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These Exclusions Are For The Following Physicians Mutual Dental Plans

(These plans are Dental Indemnity Insurance)

1. Expense incurred during any waiting period (and while the insurance policy is not in force for P150).
2. Any treatment which is for cosmetic purposes. Facings on crowns or pontics beyond the second bicuspid are considered cosmetic (We will not pay for facings on crowns or pontics beyond the second bicuspid in MD).
3. Replacement of any prosthetic appliance, crown, inlay or onlay restoration, or fixed partial denture within five years of the date of the last placement of these items; unless a) replacement is required due to an accidental injury sustained while a covered person’s coverage is in force; and b) replacement occurs while such covered person’s coverage is in force.
4. Initial placement of any prosthetic appliance or fixed partial denture unless such placement is needed because of the extraction of one or more teeth while the covered person is insured under this certificate/insurance policy. But the extraction of a third molar (wisdom tooth) will not qualify under the above. Any such appliance of fixed partial denture must include the replacement of the extracted tooth or teeth.
   Unless you have a tooth extracted while insured by this company, there is no benefit for any prosthetic appliance (dentures or partials) or fixed partial denture (bridges).
   
   
5. Any procedure started before the covered person was insured under this certificate/insurance policy.
6. Any procedure started after the covered person’s insurance under this certificate/insurance policy terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the covered person’s insurance under this certificate/insurance policy terminates.
7. The replacement of lost or stolen appliances.
8. Appliances, restorations or procedures to a) alter vertical dimension; b) restore or maintain occlusion; or c) splint or replace tooth structure lost as a result of abrasion or attrition (Appliances, restorations, or procedures to: a) alter vertical dimension; b) restore or maintain occlusion; or c) splint or replace tooth structure lost as a result of abrasion, attrition or erosion in MD).
9. Any procedure that is not shown in the schedule (not in MD; in GA: Procedures not listed in the schedule).
10. Orthodontic treatment (except as needed as a result of cleft lip or cleft palate in CO/SC).
    This is especially important for anyone in need of braces.
    
    
11. Sealants which are a) not applied to a permanent molar; b) applied after attaining the age of 17; or c) reapplied to a molar within three years from the date of a previous sealant application.
12. Periodontal scaling and root planing unless the presence of periodontal disease is confirmed by both X-ray films and pocket depth summaries of each tooth involved (not in MD).
13. Injury or sickness arising out of, or in the course of, work for wage or profit, for which the covered person receives benefits under any Workers’ Compensation Act or similar laws (Care, treatment, services, supplies or drugs for Injury or Sickness related to covered person’s job to the extent the covered person is covered or is required to be covered by the Workers’ Compensation law. If the covered person enters into settlement giving up his/her rights to recover further medical benefits under a Workers’ Compensation law, the policy will not pay those medical benefits that would have been payable in absence of that settlement in KS; Services or supplies for the treatment of an Occupational Injury or Sickness which are paid under the North Carolina Workers’ Compensation Act only to the extent such services or supplies are the liability of the employee, employer or Workers’ Compensation insurance carrier according to the final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ Compensation Act in NC; Injury or sickness for which benefits are paid under any Worker’s Compensation Act or similar laws in SD).
    Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.
    
    
14. Charges for which the covered person is not liable or which would not have been made had no insurance been in force (Charges for which the covered person is not liable or which would not have been made had no insurance been in force. This exclusion does not apply to Medicaid in MD; no legal liability to pay in TX).
15. Services which are not recommended by a dentist/physician or which are not required for necessary care and treatment (Services which are not recommended by a dentist/physician in MD).
16. War or any act of war, declared or not (OK: when serving in the military or an auxiliary unit attached thereto; “War” does not include terrorism in FL).
17. MD: Care, treatment, services, supplies or drugs determined by an appropriate regulatory board to be provided as a result of a prohibited referral.
18. SD: For services provided by a Family Member, unless: a) the family member is a physician; b) the family member is a regular employee of the organization furnishing the service or care; c) the organization receives the payment for the services; and d) the family member receives no compensation other than the normal compensation for employees in his or her job category.
19. CO: This policy does not include coverage of pediatric dental services as required under The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010. Coverage of pediatric dental services is available for purchase in the State of Colorado and can be purchased as a stand-alone plan. Please contact Connect for Health Colorado to purchase either plan that includes pediatric dental coverage or an Exchange-certified stand-alone dental plan that includes pediatric dental coverage.