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Exclusions & Limitations


The dental services appearing in this schedule are available from general practitioners and specialists listed in the DDS Dental Directory. Any services that are not listed are available at a 25% discount from normal fees charged by participating general practitioners and specialists, including pedodontics, prosthodontics and implantology.

Aside from the Annual Check-up, additional exams, x-rays and consultations are available at a 25% discount at general practitioners. All exams, x-rays and consultations at all specialists are 25% off the dentist's normal fee. Britesmile is not a covered procedure.

All participating providers may charge an OSHA sterilization fee per visit and a lab fee for crown, bridge and denture work. The administration of nitrous oxide intravenous sedation or general anesthesia is available at a 25% discount from normal fees charged by participating general practitioners and specialists.

This plan does not include all procedures, which might be provided by a general dentist. Any procedure delivered which is not listed on the fee schedule may cause additional cost to be incurred. These additional costs are the responsibility of the Member. The dollar amount specified adjacent to each procedure may not be the only cost incurred for a given treatment, because the treatment may require more than one dental procedure.


Orthodontia Exclusions and Limitations

Continuation of orthodontic treatment beyond 24 months and other orthodontic services available at a 25% discount from the normal fees charged by orthodontists listed in the DDS Dental Directory. Orthodontic treatment includes the treatment of mixed and/or permanent dentitions under the 08400 and 08500 series procedure code. Orthodontic treatment for patients over the age of 16 is a 25% reduction from the dentist's usual and customary fee. Invisalign braces are 25% off the normal fee.