Exclusion of Benefits

1. Any procedure that is not specifically listed under Schedule A, Description of Benefits and Co-payments;
   
2. Dental conditions arising out of and due to Enrollee's employment for which Worker's Compensation is paid.  Services that are provided to the Enrollee by state government or agency thereof, or are provided without cost to the Enrollee by any municipality, county or other subdivision, except as provided in Section 1373(a) of the California Health and Safety Code;
   
3. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility;
   
4. Loss or theft of full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges);
   
5. Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage;
   
6. Dental expenses incurred in connection with any dental procedure started before the Enrollee's eligibility with the DeltaCare program.  Examples include: teeth prepared for crowns, root canals in progress, orthodontics;
   
7. 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;
   
8. Dispensing of drugs not normally supplied in a dental facility;
   
9. Any procedure that in the professional opinion of the Contract Dentist or PMI’s dental consultant:
1. has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or
2. is inconsistent with generally accepted standards for dentistry;
   
10. Dental services received from any dental facility other than the assigned Contract Dentist including the services of a dental specialist, unless expressly authorized in writing by PMI or as cited under Section 4.04.  To obtain written authorization, the Enrollee should call PMI’s Customer Relations department at (800) 422-4234;
    
11. Consultations for non-covered benefits;
    
12. Implant placement or removal, appliances placed on or services associated with implants, including but not limited to prophylaxis and periodontal treatment;
    
13. Porcelain crowns, porcelain fused to metal or resin with metal type crowns and fixed partial dentures (bridges) for children under 16 years of age;
    
14. Restorations placed solely due to cosmetics, abrasions, attrition, erosion, restoring or altering vertical dimension, congenital or developmental malformation of teeth;
    
15. 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);
    
16. 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 program.  Crowns, onlays and fixed partial dentures associated with such a treatment plan are not covered benefits.  This exclusion does not eliminate the benefit for other covered services;
    
17. 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;
    
18. 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;
    
19. Treatment or extraction of primary teeth when exfoliation (normal shedding and loss) is imminent.

Orthodontic Limitations

The DeltaCare program provides coverage for orthodontic treatment plans provided through PMI’s Contract Orthodontists.  The start-up fees and the cost to the Enrollee for the treatment plan are listed in Schedule A, Description of Benefits and Copayments and subject to the following:

1. Orthodontic treatment must be provided by the Contract Orthodontist;
   
2. Benefits cover 24 months of active comprehensive orthodontic treatment.  Included is the initial examination, diagnosis, consultation, initial banding, 24 months of active treatment, de-banding and the retention phase of treatment.  The retention phase includes the initial construction, placement and adjustment to retainers and office visits for a maximum of two years;
   
3. Treatment plans extending beyond 24 months of active treatment, or 24 months of the retention phase of treatment will be subject to a monthly office visit fee to the Enrollee not to exceed $75.00 per month;
   
4. Should an Enrollee's coverage be cancelled or terminated for any reason, and at the time of cancellation or termination be receiving any orthodontic treatment, the Enrollee and not PMI will be responsible for payment of any balance due for treatment provided after cancellation or termination.  In such a case the Enrollee's payment shall be based on a maximum of $2,800.00 for covered dependent children to age 19 and $3,000.00 for covered adults and dependent children to age 23.  The amount will be prorated over the number of months to completion of the treatment and, will be payable by the Enrollee on such terms and conditions as are arranged between the Enrollee and the Contract Orthodontist;
   
5. If treatment is not required or the Enrollee chooses not to start treatment after the diagnosis and consultation has been completed by the Contract Orthodontist, the Enrollee will be charged a consultation fee of $25.00 in addition to diagnostic record fees;
   
6. Three re-cementations or replacements of a bracket/band on the same tooth or a total of five re-bracketings/re-bandings on different teeth during the covered course of treatment are benefits.  If any additional re-cementations or replacements of brackets/bands are performed, the Enrollee is responsible for the cost at the Contract Orthodontist’s usual and customary fee;
   
7. Comprehensive orthodontic treatment (Phase II) consists of repositioning all or nearly all of the permanent teeth in an effort to make the Enrollee’s occlusion as ideal as possible.  This treatment usually requires complete fixed appliances; however, when the Contract Orthodontist deems it suitable, a European or removable appliance therapy may be substituted at the same copayment amounts as for fixed appliances.

Orthodontic Exclusions

1. Pre-, mid- and post-treatment records which include cephalometric x-rays, tracings, photographs and study models;
   
2. Lost, stolen or broken orthodontic appliances;
   
3. Re-treatment of orthodontic cases;
   
4. Changes in treatment necessitated by accident of any kind;
   
5. Initial or continuing orthodontic treatment when such treatment would be inconsistent with generally accepted professional standards;
   
6. Surgical procedures incidental to orthodontic treatment;
   
7. Myofunctional therapy;
   
8. Surgical procedures related to cleft palate, micrognathia, or macrognathia;
   
9. Treatment related to temporomandibular joint disturbances;
   
10. Supplemental appliances not routinely used in typical comprehensive orthodontics;
    
11. Restorative work caused by orthodontic treatment;
    
12. Phase I orthodontics¹³, as well as activator appliances and minor treatment for tooth guidance and/or arch expansion;
    
13. Extractions solely for the purpose of orthodontics;
    
14. Treatment in progress at inception of eligibility;
    
15. Composite bands, lingual adaptation of orthodontic bands, and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances.
    
16. Phase I orthodontics is defined as early treatment including interceptive orthodontia prior to the development of late mixed dentition.