• any replacement of a crown, bridge, partial denture, or complete denture which is or can be made usable according to commonly accepted dental standards; • crowns, inlays, cast restorations, or other laboratory prepared or CAD/CAM prepared restorations on teeth unless the tooth cannot be restored with an amalgam or resin-based composite restoration due to major decay or fracture; The benefits provided under this plan will be reduced so that the total payment will not be more than 100% of the charge made for the dental service if benefits are provided for that service under this plan and any expense plan or prepaid treatment program sponsored or made available by Your Employer.
• consultations and/or evaluations associated with services that are not covered; • cosmetic dentistry or cosmetic dental surgery (dentistry or dental surgery performed solely to improve appearance) which may include but is not limited to the following: bleaching (tooth whitening), in office and/or at home, enamel microabrasion, odontoplasty, facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth will always be considered cosmetic; • replacement of fixed and/or removable appliances (including fixed and removable orthodontic appliances, if orthodontics is covered) that have been lost, stolen, or damaged due to patient abuse, misuse, or neglect; • procedures, services, supplies, restorations, or appliances (except complete dentures), whose sole or primary purpose is to change or maintain vertical dimension; • procedures, services, supplies, restorations or appliances whose main purpose is to diagnose or treat jaw joint problems, including dysfunction of the temporomandibular joint and craniomandibular disorders, or other conditions of the joints linking the jawbone and skull, including the complex muscles, nerves and other tissues related to that joint; • the restoration of teeth which have been damaged by erosion, attrition, abfraction or abrasion; • bite registration or bite analysis; • precision or semi-precision attachments; • any procedure, service, supply or appliance used primarily for the purpose of splinting; • porcelain, ceramic, resin, or acrylic materials on crowns or pontics on, or replacing the upper or lower first, second and/or third molars; • services to correct congenital malformations, including the replacement of congenitally missing teeth; • procedures, restorations, appliances or services to stabilize periodontally involved teeth; • myofunctional therapy; • replacement of a partial denture or complete denture which can be made serviceable; • prescription drugs; • treatment of jaw fractures and/or orthognathic surgery; • the treatment of cleft lip and cleft palate;
HCDFB-DEX109
06-21 V1
Expenses Not Covered Covered Dental Expenses will not include, and no payment will be made for: • any services not stated under Covered Dental Services and The Schedule; • procedures that are deemed to be medical services or are a covered expense under any other medical plan which provides group hospital, surgical, or medical benefits whether or not on an insured basis; • any charges, including ancillary charges, for services and supplies received from a hospital, outpatient facility, ambulatory surgical center or similar facility; • charges incurred due to injuries which are intentionally self- inflicted; • charges for or in connection with an injury or illness arising out of, or in the course of any employment for wage or profit; • charges for or in connection with an injury or illness which is covered under any workers’ compensation or similar law; • charges made by a hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition; • services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;
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