will be eligible for Orthodontic Services under this plan unless Orthodontic Services are provided for in the Summary of Dental Plan Benefits. Services, treatment, and procedures to correct malposed teeth (for example, braces), are subject to the following exclusions and limitations:
- Our payment for Orthodontic Services will be limited to the lifetime Maximum Payment specified in the Summary of Dental Plan Benefits;
- Orthodontic Services are payable until the end of the calendar year in which the Covered Person attains the age of 19, unless otherwise specified in the Summary of Dental Plan Benefits;
- Our payment for orthodontic retention services (removal of appliances, construction and placement of retainer) is included in its payment of overall Orthodontic Services. If a Dentist bills these services separately, payment will be denied.
- If the treatment plan is terminated before completion of the case for any reason, our obligation will cease with payment up to the date of termination;
- The Dentist may terminate treatment, with written notification to us and to the patient, for lack of patient interest and cooperation. In those cases, our obligation for payment ends on the last day of the month in which the patient was last treated;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing, or stolen appliances of any type or replacement or repair of an orthodontic appliance.
EXCLUSIONS
In addition to the exclusions listed above in the Benefits Section, we will not make payment for the following services, items or supplies and all charges for the same will be your responsibility, unless otherwise specified in the Summary of Dental Plan Benefits:
- Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;
- Services or appliances started prior to the effective date of a Covered Person’s coverage under this plan, excluding orthodontic treatment in progress (if a Covered Service);
- Charges for failure to keep a scheduled visit with the Dentist;
- Charges for completion of forms or submission of claims;
- Services, items or supplies for which no valid dental need can be demonstrated, as determined by us;
- Services, items or supplies that are specialized techniques, as determined by us;
- Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by us;
- Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;
- Services, items or supplies excluded by our policies and procedures;
- Services, items or supplies, as determined by us, which are not provided in accordance with accepted standards of dental practice;
- Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of our coverage;
- Services, items or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared;
- Services, items or supplies that are generally covered under a hospital, surgical/medical, or prescription drug program;
- Services, items or supplies that are not within the categories of Covered Services as shown in the Summary of Dental Plan Benefits;
- Prescription drugs, non-prescription drugs, premedications, fluoride rinses and self-applied fluorides, localized delivery of antimicrobial or chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustment, enamel microabrasions, odontoplasty, or bleaching;
- Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by us;
- Any appliance, restoration or surgical procedure used to: (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; and (d) splint or stabilize teeth for periodontal reasons;
- Local anesthesia;
- Gingivectomy as an aid to the placement of a restoration.
LIMITATIONS
In addition to the limitations listed above in the Benefits Section, the following limitations apply under this plan, unless otherwise specified in the Summary of Dental Plan Benefits:
- Our obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this plan;
- When services in progress are interrupted and completed later by another Dentist, we will review the claim to determine the amount of payment, if any, to each Dentist;
- Care terminated due to the death of a Covered Person will be paid to the limit of our liability for the services completed or in progress;
- The Maximum Payment will be limited to the amount specified in the Summary of Dental Plan Benefits;
- If a Deductible amount is specified in the Summary of Dental Plan Benefits, we will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies, until the Deductible amount is met.
MAX CHOICE PLUS
COVERED SERVICES
We agree to provide Benefits to you and your Eligible Dependents under our policies and procedures and under the terms and conditions of this plan, including, but not limited to, the categories of Covered Services, exclusions, and limitations listed below.
Diagnostic and Preventive Services
Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include oral evaluations (examinations) and prophylaxes (cleanings). These services are subject to the following exclusions and limitations:
- Oral examination submitted as a consultation or evaluation are payable twice in any Benefit Year, whether provided under one or more Renaissance Plans. An evaluation is not a Covered Service when done in conjunction with a consultation;
- Prophylaxes, including periodontal maintenance procedures, are payable three times in any Benefit Year;
- We will not make payment for preventive control programs, including home care items, oral hygiene instructions, nutritional counseling, and tobacco counseling and all charges for the same will be your responsibility;
- We will not make payment for tests and laboratory examinations (including, but not limited to cytology, bacteriology or pathology) and caries susceptibility tests and all charges for the same will be your responsibility, unless otherwise indicated in the Summary of Dental Plan Benefits.
Brush Biopsy
Oral brush biopsy procedure and laboratory analysis used to detect oral cancer, an important tool that identifies and analyzes precancerous and cancerous cells.
Basic Services
Fluoride Treatment
Topical fluoride treatments are payable once in any Benefit Year for Covered Persons under age 16.
Bitewing Radiographs
Bitewing X-rays are payable once in any Benefit Year.
Emergency Palliative Treatment
Emergency treatment to temporarily relieve pain is not a Covered Service when done in conjunction with any services except X-rays, tests or examinations.
Radiographs (X-rays) / Diagnostic Imaging / Diagnostic Casts
X-rays as required for routine care or as necessary for the diagnosis of a specific condition, subject to the following exclusions and limitations:
- Full mouth X-rays (which include bitewing X-rays) or a panoramic X-ray (with or without bitewing X-rays) are payable once in any 3 year period;
- A serial listing of X-rays is paid as full mouth X-rays if the total fee equals or exceeds the fee for full mouth X-rays;
- Any supplemental films with full mouth X-rays are part of the complete procedure;
- Cephalometric films, oral/facial photographic images or diagnostic casts are not payable except in conjunction with Orthodontic Services and all charges for the same will be your responsibility;
- Posterior-anterior or lateral skull and facial bone survey, sialography, temporomandibular joint films (including arthrograms) or tomographic films are not payable and all charges for the same will be your responsibility.
Minor Restorative Services
Minor restorative services to rebuild and repair natural tooth structure when damaged by disease or injury. These services include amalgam (silver) and composite resin (white) restoration (fillings), subject to the following exclusions and limitations:
- Amalgam and composite resin restorations are payable once per posterior tooth surface within a 24 month period regardless of the number or combination of restorations placed on a surface;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility.
- Retention pins are payable once in a two-year period. Only one substructure per tooth is a Covered Service.
Sealants
Sealants are payable only for the occlusal (biting) surface of first permanent molars for Covered Persons under age 16 and second permanent molars for Covered Persons under age 16. The surface must be free from decay and restorations. Sealants are a Benefit payable once in any 3 year period.
Major Services
Simple Extractions
Simple extractions including local anesthesia, suturing, if needed, and routine post-operative care.
Space Maintenance
Space maintenance services are payable once per lifetime, per area on posterior teeth, for Covered Persons under age 16.
Periodontal Maintenance Following Therapy
Periodontal maintenance following active periodontal therapy procedures to treat diseases of the gums and supportive structures of the teeth along with benefits for prophylaxes, including periodontal maintenance procedures are payable three times in any Benefit Year.
Oral Surgery Services
Surgical extractions and dental surgery, including local anesthesia, suturing, if needed, and routine postoperative care are subject to the following exclusions and limitations:
- We will not make payment for the following services and items and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits: appliances, restorations, X-rays or other services for the diagnosis or treatment of temporomandibular disorders (“TMD”) including myofunctional therapy;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown.
Endodontic Services
The treatment of teeth with diseased or damaged nerves (for example, root canals) is subject to the following exclusions and limitations:
- Endodontic therapy, endodontic retreatment, and apicoectomy/periradicular services are payable once per tooth in any 24 month period;
- Root canal fillings on primary teeth are limited to primary teeth without succedaneous (replacement) teeth;
- We will not make payment for pulp caps and all charges for the same will be your responsibility.
Maxillofacial Prosthetics
RLHICA will not make payment for maxillofacial prosthetics and all charges for the same will be your responsibility.
Periodontic Services
The treatment of diseases of the gums and supporting structures of the teeth is subject to the following exclusions and limitations:
- Full mouth debridement will be payable once in Covered Person’s lifetime;
- Scaling and root planing are payable once per area in any 24 month period;
- Periodontal surgery is payable once per area in any 3 year period;
Major Restorative Services
Major restorative services, such as crowns, are payable only for extensive loss of tooth structure due to caries (decay) or fracture. These services are subject to the following further exclusions and limitations:
- Indirect restorations including porcelain/ceramic substrate, porcelain/resin processed to metal and cast metal restorations (including crowns and onlays) and associated procedures such as cores and post and core substructures on the same posterior tooth are payable once in any 5 year period;
- Substructures and indirect restorations, including porcelain/ceramic substrate, porcelain/resin processed to metal, and cast restorations are not payable for Covered Persons under age 12 and all charges for the same will be your responsibility. Cores are payable only when necessary to retain a crown or a tooth with extensive breakdown due to decay or fracture;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Inlays, regardless of the material used: we will pay only the applicable amount that it would have paid for a resin-based composite restoration. You will be responsible for any additional charges;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility;
- Veneers are not a Covered Service and all charges for the same will be your responsibility.
Prosthodontic Services
Services and appliances that replace missing natural teeth (such as fixed bridges, endosteal implants, partial dentures, and complete dentures) are subject to the following exclusions and limitations:
- One complete upper and one complete lower denture is payable once in any 5 year period for any individual;
- A partial denture, fixed bridge, or removable bridge and any associated services are payable once in any 5 year period;
- Fixed bridges, endosteal implants and removable partial dentures are not payable for Covered Persons under age 16 and all charges for the same will be your responsibility;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Services for tissue conditioning are payable twice per denture unit in any 3 year period.
- Endosteal implants are allowed once per tooth, per lifetime. We will not make payment if the implant is placed within 5 years following prosthodontic or major restorative services involving that tooth and all charges for the same will be your responsibility;
- We will not make payment for specialized implant surgical techniques, bone replacement grafts, removal of an implant, implant maintenance procedures, or implant repairs and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing or stolen appliances of any type; temporary, provisional, or interim prosthodontic appliances; precision or semi-precision attachments, copings or myofunctional therapy.
- We will not make payment for (a) procedures to replace a missing tooth or teeth that were lost prior to the date that a Covered Person was covered under this plan; or (b) the replacement of teeth beyond the normal complement of teeth; or (c) services associated with overdentures; or (d) posterior bridges in conjunction with partial dentures in the same arch, and all charges for the same will be your responsibility.
Relines and Repairs
Relines and repairs to fixed bridges, partial dentures, and complete dentures. A reline or a complete replacement of denture base material is limited to once in any 3 year period per appliance.
Other Major Services
- An occlusal guard is payable once in a Covered Person’s lifetime;
- Limited occlusal adjustments are limited to once in a five year period;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: repair, relines, or adjustments of occlusal guards.
Orthodontics
Orthodontic Services
No person will be eligible for Orthodontic Services under this plan unless Orthodontic Services are provided for in the Summary of Dental Plan Benefits. Services, treatment, and procedures to correct malposed teeth (for example, braces), are subject to the following exclusions and limitations:
- Our payment for Orthodontic Services will be limited to the lifetime Maximum Payment specified in the Summary of Dental Plan Benefits;
- Orthodontic Services are payable until the end of the calendar year in which the Covered Person attains the age of 19, unless otherwise specified in the Summary of Dental Plan Benefits;
- Our payment for orthodontic retention services (removal of appliances, construction and placement of retainer) is included in its payment of overall Orthodontic Services. If a Dentist bills these services separately, payment will be denied.
- If the treatment plan is terminated before completion of the case for any reason, our obligation will cease with payment up to the date of termination;
- The Dentist may terminate treatment, with written notification to us and to the patient, for lack of patient interest and cooperation. In those cases, our obligation for payment ends on the last day of the month in which the patient was last treated;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing, or stolen appliances of any type or replacement or repair of an orthodontic appliance.
EXCLUSIONS
In addition to the exclusions listed above in the Benefits Section, we will not make payment for the following services, items or supplies and all charges for the same will be your responsibility, unless otherwise specified in the Summary of Dental Plan Benefits:
- Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;
- Services or appliances started prior to the effective date of a Covered Person’s coverage under this plan, excluding orthodontic treatment in progress (if a Covered Service);
- Charges for failure to keep a scheduled visit with the Dentist;
- Charges for completion of forms or submission of claims;
- Services, items or supplies for which no valid dental need can be demonstrated, as determined by us;
- Services, items or supplies that are specialized techniques, as determined by us;
- Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by us;
- Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;
- Services, items or supplies excluded by our policies and procedures;
- Services, items or supplies, as determined by us, which are not provided in accordance with accepted standards of dental practice;
- Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of our coverage;
- Services, items or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared;
- Services, items or supplies that are generally covered under a hospital, surgical/medical, or prescription drug program;
- Services, items or supplies that are not within the categories of Covered Services as shown in the Summary of Dental Plan Benefits;
- Prescription drugs, non-prescription drugs, premedications, fluoride rinses and self-applied fluorides, localized delivery of antimicrobial or chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustment, enamel microabrasions, odontoplasty, or bleaching;
- Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by us;
- Any appliance, restoration or surgical procedure used to: (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; and (d) splint or stabilize teeth for periodontal reasons;
- Local anesthesia;
- Gingivectomy as an aid to the placement of a restoration.
LIMITATIONS
In addition to the limitations listed above in the Benefits Section, the following limitations apply under this plan, unless otherwise specified in the Summary of Dental Plan Benefits:
- Our obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this plan;
- When services in progress are interrupted and completed later by another Dentist, we will review the claim to determine the amount of payment, if any, to each Dentist;
- Care terminated due to the death of a Covered Person will be paid to the limit of our liability for the services completed or in progress;
- The Maximum Payment will be limited to the amount specified in the Summary of Dental Plan Benefits;
- If a Deductible amount is specified in the Summary of Dental Plan Benefits, we will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies, until the Deductible amount is met.
MAX CHOICE ESSENTIALS
COVERED SERVICES
We agree to provide Benefits to you and your Eligible Dependents under our policies and procedures and under the terms and conditions of this plan, including, but not limited to, the categories of Covered Services, exclusions, and limitations listed below.
Diagnostic and Preventive Services
Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include oral evaluations (examinations), prophylaxes (cleanings), bitewing X-rays and fluoride treatments. These services are subject to the following exclusions and limitations:
- Topical fluoride treatments are payable twice in any Benefit Year for Covered Persons under age 19;
- Oral examination submitted as a consultation or evaluation are payable twice in any Benefit Year, whether provided under one or more Renaissance Plans. An evaluation is not a Covered Service when done in conjunction with a consultation;
- Prophylaxes, including periodontal maintenance procedures, are payable twice in any Benefit Year;
- Bitewing X-rays are payable once in any Benefit Year;
- Space maintenance services are payable once per lifetime, per area on posterior teeth, for Covered Persons under age 14;
- We will not make payment for preventive control programs, including home care items, oral hygiene instructions, nutritional counseling, and tobacco counseling and all charges for the same will be your responsibility;
- We will not make payment for tests and laboratory examinations (including, but not limited to cytology, bacteriology or pathology) and caries susceptibility tests and all charges for the same will be your responsibility, unless otherwise indicated in the Summary of Dental Plan Benefits.
Brush Biopsy
Oral brush biopsy procedure and laboratory analysis used to detect oral cancer, an important tool that identifies and analyzes precancerous and cancerous cells.
Basic Services
Emergency Palliative Treatment
Emergency treatment to temporarily relieve pain is not a Covered Service when done in conjunction with any services except X-rays, tests or examinations.
Radiographs (X-rays) / Diagnostic Imaging / Diagnostic Casts
X-rays as required for routine care or as necessary for the diagnosis of a specific condition, subject to the following exclusions and limitations:
- Full mouth X-rays (which include bitewing X-rays) or a panoramic X-ray (with or without bitewing X-rays) are payable once in any 5 year period;
- A serial listing of X-rays is paid as full mouth X-rays if the total fee equals or exceeds the fee for full mouth X-rays;
- Any supplemental films with full mouth X-rays are part of the complete procedure;
- Cephalometric films, oral/facial photographic images or diagnostic casts are not payable except in conjunction with Orthodontic Services and all charges for the same will be your responsibility;
- Posterior-anterior or lateral skull and facial bone survey, sialography, temporomandibular joint films (including arthrograms) or tomographic films are not payable and all charges for the same will be your responsibility.
Minor Restorative Services
Minor restorative services to rebuild and repair natural tooth structure when damaged by disease or injury. These services include amalgam (silver) and composite resin (white) restoration (fillings), subject to the following exclusions and limitations:
- Amalgam and composite resin restorations are payable once per posterior tooth surface within a 24 month period regardless of the number or combination of restorations placed on a surface;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility.
- Retention pins are payable once in a two-year period. Only one substructure per tooth is a Covered Service.
Sealants
Sealants are payable only for the occlusal (biting) surface of first permanent molars for Covered Persons under age 16 and second permanent molars for Covered Persons under age 16. The surface must be free from decay and restorations. Sealants are a Benefit payable once in any 3 year period.
- Major Services – Excluded
- Orthodontics – Excluded
EXCLUSIONS
In addition to the exclusions listed above in the Benefits Section, we will not make payment for the following services, items or supplies and all charges for the same will be your responsibility, unless otherwise specified in the Summary of Dental Plan Benefits:
- Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;
- Services or appliances started prior to the effective date of a Covered Person’s coverage under this plan, excluding orthodontic treatment in progress (if a Covered Service);
- Charges for failure to keep a scheduled visit with the Dentist;
- Charges for completion of forms or submission of claims;
- Services, items or supplies for which no valid dental need can be demonstrated, as determined by us;
- Services, items or supplies that are specialized techniques, as determined by us;
- Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by us;
- Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;
- Services, items or supplies excluded by our policies and procedures;
- Services, items or supplies, as determined by us, which are not provided in accordance with accepted standards of dental practice;
- Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of our coverage;
- Services, items or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared;
- Services, items or supplies that are generally covered under a hospital, surgical/medical, or prescription drug program;
- Services, items or supplies that are not within the categories of Covered Services as shown in the Summary of Dental Plan Benefits;
- Prescription drugs, non-prescription drugs, premedications, fluoride rinses and self-applied fluorides, localized delivery of antimicrobial or chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustment, enamel microabrasions, odontoplasty, or bleaching;
- Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by us;
- Any appliance, restoration or surgical procedure used to: (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; and (d) splint or stabilize teeth for periodontal reasons;
- Local anesthesia;
- Gingivectomy as an aid to the placement of a restoration.
LIMITATIONS
In addition to the limitations listed above in the Benefits Section, the following limitations apply under this plan, unless otherwise specified in the Summary of Dental Plan Benefits:
- Our obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this plan;
- When services in progress are interrupted and completed later by another Dentist, we will review the claim to determine the amount of payment, if any, to each Dentist;
- Care terminated due to the death of a Covered Person will be paid to the limit of our liability for the services completed or in progress;
- The Maximum Payment will be limited to the amount specified in the Summary of Dental Plan Benefits;
- If a Deductible amount is specified in the Summary of Dental Plan Benefits, we will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies, until the Deductible amount is met.
Group Plans
Reward Plan
COVERED SERVICES
We agree to provide Benefits to you and your Eligible Dependents under our policies and procedures and under the terms and conditions of this plan, including, but not limited to, the categories of Covered Services, exclusions, and limitations listed below.
Diagnostic and Preventive Services
Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include oral evaluations (examinations), prophylaxes (cleanings), bitewing X-rays and fluoride treatments. These services are subject to the following exclusions and limitations:
- Topical fluoride treatments are payable once in any Benefit Year for Covered Persons under age 18;
- Oral examination submitted as a consultation or evaluation are payable twice in any Benefit Year, whether provided under one or more our plans. An evaluation is not a Covered Service when done in conjunction with a consultation;
- Prophylaxes, including periodontal maintenance procedures, are payable twice in any Benefit Year;
- Bitewing X-rays are payable twice in any Benefit Year;
- Space maintenance services are payable once per lifetime, per area on posterior teeth, for Covered Persons under age 14;
- We will not make payment for preventive control programs, including home care items, oral hygiene instructions, nutritional counseling, and tobacco counseling and all charges for the same will be your responsibility;
- We will not make payment for tests and laboratory examinations (including, but not limited to cytology, bacteriology or pathology) and caries susceptibility tests and all charges for the same will be your responsibility, unless otherwise indicated in the Summary of Dental Plan Benefits.
Brush Biopsy
Oral brush biopsy procedure and laboratory analysis used to detect oral cancer, an important tool that identifies and analyzes precancerous and cancerous cells.
Radiographs (X-rays) / Diagnostic Imaging / Diagnostic Casts
X-rays as required for routine care or as necessary for the diagnosis of a specific condition, subject to the following exclusions and limitations:
- Full mouth X-rays (which include bitewing X-rays) or a panoramic X-ray (with or without bitewing X-rays) are payable once in any 3 year period;
- A serial listing of X-rays is paid as full mouth X-rays if the total fee equals or exceeds the fee for full mouth X-rays;
- Any supplemental films with full mouth X-rays are part of the complete procedure;
- Cephalometric films, oral/facial photographic images or diagnostic casts are not payable except in conjunction with Orthodontic Services and all charges for the same will be your responsibility;
- Posterior-anterior or lateral skull and facial bone survey, sialography, temporomandibular joint films (including arthrograms) or tomographic films are not payable and all charges for the same will be your responsibility.
Basic Services
Emergency Palliative Treatment
Emergency treatment to temporarily relieve pain is not a Covered Service when done in conjunction with any services except X-rays, tests or examinations.
Minor Restorative Services
Minor restorative services to rebuild and repair natural tooth structure when damaged by disease or injury. These services include amalgam (silver) and composite resin (white) restorations (fillings), subject to the following exclusions and limitations:
- Amalgam and composite resin restorations are payable once per posterior tooth surface within a 24 month period regardless of the number or combination of restorations placed on a surface; composite resins are not payable for posterior resins;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility.
Simple Extractions
Simple extractions including local anesthesia, suturing, if needed, and routine post-operative care.
Sealants
Sealants are payable only for the occlusal (biting) surface of first permanent molars for Covered Persons under age 18 and second permanent molars for Covered Persons under age 18. The surface must be free from decay and restorations. Sealants are a Benefit payable once in any 3 year period.
Periodontal Maintenance Following Therapy
Periodontal maintenance following active periodontal therapy procedures to treat diseases of the gums and supportive structures of the teeth along with benefits for prophylaxes, including periodontal maintenance procedures are payable twice in any Benefit Year.
Other Basic Services
After hours visits, not to exceed once per Benefit Year.
Oral Surgery Services
Surgical extractions and dental surgery, including local anesthesia, suturing, if needed, and routine postoperative care are subject to the following exclusions and limitations:
- We will not make payment for the following services and items and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits: appliances, restorations, X-rays or other services for the diagnosis or treatment of temporomandibular disorders (“TMD”) including myofunctional therapy;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown.
Endodontic Services
The treatment of teeth with diseased or damaged nerves (for example, root canals) is subject to the following exclusions and limitations:
- Endodontic therapy, endodontic retreatment, and apicoectomy/periradicular services are payable once per tooth in any 24 month period;
- Root canal fillings on primary teeth are limited to primary teeth without succedaneous (replacement) teeth;
- We will not make payment for pulp caps and all charges for the same will be your responsibility.
Maxillofacial Prosthetics
We will not make payment for maxillofacial prosthetics and all charges for the same will be your responsibility.
Periodontic Services
The treatment of diseases of the gums and supporting structures of the teeth is subject to the following exclusions and limitations:
- Full mouth debridement will be payable once in a Covered Person’s lifetime;
- Scaling and root planing are payable once per area in any 24 month period;
- Periodontal surgery is payable once per area in any 3 year period.
Major Services [EXCLUDED/NO COVERAGE IN YEAR 1]
Major Restorative Services
Major restorative services, such as crowns, are payable only for extensive loss of tooth structure due to caries (decay) or fracture. These services are subject to the following further exclusions and limitations:
- Indirect restorations including porcelain/ceramic substrate, porcelain/resin processed to metal and cast metal restorations (including crowns and onlays) and associated procedures such as cores and post and core substructures on the same posterior tooth are payable once in any 5 year period;
- Substructures and indirect restorations, including porcelain/ceramic substrate, porcelain/resin processed to metal, and cast restorations are not payable for Covered Persons under age 12 and all charges for the same will be your responsibility. Cores are payable only when necessary to retain a crown or a tooth with extensive breakdown due to decay or fracture;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Inlays, regardless of the material used: we will pay only the applicable amount that we would have paid for a resin-based composite restoration. You will be responsible for any additional charges;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility;
- Veneers are not a Covered Service and all charges for the same will be your responsibility.
Prosthodontic Services
Services and appliances that replace missing natural teeth (such as fixed bridges, endosteal implants, partial dentures, and complete dentures) are subject to the following exclusions and limitations:
- One complete upper and one complete lower denture is payable once in any 5 year period for any individual;
- A partial denture, fixed bridge, or removable bridge and any associated services are payable once in any 5 year period;
- Fixed bridges, endosteal implants and removable partial dentures are not payable for Covered Persons under age 16 and all charges for the same will be your responsibility;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Services for tissue conditioning are payable twice per denture unit in any 3 year period.
- Endosteal implants are allowed once per tooth, per lifetime. We will not make payment if the implant is placed within 5 years following prosthodontic or major restorative services involving that tooth and all charges for the same will be your responsibility;
- We will not make payment for specialized implant surgical techniques, bone replacement grafts, removal of an implant, implant maintenance procedures, or implant repairs and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing or stolen appliances of any type; temporary, provisional, or interim prosthodontic appliances; precision or semi-precision attachments, copings or myofunctional therapy.
- We will not make payment for (a) procedures to replace a missing tooth or teeth that were lost prior to the date that a Covered Person was covered under this plan.
Relines and Repairs
Relines and repairs to fixed bridges, partial dentures, and complete dentures. A reline or a complete replacement of denture base material is limited to once in any 3 year period per appliance.
Other Major Services
- An occlusal guard is not a Covered Service;
- Limited occlusal adjustments are limited to 1 in a 5 year period;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: repair, relines, or adjustments of occlusal guards.
Orthodontics [EXCLUDED/NO COVERAGE IN YEARS 1 & 2]
Orthodontic Services
No person will be eligible for Orthodontic Services under this plan unless Orthodontic Services are provided for in the Summary of Dental Plan Benefits. Services, treatment, and procedures to correct malposed teeth (for example, braces), are subject to the following exclusions and limitations:
- Our payment for Orthodontic Services will be limited to the lifetime Maximum Payment specified in the Summary of Dental Plan Benefits;
- Orthodontic Services are payable until the end of the calendar year in which the Covered Person attains the age of 19, unless otherwise specified in the Summary of Dental Plan Benefits;
- Our payment for orthodontic retention services (removal of appliances, construction and placement of retainer) is included in ours payment of overall Orthodontic Services. If a Dentist bills these services separately, payment will be denied.
- If the treatment plan is terminated before completion of the case for any reason, our obligation will cease with payment up to the date of termination;
- The Dentist may terminate treatment, with written notification to us and to the patient, for lack of patient interest and cooperation. In those cases, our obligation for payment ends on the last day of the month in which the patient was last treated;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing, or stolen appliances of any type or replacement or repair of an orthodontic appliance.
EXCLUSIONS
In addition to the exclusions listed above in the Benefits Section, we will not make payment for the following services, items or supplies and all charges for the same will be your responsibility, unless otherwise specified in the Summary of Dental Plan Benefits:
- Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;
- Services or appliances started prior to the effective date of a Covered Person’s coverage under this plan, excluding orthodontic treatment in progress (if a Covered Service);
- Charges for failure to keep a scheduled visit with the Dentist;
- Charges for completion of forms or submission of claims;
- Services, items or supplies for which no valid dental need can be demonstrated, as determined by us;
- Services, items or supplies that are specialized techniques, as determined by us;
- Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by us;
- Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;
- Services, items or supplies excluded by our policies and procedures;
- Services, items or supplies, as determined by us, which are not provided in accordance with accepted standards of dental practice;
- Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of our coverage;
- Services, items or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared;
- Services, items or supplies that are generally covered under a hospital, surgical/medical, or prescription drug program;
- Services, items or supplies that are not within the categories of Covered Services as shown in the Summary of Dental Plan Benefits;
- Prescription drugs, non-prescription drugs, premedications, fluoride rinses and self-applied fluorides, localized delivery of antimicrobial or chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustment, enamel microabrasions, odontoplasty, or bleaching;
- Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by us;
- Any appliance, restoration or surgical procedure used to: (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; and (d) splint or stabilize teeth for periodontal reasons;
- Local anesthesia;
- Gingivectomy as an aid to the placement of a restoration.
LIMITATIONS
In addition to the limitations listed above in the Benefits Section, the following limitations apply under this plan, unless otherwise specified in the Summary of Dental Plan Benefits:
- Our obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this plan;
- When services in progress are interrupted and completed later by another Dentist, we will review the claim to determine the amount of payment, if any, to each Dentist;
- Care terminated due to the death of a Covered Person will be paid to the limit of our liability for the services completed or in progress;
- The Maximum Payment will be limited to the amount specified in the Summary of Dental Plan Benefits;
- If a Deductible amount is specified in the Summary of Dental Plan Benefits, we will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies, until the Deductible amount is met.
FLEX Basic Plan
COVERED SERVICES
We agree to provide Benefits to you and your Eligible Dependents under our policies and procedures and under the terms and conditions of this Policy, including, but not limited to, the categories of Covered Services, exclusions, and limitations listed below.
Diagnostic and Preventive Services
Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include oral evaluations (examinations), prophylaxes (cleanings), bitewing X-rays and fluoride treatments. These services are subject to the following exclusions and limitations:
- Topical fluoride treatments are payable twice in any Benefit Year for Covered Persons under age 19;
- Oral examination submitted as a consultation or evaluation are payable twice in any Benefit Year, whether provided under one or more RLHICA Plans. An evaluation is not a Covered Service when done in conjunction with a consultation;
- Prophylaxes, including periodontal maintenance procedures, are payable twice in any Benefit Year;
- Bitewing X-rays are payable once in any Benefit Year;
- Space maintenance services are payable once per lifetime, per area on posterior teeth, for Covered Persons under age 14;
- We will not make payment for preventive control programs, including home care items, oral hygiene instructions, nutritional counseling, and tobacco counseling and all charges for the same will be your responsibility;
- We will not make payment for tests and laboratory examinations (including, but not limited to cytology, bacteriology or pathology) and caries susceptibility tests and all charges for the same will be your responsibility, unless otherwise indicated in the Summary of Dental Plan Benefits.
Brush Biopsy
Oral brush biopsy procedure and laboratory analysis used to detect oral cancer, an important tool that identifies and analyzes precancerous and cancerous cells.
Basic Services
Emergency Palliative Treatment
Emergency treatment to temporarily relieve pain is not a Covered Service when done in conjunction with any services except X-rays, tests or examinations.
Radiographs (X-rays) / Diagnostic Imaging / Diagnostic Casts
X-rays as required for routine care or as necessary for the diagnosis of a specific condition, subject to the following exclusions and limitations:
- Full mouth X-rays (which include bitewing X-rays) or a panoramic X-ray (with or without bitewing X-rays) are payable once in any 5 year period;
- A serial listing of X-rays is paid as full mouth X-rays if the total fee equals or exceeds the fee for full mouth X-rays;
- Any supplemental films with full mouth X-rays are part of the complete procedure;
- Cephalometric films, oral/facial photographic images or diagnostic casts are not payable except in conjunction with Orthodontic Services and all charges for the same will be your responsibility;
- Posterior-anterior or lateral skull and facial bone survey, sialography, temporomandibular joint films (including arthrograms) or tomographic films are not payable and all charges for the same will be your responsibility.
Minor Restorative Services
Minor restorative services to rebuild and repair natural tooth structure when damaged by disease or injury. These services include amalgam (silver) and composite resin (white) restoration (fillings), subject to the following exclusions and limitations:
- Amalgam and composite resin restorations are payable once per posterior tooth surface within a 24 month period regardless of the number or combination of restorations placed on a surface;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility.
Simple Extractions
Simple extractions including local anesthesia, suturing, if needed, and routine post-operative care.
Sealants
Sealants are payable only for the occlusal (biting) surface of first permanent molars for Covered Persons under age 16 and second permanent molars for Covered Persons under age 16. The surface must be free from decay and restorations. Sealants are a Benefit payable once in any 3 year period.
Periodontal Maintenance Following Therapy
Periodontal maintenance following active periodontal therapy procedures to treat diseases of the gums and supportive structures of the teeth along with benefits for prophylaxes, including periodontal maintenance procedures are payable twice in any Benefit Year.
Other Basic Services
After hours visits, not to exceed once per Benefit Year.
Major Services
Oral Surgery Services
Surgical extractions and dental surgery, including local anesthesia, suturing, if needed, and routine postoperative care are subject to the following exclusions and limitations:
- We will not make payment for the following services and items and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits: appliances, restorations, X-rays or other services for the diagnosis or treatment of temporomandibular disorders (“TMD”) including myofunctional therapy;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown.
Endodontic Services
The treatment of teeth with diseased or damaged nerves (for example, root canals) is subject to the following exclusions and limitations:
- Endodontic therapy, endodontic retreatment, and apicoectomy/periradicular services are payable once per tooth in any 24 month period;
- Root canal fillings on primary teeth are limited to primary teeth without succedaneous (replacement) teeth;
- We will not make payment for pulp caps and all charges for the same will be your responsibility.
Maxillofacial Prosthetics
We will not make payment for maxillofacial prosthetics and all charges for the same will be your responsibility.
Periodontic Services
The treatment of diseases of the gums and supporting structures of the teeth is subject to the following exclusions and limitations:
- Full mouth debridement will be payable once in Covered Person’s lifetime;
- Scaling and root planing are payable once per area in any 24 month period;
- Periodontal surgery is payable once per area in any 3 year period;
Major Restorative Services
Major restorative services, such as crowns, are payable only for extensive loss of tooth structure due to caries (decay) or fracture. These services are subject to the following further exclusions and limitations:
- Indirect restorations including porcelain/ceramic substrate, porcelain/resin processed to metal and cast metal restorations (including crowns and onlays) and associated procedures such as cores and post and core substructures on the same posterior tooth are payable once in any 5 year period;
- Substructures and indirect restorations, including porcelain/ceramic substrate, porcelain/resin processed to metal, and cast restorations are not payable for Covered Persons under age 12 and all charges for the same will be your responsibility. Cores are payable only when necessary to retain a crown or a tooth with extensive breakdown due to decay or fracture;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Inlays, regardless of the material used: we will pay only the applicable amount that it would have paid for a resin-based composite restoration. You will be responsible for any additional charges;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility;
- Veneers are payable once in a 5 year period.
Prosthodontic Services
Services and appliances that replace missing natural teeth (such as fixed bridges, endosteal implants, partial dentures, and complete dentures) are subject to the following exclusions and limitations:
- One complete upper and one complete lower denture is payable once in any 5 year period for any individual;
- A partial denture, fixed bridge, or removable bridge and any associated services are payable once in any 5 year period;
- Fixed bridges, endosteal implants and removable partial dentures are not payable for Covered Persons under age 16 and all charges for the same will be your responsibility;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Services for tissue conditioning are payable twice per denture unit in any 3 year period.
- Endosteal implants are allowed once per tooth, per lifetime. We will not make payment if the implant is placed within 5 years following prosthodontic or major restorative services involving that tooth and all charges for the same will be your responsibility;
- We will not make payment for specialized implant surgical techniques, bone replacement grafts, removal of an implant, implant maintenance procedures, or implant repairs and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing or stolen appliances of any type; temporary, provisional, or interim prosthodontic appliances; precision or semi-precision attachments, copings or myofunctional therapy.
- We will not make payment for (a) procedures to replace a missing tooth or teeth that were lost prior to the date that a Covered Person was covered under this Policy; or (b) the replacement of teeth beyond the normal complement of teeth; or (c) services associated with overdentures; or (d) posterior bridges in conjunction with partial dentures in the same arch, and all charges for the same will be your responsibility.
Relines and Repairs
Relines and repairs to fixed bridges, partial dentures, and complete dentures. A reline or a complete replacement of denture base material is limited to once in any 3 year period per appliance.
Other Major Services
- An occlusal guard is payable once in a Covered Person’s lifetime;
- Limited occlusal adjustments are limited to 1 in a lifetime;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: repair, relines, or adjustments of occlusal guards.
Orthodontics
Orthodontic Services
No person will be eligible for Orthodontic Services under this Policy unless Orthodontic Services are provided for in the Summary of Dental Plan Benefits. Services, treatment, and procedures to correct malposed teeth (for example, braces), are subject to the following exclusions and limitations:
- Our payment for Orthodontic Services will be limited to the lifetime Maximum Payment specified in the Summary of Dental Plan Benefits;
- Orthodontic Services are payable until the end of the calendar year in which the Covered Person attains the age of 99, unless otherwise specified in the Summary of Dental Plan Benefits;
- Our payment for orthodontic retention services (removal of appliances, construction and placement of retainer) is included in its payment of overall Orthodontic Services. If a Dentist bills these services separately, payment will be denied.
- If the treatment plan is terminated before completion of the case for any reason, our obligation will cease with payment up to the date of termination;
- The Dentist may terminate treatment, with written notification to us and to the patient, for lack of patient interest and cooperation. In those cases, our obligation for payment ends on the last day of the month in which the patient was last treated;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing, or stolen appliances of any type or replacement or repair of an orthodontic appliance.
EXCLUSIONS
In addition to the exclusions listed above in the Benefits Section, we will not make payment for the following services, items or supplies and all charges for the same will be your responsibility, unless otherwise specified in the Summary of Dental Plan Benefits:
- Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;
- Services or appliances started prior to the effective date of a Covered Person’s coverage under this Policy, excluding orthodontic treatment in progress (if a Covered Service);
- Charges for failure to keep a scheduled visit with the Dentist;
- Charges for completion of forms or submission of claims;
- Services, items or supplies for which no valid dental need can be demonstrated, as determined by us;
- Services, items or supplies that are specialized techniques, as determined by us;
- Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by us;
- Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;
- Services, items or supplies excluded by our policies and procedures;
- Services, items or supplies, as determined by us, which are not provided in accordance with accepted standards of dental practice;
- Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of our coverage;
- Services, items or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared;
- Services, items or supplies that are generally covered under a hospital, surgical/medical, or prescription drug program;
- Services, items or supplies that are not within the categories of Covered Services as shown in the Summary of Dental Plan Benefits;
- Prescription drugs, non-prescription drugs, premedications, fluoride rinses and self-applied fluorides, localized delivery of antimicrobial or chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustment, enamel microabrasions, odontoplasty, or bleaching;
- Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by us;
- Any appliance, restoration or surgical procedure used to: (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; and (d) splint or stabilize teeth for periodontal reasons;
- Local anesthesia;
- Gingivectomy as an aid to the placement of a restoration.
LIMITATIONS
In addition to the limitations listed above in the Benefits Section, the following limitations apply under this Policy, unless otherwise specified in the Summary of Dental Plan Benefits:
- Our obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this Policy;
- When services in progress are interrupted and completed later by another Dentist, we will review the claim to determine the amount of payment, if any, to each Dentist;
- Care terminated due to the death of a Covered Person will be paid to the limit of our liability for the services completed or in progress;
- The Maximum Payment will be limited to the amount specified in the Summary of Dental Plan Benefits;
- If a Deductible amount is specified in the Summary of Dental Plan Benefits, we will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies, until the Deductible amount is met.
FLEX Basic Plus Plan
COVERED SERVICES
We agree to provide Benefits to you and your Eligible Dependents under our policies and procedures and under the terms and conditions of this Policy, including, but not limited to, the categories of Covered Services, exclusions, and limitations listed below.
Diagnostic and Preventive Services
Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include oral evaluations (examinations), prophylaxes (cleanings), bitewing X-rays and fluoride treatments. These services are subject to the following exclusions and limitations:
- Topical fluoride treatments are payable twice in any Benefit Year for Covered Persons under age 19;
- Oral examination submitted as a consultation or evaluation are payable twice in any Benefit Year, whether provided under one or more RLHICA Plans. An evaluation is not a Covered Service when done in conjunction with a consultation;
- Prophylaxes, including periodontal maintenance procedures, are payable twice in any Benefit Year;
- Bitewing X-rays are payable once in any Benefit Year;
- Space maintenance services are payable once per lifetime, per area on posterior teeth, for Covered Persons under age 14;
- We will not make payment for preventive control programs, including home care items, oral hygiene instructions, nutritional counseling, and tobacco counseling and all charges for the same will be your responsibility;
- We will not make payment for tests and laboratory examinations (including, but not limited to cytology, bacteriology or pathology) and caries susceptibility tests and all charges for the same will be your responsibility, unless otherwise indicated in the Summary of Dental Plan Benefits.
Brush Biopsy
Oral brush biopsy procedure and laboratory analysis used to detect oral cancer, an important tool that identifies and analyzes precancerous and cancerous cells.
Basic Services
Emergency Palliative Treatment
Emergency treatment to temporarily relieve pain is not a Covered Service when done in conjunction with any services except X-rays, tests or examinations.
Radiographs (X-rays) / Diagnostic Imaging / Diagnostic Casts
X-rays as required for routine care or as necessary for the diagnosis of a specific condition, subject to the following exclusions and limitations:
- Full mouth X-rays (which include bitewing X-rays) or a panoramic X-ray (with or without bitewing X-rays) are payable once in any 5 year period;
- A serial listing of X-rays is paid as full mouth X-rays if the total fee equals or exceeds the fee for full mouth X-rays;
- Any supplemental films with full mouth X-rays are part of the complete procedure;
- Cephalometric films, oral/facial photographic images or diagnostic casts are not payable except in conjunction with Orthodontic Services and all charges for the same will be your responsibility;
- Posterior-anterior or lateral skull and facial bone survey, sialography, temporomandibular joint films (including arthrograms) or tomographic films are not payable and all charges for the same will be your responsibility.
Minor Restorative Services
Minor restorative services to rebuild and repair natural tooth structure when damaged by disease or injury. These services include amalgam (silver) and composite resin (white) restoration (fillings), subject to the following exclusions and limitations:
- Amalgam and composite resin restorations are payable once per posterior tooth surface within a 24 month period regardless of the number or combination of restorations placed on a surface;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility.
Simple Extractions
Simple extractions including local anesthesia, suturing, if needed, and routine post-operative care.
Sealants
Sealants are payable only for the occlusal (biting) surface of first permanent molars for Covered Persons under age 16 and second permanent molars for Covered Persons under age 16. The surface must be free from decay and restorations. Sealants are a Benefit payable once in any 3 year period.
Periodontal Maintenance Following Therapy
Periodontal maintenance following active periodontal therapy procedures to treat diseases of the gums and supportive structures of the teeth along with benefits for prophylaxes, including periodontal maintenance procedures are payable twice in any Benefit Year.
Other Basic Services
After hours visits, not to exceed once per Benefit Year.
Major Services
Oral Surgery Services
Surgical extractions and dental surgery, including local anesthesia, suturing, if needed, and routine postoperative care are subject to the following exclusions and limitations:
- We will not make payment for the following services and items and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits: appliances, restorations, X-rays or other services for the diagnosis or treatment of temporomandibular disorders (“TMD”) including myofunctional therapy;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown.
Endodontic Services
The treatment of teeth with diseased or damaged nerves (for example, root canals) is subject to the following exclusions and limitations:
- Endodontic therapy, endodontic retreatment, and apicoectomy/periradicular services are payable once per tooth in any 24 month period;
- Root canal fillings on primary teeth are limited to primary teeth without succedaneous (replacement) teeth;
- We will not make payment for pulp caps and all charges for the same will be your responsibility.
Maxillofacial Prosthetics
We will not make payment for maxillofacial prosthetics and all charges for the same will be your responsibility.
Periodontic Services
The treatment of diseases of the gums and supporting structures of the teeth is subject to the following exclusions and limitations:
- Full mouth debridement will be payable once in Covered Person’s lifetime;
- Scaling and root planing are payable once per area in any 24 month period;
- Periodontal surgery is payable once per area in any 3 year period;
Major Restorative Services
Major restorative services, such as crowns, are payable only for extensive loss of tooth structure due to caries (decay) or fracture. These services are subject to the following further exclusions and limitations:
- Indirect restorations including porcelain/ceramic substrate, porcelain/resin processed to metal and cast metal restorations (including crowns and onlays) and associated procedures such as cores and post and core substructures on the same posterior tooth are payable once in any 5 year period;
- Substructures and indirect restorations, including porcelain/ceramic substrate, porcelain/resin processed to metal, and cast restorations are not payable for Covered Persons under age 12 and all charges for the same will be your responsibility. Cores are payable only when necessary to retain a crown or a tooth with extensive breakdown due to decay or fracture;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Inlays, regardless of the material used: we will pay only the applicable amount that it would have paid for a resin-based composite restoration. You will be responsible for any additional charges;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: charges related to hospitalization or general anesthesia and/or intravenous sedation for restorative dentistry or surgical procedure unless a specified need is shown;
- We will not make payment for dentistry for aesthetic reasons and all charges for the same will be your responsibility;
- Veneers are payable once in a 5 year period.
Prosthodontic Services
Services and appliances that replace missing natural teeth (such as fixed bridges, endosteal implants, partial dentures, and complete dentures) are subject to the following exclusions and limitations:
- One complete upper and one complete lower denture is payable once in any 5 year period for any individual;
- A partial denture, fixed bridge, or removable bridge and any associated services are payable once in any 5 year period;
- Fixed bridges, endosteal implants and removable partial dentures are not payable for Covered Persons under age 16 and all charges for the same will be your responsibility;
- Optional treatment: if a Covered Person selects a more expensive service than is customarily provided, we may make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost;
- Services for tissue conditioning are payable twice per denture unit in any 3 year period.
- Endosteal implants are allowed once per tooth, per lifetime. We will not make payment if the implant is placed within 5 years following prosthodontic or major restorative services involving that tooth and all charges for the same will be your responsibility;
- We will not make payment for specialized implant surgical techniques, bone replacement grafts, removal of an implant, implant maintenance procedures, or implant repairs and all charges for the same will be your responsibility unless otherwise specified in the Summary of Dental Plan Benefits;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing or stolen appliances of any type; temporary, provisional, or interim prosthodontic appliances; precision or semi-precision attachments, copings or myofunctional therapy.
- We will not make payment for (a) procedures to replace a missing tooth or teeth that were lost prior to the date that a Covered Person was covered under this Policy; or (b) the replacement of teeth beyond the normal complement of teeth; or (c) services associated with overdentures; or (d) posterior bridges in conjunction with partial dentures in the same arch, and all charges for the same will be your responsibility.
Relines and Repairs
Relines and repairs to fixed bridges, partial dentures, and complete dentures. A reline or a complete replacement of denture base material is limited to once in any 3 year period per appliance.
Other Major Services
- An occlusal guard is payable once in a Covered Person’s lifetime;
- Limited occlusal adjustments are limited to 1 in a lifetime;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: repair, relines, or adjustments of occlusal guards.
Orthodontics
Orthodontic Services
No person will be eligible for Orthodontic Services under this Policy unless Orthodontic Services are provided for in the Summary of Dental Plan Benefits. Services, treatment, and procedures to correct malposed teeth (for example, braces), are subject to the following exclusions and limitations:
- Our payment for Orthodontic Services will be limited to the lifetime Maximum Payment specified in the Summary of Dental Plan Benefits;
- Orthodontic Services are payable until the end of the calendar year in which the Covered Person attains the age of 99, unless otherwise specified in the Summary of Dental Plan Benefits;
- Our payment for orthodontic retention services (removal of appliances, construction and placement of retainer) is included in its payment of overall Orthodontic Services. If a Dentist bills these services separately, payment will be denied.
- If the treatment plan is terminated before completion of the case for any reason, our obligation will cease with payment up to the date of termination;
- The Dentist may terminate treatment, with written notification to us and to the patient, for lack of patient interest and cooperation. In those cases, our obligation for payment ends on the last day of the month in which the patient was last treated;
- We will not make payment for the following services and items and all charges for the same will be your responsibility: lost, missing, or stolen appliances of any type or replacement or repair of an orthodontic appliance.
EXCLUSIONS
In addition to the exclusions listed above in the Benefits Section, we will not make payment for the following services, items or supplies and all charges for the same will be your responsibility, unless otherwise specified in the Summary of Dental Plan Benefits:
- Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;
- Services or appliances started prior to the effective date of a Covered Person’s coverage under this Policy, excluding orthodontic treatment in progress (if a Covered Service);
- Charges for failure to keep a scheduled visit with the Dentist;
- Charges for completion of forms or submission of claims;
- Services, items or supplies for which no valid dental need can be demonstrated, as determined by us;
- Services, items or supplies that are specialized techniques, as determined by us;
- Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by us;
- Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;
- Services, items or supplies excluded by our policies and procedures;
- Services, items or supplies, as determined by us, which are not provided in accordance with accepted standards of dental practice;
- Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of our coverage;
- Services, items or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared;
- Services, items or supplies that are generally covered under a hospital, surgical/medical, or prescription drug program;
- Services, items or supplies that are not within the categories of Covered Services as shown in the Summary of Dental Plan Benefits;
- Prescription drugs, non-prescription drugs, premedications, fluoride rinses and self-applied fluorides, localized delivery of antimicrobial or chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustment, enamel microabrasions, odontoplasty, or bleaching;
- Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by us;
- Any appliance, restoration or surgical procedure used to: (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; and (d) splint or stabilize teeth for periodontal reasons;
- Local anesthesia;
- Gingivectomy as an aid to the placement of a restoration.
LIMITATIONS
In addition to the limitations listed above in the Benefits Section, the following limitations apply under this Policy, unless otherwise specified in the Summary of Dental Plan Benefits:
- Our obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this Policy;
- When services in progress are interrupted and completed later by another Dentist, we will review the claim to determine the amount of payment, if any, to each Dentist;
- Care terminated due to the death of a Covered Person will be paid to the limit of our liability for the services completed or in progress;
- The Maximum Payment will be limited to the amount specified in the Summary of Dental Plan Benefits;
- If a Deductible amount is specified in the Summary of Dental Plan Benefits, we will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies, until the Deductible amount is met.