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These Exclusions Are For The Following UnitedHealth Dental Plans

(All of these plans are PPO's)

UnitedHealth Dental Primary UnitedHealth Dental Primary Preferred
UnitedHealth Dental Essential UnitedHealth Dental Essential Preferred
UnitedHealth Dental Premier Choice UnitedHealth Dental Premier Elite

Comments that are highlighted in Blue are observations by Savon

General Dental Exclusions and Limitations

No benefits will be paid for any services not identified or included as covered expenses under the policy. You will be fully responsible for payment for any services which are not covered expenses, nor part of the insurance policy.

No benefits are payable for:
  1. Any expense or service related to that expense: incurred prior to the effective date, during the waiting period, or after the termination date of the policy; which exceeds the non-network provider reimbursement; for a dental service that is not rendered or that is not rendered within the scope of the dentist’s license; for dental services, including braces for any medical or dental condition, surgery and treatment for oral surgery, except as expressly provided for in the policy; or billed for incision and drainage if the involved abscessed tooth is removed on the same date of service.
  2. Any dental services for which benefits are payable under a medical policy issued by us. Not applicable in CA.
  3. Major services for the Dental PrimarySM plan. This includes all procedures or services related to endodontics, periodontics, major restorative services (crowns, inlays, onlays, and veneers), dental implants, prosthetics (bridges and dentures, fixed or removable), and oral surgery.
  4. Charges for dental services that are not documented in the dentist records, not directly associated with dental disease, or not performed in a dental setting.
  5. Hospital or other facility charges and related anesthesia charges, analgesia, or conscious sedation.
  6. Oral hygiene instructions; plaque control; charges completing dental claim forms; photographs; any dental supplies, including but not limited to, take-home fluoride; prescription and non-prescription drugs, with or without a prescription, unless they are dispensed and utilized in the dental office during your or your covered dependents’ dental visit, except we will pay for injection of antibiotic drugs at the time of initial treatment; sterilization fees; diagnostic casts; treatment of halitosis and any related procedures; lab procedures.
  7. Removal of sound functional restorations (not applicable in CA); temporary crowns and temporary prosthetics; provisional crowns and provisional prosthesis.
  8. Initial placement of full or partial dentures or bridges and related services, to replace functional natural teeht that are
    • Congenitally missing; or
    • Lost before insurance under this policy is in effect.
      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).

  9. Acupuncture, acupressure, and other forms of alternative treatment.
  10. Telephone consultations or for failure to keep a scheduled appointment.
  11. Bone grafts, guided tissue regeneration, biologic materials to aid in soft and osseous tissue regeneration when performed in edentulous (toothless areas, ridge augmentation or preservations).
  12. Any dental services which result from intoxication, as defined by applicable state law in the state where the loss occurred, or under the influence of illegal narcotics or controlled substance, unless administered or prescribed by a doctor. Not applicable in CA, MD, MI, NV, OR, SD, or WA.
  13. In CT, for any dental service incurred by voluntary use of any controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now hereafter amended, unless administered or prescribed by a doctor.
  14. Any dental services in relation to, or incurred in conjunction with, investigational treatment.
  15. Any dental service which results from or in the course of your employment for wage or profit. Applicable in FL and SD, if services are paid by workers’ compensation.
  16. In CT, as the result of an injury or illness arising out of, or in the course of, employment for wage or profit, if the covered person is insured, or is required to be insured, by workers’ compensation insurance pursuant to applicable state or federal law. If you enter into a settlement that waives a covered person’s right to recover future medical benefits under a workers’ compensation law or insurance plan, this exclusion will still apply. This exclusion does not apply to a corporate officer of a corporation whether or not the officer is covered by workers’ compensation.
    Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.

  17. Any dental service which results from war, participation in a riot, intentionally self-inflicted bodily harm (whether sane or insane — insane is not applicable for MO and MT), or participation in a felony — whether or not charged. (In IA, only if charged, in NV, only if convicted. In OR, whether or not charged does not apply.) In MD, the exclusions for participation in a riot or felony do not apply.
  18. Any dental service which would be free of charge without insurance, unless provided by Medicaid, the Veterans Administration, or the Maryland Department of Health and Mental Hygiene for non-service related dental services and which by law we are required to pay.
  19. Any dental service provided by a family member or by someone who ordinarily resides with you or your covered dependent. Not applicable in TX; In NE and NJ, must be immediate family member.
  20. Any dental service received outside of the United States, except for a dental emergency.
  21. Jaw or joint problems or malposition of jaw bones, except as provided for under the policy (does not apply in MN).
  22. Any dental service relating to teeth that can be restored by other means; for purposes of periodontal splinting; to correct abrasion, erosion, attrition, bruxism, abfraction, or for desensitization; or teeth that are not periodontally sound or have a questionable prognosis.
  23. Orthodontia or braces
    This is especially important for anyone in need of braces.

  24. Oral surgery, except as expressly provided for in the policy.
  25. Cosmetic dentistry, or dental implants.
  26. Orthognathic surgery, changing vertical dimension, restoring occlusion, bite analysis, or congenital malformation.
  27. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.
  28. Treatment of malignant or benign neoplasms, cysts, or other pathology, except excisional removal.
  29. Mouthguards, precision or semi-precision attachments, occlusal guard, replacement of orthodontic retainers, treatment splints, bruxism appliance, duplicate dentures, harmful habit appliances, replacement of lost or stolen appliances, sleep disorder appliance, and gold foil restorations (except as provided for in the policy).
Updated 09/30/2016

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