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These Exclusions Are For The Following Blue Cross Blue Sheild Dental Plans

BCBS BluePreferred Dental Plan 1i BCBS BluePreferred Dental Plan 5i
BCBS BluePreferred Dental Plan 6i BCBS Dental Plan Plus

These Exclusions Are For All Of The BCBS BluePreferred Dental Plans

BCBS BluePreferred plans network is Arizona.  Outside Arizona, reimbursement is based on the lesser of billed charges or the Arizona in-network fee schedule, increased by 25%.

Notwithstanding any other provision in this benefit plan, no benefits will be paid for expenses associated with the following:
  • Alternative Dentistry – Non-traditional or alternative dental therapies, interventions, services and procedures; naturopathic and homeopathic dentistry; diet therapies; nutritional or lifestyle therapies
  • Appliances, procedures, devices and services necessary to alter vertical dimension and/or restore an occlusion
  • Athletic Mouth Guards – including but not limited to, any procedures and services necessary to fabricate or create such mouth guards
  • Behavior management of any kind
  • Benefit-specific exclusions and services in excess of limitations listed in thisbook under particular benefits
  • Biologic materials to aid in tissue regeneration
  • Bleaching of any kind; both internal and external bleaching
  • Body Art, Piercing and Tattooing – Services related to body piercing, cosmetic implants, body art, tattooing and any related complications
  • Charges associated with the preparation, copying or production of health records
  • Complications of Noncovered Services – Complications and consequences, whether immediate or delayed, arising from any condition or service not covered under this plan
  • CT scans (e.g., cone beam)
  • Correction of congenital malformations except as required by state law for newborns, adopted children and children placed for adoption
  • Cosmetic Services and Any Related Complications – Surgery and any related complications, procedures, treatment, office visits, consultations and other services for cosmetic purposes
  • Counseling – Counseling and behavioral modification services
  • Court-Ordered Services – Court-ordered testing, treatment and therapy, unless such services are otherwise covered under this plan as determined by BCBSAZ
  • Deep sedation and general anesthesia, except as stated in this plan
  • Dental implants and any related services or treatment for complications
  • Enamel microabrasion
  • Expenses for services that exceed benefit limitations
  • Experimental or investigational services
  • Fees – Fees for unspecified adjunctive procedures, by report
  • Fees – Fees other than for dentally appropriate, in-person, direct member services
  • Free Services – Services you receive at no charge or for which you have no legal obligation to pay
  • Gold foil restorations
  • Government Services – Services provided at no charge to the member through a governmental program or facility
  • Inpatient or outpatient facility services – any facility charges associated with covered professional services provided in an inpatient or outpatient facility
  • Laboratory and pathology services
  • Laminate veneers
  • Local, regional block, and trigeminal division block anesthesia
  • Locally administered antibiotics
  • Major restorative and prosthodontics services performed on other than a permanent tooth
  • Maxillofacial prosthetics and any related services
  • Medications Dispensed in a Dentist’s Office – prescription medications and over-the-counter medications, including pharmaceutical manufacturers’ samples, dispensed to the patient in a dentist’s office by any mode of administration. This does not include eligible injectable medications administered in the dentist’s office
  • Non-Dentally Necessary Services – services that are not dentally necessary as determined by BCBSAZ. BCBSAZ may not be able to determine dental necessity until after services are rendered
  • Nitrous oxide; oral or intravenous conscious sedation; oral, intravenous or intramuscular analgesics or anxiolytics
  • Occlusal guards for the treatment of temporomandibular joint syndrome or sleep apnea – including but not limited to, any procedures and services necessary to fabricate or create such mouth guards
  • Office visit for observation, during which no services are provided
  • Oral appliances for treatment of bruxism
  • Oral hygiene instruction, except when provided as an integral part of a routine covered oral examination.
  • Orthodontic services and tooth extractions relating to those services
  • Over-the-Counter Items – Medications, devices, equipment and supplies that are lawfully obtainable without a prescription
  • Personal Comfort Items – Services intended primarily for assistance in daily living, socialization, personal comfort, convenience and other non-medical reasons
  • Services and Supplies Not Provided by a Dentist – except dental prophylaxis and root planing performed by a licensed dental hygienist under the supervision and direction of a dentist
  • Services for Idiopathic Environmental Intolerance – Services associated with environmental intolerance from unknown causes (idiopathic), multiple chemical sensitivity, the diagnosis or treatment of environmental illness (clinical ecology), such as chemical sensitivity or toxicity from exposure to atmospheric or environmental contaminants, pesticides or herbicides
  • Services from a Family Member – Services delivered by an eligible provider who is a member of your immediate family. “Immediate family” means your parents, siblings, children, stepparents, stepchildren, spouse, grandparents, grandchildren and anyone related to you by marriage to the same degree as any of the preceding individuals. When a provider is also the covered person, services rendered by that provider for himself or herself are also excluded from coverage
  • Services from ineligible providers
  • Services paid for by other organizations – Services customarily paid for by an employer, such as worksite or ergonomic evaluations; the government; a school; biotechnical, pharmaceutical or dental device industry sources; or other individuals and organizations
  • Services prior to effective date
  • Services provided after the member’s coverage termination date
  • Services related to or associated with noncovered services
  • Skin grafts
  • Telephonic and electronic consultations
  • Therapy or treatment of the temporomandibular joint, orthognathic surgery, or ridge augmentation
  • Training and education
  • Transportation – Transport services and travel expenses
  • Workers’ Compensation – Illnesses or injuries covered by Workers’ Compensation, unless the member is exempt from such coverage or has made a statutory opt-out election
Plan 1i – Additional Exclusions

• All Type III services—Prosthodontics (Bridges and Dentures); Oral Surgery (Extractions); Simple Extractions; General Anesthesia; Endodontics (Root Canal and Pulpal Therapy); Crowns/Inlays/Onlays; Periodontics (Surgical and Non-Surgical)


These Exclusions Are For The BCBS DentalPlus Plan

BCBS DentalPlus plan benefits are available only in Arizona, expect for emergency/urgent care or authorized follow-up care.

Comments that are highlighted in Blue are observations by Savon

The following is a partial list of conditions and services that are limited or excluded.  A complete listing can be found in the contract booklet, which will be sent to you when you enroll or prior to enrollment upon request.

Exclusions and Limitations
  1. A service not rendered or authorized by your DentalPlus primary dentist, except for emergency treatment as described in this booklet
  2. Any procedures or services not listed on the DentalPlus Fee Schedule
    With Savon, even unlisted procedures and/or services are discounted by 50%

  3. Appliances or restoration necessary to increase vertical dimension or restore an occlusion
  4. Complications related to an ineligible or excluded treatment, condition, procedure or service
  5. Cosmetic or aesthetic services or surgery
  6. Extractions of asymptomatic third molars
  7. Orthodontic services or treatment that began before your effective date of coverage under this contract or continues after your termination
  8. Services or treatment associated with prior orthodontic treatment or services
  9. Prescription and over-the-counter drugs
  10. Repair or replacement of orthodontic appliances
  11. Replacement of a lost or stolen denture
  12. Services covered by Workers’ Compensation or similar benefits
    Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits

  13. Services or treatment for, or associated with, temporomandibular joint (TMJ) dysfunction or disorder, or for orthognatic surgery
  14. Services rendered by a hospital or other facility, or related to a hospital or facility visit
  15. Services rendered before your effective date of coverage under this contract or after this coverage terminates
  16. Services that are not approved by the American Dental Association (ADA), or those considered investigative or experimental
  17. Services that are not dentally necessary, as determined by Blue Cross Blue Sheild of Arizona
Updated 09/12/2016

Savon Dental Plan Is Not Available For Purchase In The State Of Florida
 
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