SCHEDULE OF BENEFITS - DENTAL (ACTIVE PARTICIPANTS ONLY)

Exclusions and Limitations:

• Dental services that are not necessary.
• Hospitalization or other facility charges.
• Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance).
• Any procedure not performed in a dental setting.
• Procedures that are considered to be Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.
• Services for injuries or conditions covered by Worker’s Compensation, Jones Act or other employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.
• Dental services otherwise covered, but rendered after the date eligibility terminates, including Dental services for dental conditions arising prior to the date eligibility terminates.
• Services rendered by a provider with the same legal residence as the participant or dependent or who is a member of participant’s or dependent’s family, including spouse, brother, sister, parent or child.
• Services related to the temporomandibular joint (TMJ), either bilateral or unilateral, upper and lower jaw bone surgery (including that related to the temporomandibular joint).
• Acupuncture, acupressure and other forms of alternative treatment.
• Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.
• Charges for failure to keep a scheduled appointment.
• Services performed by anyone other than by a legally qualified dentist or physician who is recognized by the law of the State in which treatment is received as qualified to treat the type of sickness or injury causing the expenses, or loss, for which claim is made. This exclusion does not apply when scaling or cleaning of teeth and topical application of fluoride is performed by a licensed dental hygienist if the treatment is rendered under the supervision and guidance of and billed for by the dentist;
• Dental work resulting from accidental injury.
• Services covered under Medical Benefits.
• Expenses in excess of the maximum benefits provided in Schedule of Dental Benefits.