Limitations & Exclusions

The following applies to Safeguard’s Managed Care Dental Plans.

Limitations

These limitations are applicable to this Plan:

1. Dentures:  (full or partial): Dentures or appliances will be replaced only after 3 years have elapsed following any prior provision of such dentures or appliances under any SafeGuard Benefit Plan.  Replacements will be made only if the existing denture or appliance is unsatisfactory and cannot be made satisfactory.
2. Denture Relines:  Twice a year.
3. Prophylaxis:  Once every six months.
4. Full mouth x-rays:  Once initially and thereafter when diagnostically necessary.
5. Fluoride Treatment:  Once every 6 months to age 18.
6. Reimbursement shall not be made for the cost of services secured from any other health care provider other than the Member’s Dentist, unless authorized in writing by SafeGuard prior to the receipt of such services.
7. Crowns or replacement of missing teeth with complete or partial dentures or fixed bridges are provided using standard procedures.
8. An additional fee of $75 will be charged for Porcelain on any molar crown or pontic.

Exclusions

These procedures and services are not included in the Plan:

1. Any treatment requested, or appliances made, which are either not necessary for maintaining or improving dental health, or are for cosmetic purposes unless otherwise covered as a benefit.
2. Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, including prescriptions and medications not normally supplied or dispensed by a dental office.
3. General anesthesia and/or intravenous sedation.
4. Replacement of lost or stolen dentures, crowns, appliances or bridgework.
5. Treatment of malignancies, cysts and neoplasms.
6. Procedures, appliances, or restorations to correct congenital, developmental or medically induced dental disorders, including, but not limited to, treatment of myofunctional, myoskeletal, or temporomandibular joint dysfunctions unless otherwise covered as an orthodontic benefit.
7. Implants.
8. Dental treatment started prior to the Member’s eligibility under this Benefit Plan, or started after a Member’s termination from the Plan.
9. Any dental procedure unable to be performed in the dental office due to the general health or physical limits of the Member, including, but not limited to, physical or emotional resistance, inability to visit the dental office, or allergy to all commonly utilized local anesthetics.
10. Complex or full mouth rehabilitation consisting of 10 or more posterior crown and/or fixed bridge units in the same treatment plan.
11. Any procedure not specifically listed as a covered benefit may be available on a fee-for-service basis.

Orthodontic Limitations and Exclusions

Orthodontic treatment is subject to the following:

1. Orthodontic treatment must be provided by a participating SafeGuard B Plan benefits shall cover 24 months of active, usual and customary orthodontic treatment and an additional 24 months of retention.  Treatment that extends beyond such time periods will be subject to a per-office-visit charge of $25.00.
2. The following are not included as orthodontic benefits:
1. Diagnostic Records:
   1. Cephalometric X-rays and other X-rays, if needed;
   2. Diagnostic tracings of cephalometric
   X-rays;
   3. Photographs; and
   4. Study models.
2. Replacement or repair of lost or broken appliances;
3. Retreatment of orthodontic cases;
4. Treatment in progress at inception of eligibility;
5. Changes in treatment necessitated by an accident;
6. Orthodontic treatment that involves:
   1. Maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia;
   2. Surgically exposing impacted teeth (i.e. maxillary cuspids);
   3. Hormonal imbalances or other factors causing growth and developmental abnormalities;
   4. Treatment related to temporomandibular joint disturbances;
   5. Lingually placed direct bonded appliances and arch wires — "invisible braces";
   6. Functional appliances that are used in conjunction with fixed appliances;
   7. First phase treatment, defined as any orthodontic treatment that occurs while deciduous (primary or baby) teeth are still in the mouth.
3. Should a member or client terminate from the Plan for any reason and at that time be receiving orthodontic treatment, the Member and not SafeGuard shall be responsible for payment of the balance due for any orthodontic treatment performed after termination. The member’s payment shall be increased by an additional $400 above the member’s copayment and excluding any charges for diagnostic records, shall be prorated over the number of months to completion of active treatment, and be payable on such terms and conditions as are arranged between the Member and the orthodontist.
4. The retention phase of treatment, if required, shall include the construction, placement and adjustment of retainers, the maximum cost of which shall not exceed $250.00.
5. If a member does not require treatment or chooses not to start treatment after the participating SafeGuard orthodontist has completed a diagnosis and consultation, the Member will be charged a consultation fee of $25.00 in addition to the fees for such diagnostic records.