Consultation – diagnostic service provided by Dentist or physician other than the requesting Dentist or physician. Nitrous oxide.
Fixed partial dentures/bridges, inlays and onlays (pontics and retainer crowns) - replacement is limited to 1 service per tooth per 5 Calendar Years if the previous fixed partial denture/bridges is not serviceable and cannot be repaired. Temporary clear appliance – limited to 1 service per arch per 12 consecutive months. Prosthesis Over Implant - A prosthetic device, supported by an implant or implant abutment is a Covered Dental Expense. Replacement of any type of prosthesis with a prosthesis supported by an implant or implant abutment is only payable if the existing prosthesis is at least 5 Calendar Years old, is not serviceable and cannot be repaired.
HC-DEN342
06-21 V2 M
Class III Services - Major Restorations, Dentures and Bridgework Crowns - Initial placement of a crown is covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration due to major decay or fracture. Replacement of a crown within 5 Calendar Years after the date it was originally installed is not covered. Stainless Steel Crowns, Resin Crowns - covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration. Inlays - covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration due to major decay or fracture. Onlays - covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration due to major decay or fracture. Core buildup, including any pins. Post/post and core - covered only for endodontically treated teeth when there is insufficient tooth structure to retain the final restoration. Complete dentures - limited to 1 complete denture per arch within 5 Calendar Years. ` Partial Dentures - limited to 1 partial denture per arch within 5 Calendar Years. Overdentures - complete and partial - limited to 1 denture per arch per 5 Calendar Years.
HC-DEN343
06-21 V2
General Limitations and Expenses Not Covered General Limitations For limitations on specific Covered Dental Services, please see the Covered Dental Services. • any treatment received outside of the United States is not covered unless the treatment is a Covered Dental Service under the plan. Any benefits for services received outside of the United States will be subject to the limitations, if any, stated under the Covered Dental Services and paid based on the Out-of-Network reimbursement shown in The Schedule; • replacement of a partial denture, complete denture, fixed bridge, any prosthesis over implant, or the addition of teeth to a partial denture is not covered, unless the replacement is needed due to a Medically Necessary and/or Dentally Necessary extraction of an additional Functioning Natural Tooth while the person is covered under this plan; • replacement of a crown, bridge, onlay, post/post and core, or other laboratory prepared or CAD/CAM prepared restoration, partial denture, or complete denture within the frequency limitation stated under the Covered Dental Services is not covered unless: • the replacement is made necessary by the placement of an original opposing complete denture or the Medically Necessary and/or Dentally Necessary extraction of a Functioning Natural Tooth; or • the crown, bridge, onlay, post/post and core, other laboratory prepared or CAD/CAM prepared restoration, partial denture, or complete denture while in the mouth,
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