 |
 |
 |
 |
 |
 |
 |
 |
|
|
|
|
|
|
 |
|
|
 |
|
|
 |
 |
|
|
|
 |
Summary Plan Description (SPD)
Limitations on Covered Services
Listed below are limitations on services covered by the Dental Plan:
- Frequency - The frequency of certain covered services, such as cleanings, is limited. The Patient Charge Schedule lists any limitations on frequency.
- Specialty Care - Payment authorization is required for coverage of services by a Network Specialist.
- Oral Surgery - The surgical removal of an impacted wisdom tooth is not covered if the tooth is not diseased or if the removal is only for orthodontic reasons.