Exclusions for Alpha Dental Plans

These Exclusions Are For The Following Alpha Dental Plans

(This Includes Indemnity and PPO's)

Alpha Bronze PPO MAC Network Plan - PPO	Alpha Bronze Indemity Plan - Indemnity Insurance
Alpha Silver PPO MAC Network Plan - PPO	Alpha Silver Indemity Plan - Indemnity Insurance
Alpha Gold PPO MAC Network Plan - PPO	Alpha Gold Indemity Plan - Indemnity Insurance

Comments that are highlighted in Blue are observations by Savon

GENERAL INFORMATION
Eligibility: Individuals 18+, plus their eligible dependents. This is subject to individual state regulations.

Predetermination of Benefits: It is recommended that a treatment plan/course of treatment be submitted when the total cost of eligible expenses for any insured is expected to exceed the amount shown on the coverage schedule. This should be submitted to us before the work is started. If actual services submitted do not agree with the treatment plan, or if a treatment plan is not sent in, we will base our payment on treatment consistent with reasonable and customary charges. Predetermination of benefits is not a guarantee of what we will pay. The estimated benefit payment is based on your current eligibility and benefits in effect at the time of the completed service. Submission of other claims or changes in eligibility or this policy may alter final payment.

Alternate Benefit: If we determine that a less expensive procedure, service, or treatment plan/course of treatment that is customarily used to treat the dental problem and recognized by the dental profession to be appropriate according to broadly accepted standards of dental practice, then the maximum we will allow will be the charge for the less expensive treatment.

The 2 paragraphs above basically states that the insurance company can actually determine your course of treatment if you want them to pay their share. With Savon your treatment is always between you and your doctor.

Reasonable & Customary: The usual, customary and regular charges for the area where such expenses are incurred.

Your coverage under this policy does not cover any miscellaneous separate expense not considered a covered service or procedure.

We will not pay or provide alternate benefits for any of the following:

Items, treatments or services:
- a. not listed as an eligible expense on the Coverage Schedule;
- b. not prescribed by or performed by or under the direct supervision of a dental practitioner;
- c. not dentally necessary as determined by us;
- d. not meeting the accepted standards of dental practice;
- e. experimental in nature;
- f. that have a questionable prognosis;
- g. covered under any medical insurance policy; or
- h. performed by a member of your or your spouse's family (family includes parents, step-parents, in-laws, spouse or former spouse, domestic partner, children, siblings, aunts, uncles, cousins, nieces, nephews, grandparents, and guardians).
Services furnished primarily for cosmetic reasons, including but not limited to:
- a. specialized techniques, characterizing and personalizing prosthetic devices;
- b. making facings on prosthetic devices for any tooth in back of the second bicuspid; or
- c. replacements of restorations performed for cosmetic reasons.
Savon covers all cosmetic dentistry.

Charges for any appliance or service that is used to:
- a. change vertical dimension;
- b. restore or maintain occlusion, except to the extent that this policy covers orthodontic treatment;
  Some of these policies have very limited to no coverage for braces.
- c. splint or stabilize teeth for periodontal reasons; or
- d. treat disturbances of the temporomandibular joint (TMJ).
Charges for any service performed as a result of abrasion, attrition, bruxism, erosion or abfraction.
Athletic mouth guards.
Preventive root canal therapy.
Full mouth debridement.
In some cases, this is a very important diagnostic tool.

Charges for any services that are considered to be an integral part of another service, such as pulp capping, surgical trays, or sutures.
Ridge preservation, augmentation, bone grafts and regeneration procedures performed in edentulous sites.
Overdentures or precision attachments.
Preparation and fitting of preformed dowel or post for root canal tooth; pulp cap either directly or indirectly.
Duplicate or temporary devices, appliances, and services except as listed as an eligible expense.
Replacing a lost, stolen or missing appliance or prosthetic device.
Application of chemotherapeutic agents.
Oral hygiene, plaque control, diet instruction or infection control.
Charges for sterilization of equipment; disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies.
Non-emergency services performed outside the United States, Canada and Mexico.
Treatment which is:
- a. due to an on-the-job or job-related illness or injury; or
  Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.
- b. a condition for which benefits are payable by Workers’ Compensation or similar laws, whether or not benefits are claimed.
Treatment for which no charge is made or for which you are not legally obligated to pay including, but not limited to, treatment (or charges made) by:
- a. your covered employer, labor union or similar group, in its dental or medical department or clinic;
- b. a facility owned or run by any government body; or
- c. any public program, except Medicaid, paid for or sponsored by any government body.
Telephone consultations, charges for failure to keep a scheduled appointment, X-ray copy fees, or charges for completion of a claim form.
Codes that are by report.
Ancillary charges, including but not limited to, hospital, ambulatory surgical center or similar facility; or use of provider office space.
Treatment resulting from:
- a. your participation in a war or an act of war, declared or undeclared;
- b. your attempting to commit, or committing, an assault or felony;
- c. your unlawful participation in a riot, rebellion, or insurrection; or
- d. an intentionally self-inflicted injury while sane or insane.

Benefits are limited as follows:

In the event you transfer from the care of one dental practitioner to that of another during the course of treatment, or if more than one dental practitioner performs services for one eligible expense, we shall be liable for not more than the amount we would have been liable for had but one dental practitioner performed the service.

In all cases involving eligible expenses in which the dental practitioner and you select a more expensive course of treatment than is customarily provided by the dental profession, consistent with sound professional standards of dental practice for the eligible expense concerned, payment under the plan will be based on the charge allowed for the lesser procedure.

Updated 09/20/2016