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| SCHEDULE B - EXCLUSIONS OF BENEFITS |
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- All procedures not shown in Schedule A, Description of Benefits and Copayments.
- Dental conditions arising out of and due to Enrollee's employment for which Workers' Compensation is paid. Services that are provided to you by state government or agency thereof, or are provided without cost by any municipality, county or other subdivision, except as provided in Section 1373(a) of the California Health and Safety Code.
- All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility.
- Loss or theft of full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges).
- Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage.
- Dental expenses incurred in connection with any dental procedure started before the Enrollee's eligibility with the DeltaCare USA program. Examples include: teeth prepared for crowns, root canals in progress, orthodontics.
- Congenital malformations (e.g. congenitally missing teeth, supernumerary teeth, enamel and dentinal dysplasias, etc.), except for the treatment of newborn children with congenital defects or birth abnormalities.
- Dispensing of drugs not normally supplied in a dental facility.
- Any procedure that in the professional opinion of the Contract Dentist or our dental consultant:
- has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or
- is inconsistent with generally accepted standards for dentistry.
- Dental services received from any dental facility other than the assigned Contract Dentist, including the services of a dental specialist, unless expressly preauthorized in writing by us or as cited under Emergency Services. To obtain written authorization, the Enrollee should call the Customer Service department at (800) 422-4234.
- Consultations for non-covered benefits.
- Implant placement or removal, appliances placed on or services associated with implants, including but not limited to prophylaxis and periodontal treatment.
- Porcelain crowns, porcelain fused to metal or resin with metal type crowns and fixed partial dentures (bridges) for children under 16 years of age.
- Restorations placed solely due to cosmetics, abrasions, attrition, erosion, restoring or altering vertical dimension, congenital or developmental malformation of teeth.
- Appliances or restorations necessary to increase vertical dimension, replace or stabilize tooth structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings, equilibration or treatment of disturbances of the temporomandibular joint (TMJ).
- An initial treatment plan which involves the removal and reestablishment of the occlusal contacts of 10 or more teeth with crowns, onlays, fixed partial dentures (bridges), or any combination of these is considered to be full mouth reconstruction under the DeltaCare USA program. Crowns, onlays and fixed partial dentures associated with such a treatment plan are not covered Benefits. This exclusion does not affect any other Benefits.
- Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures.
- Extraction of teeth, when teeth are asymptomatic/non-pathologic (no signs or symptoms of pathology or infection), including but not limited to the removal of third molars and orthodontic extractions.
- Treatment or extraction of primary teeth when exfoliation (normal shedding and loss) is imminent.
- Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.
- Accidental injury. Accidental injury is defined as damage to the hard and soft tissue of the oral cavity resulting from forces external to the mouth. Damages to the hard and soft tissues of the oral cavity from normal masticatory (chewing) function will be covered at the normal schedule of benefits.
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