Small Group Dental Plans Limitations & Exclusions

We will not furnish benefits for:

Excess amounts: Any amounts in excess of the maximum amounts stated in the Maximum Benefits section.
Covered expense: Any amounts which exceed the covered expense as determined by UniCare.
Customary and reasonable charge: Any amounts which exceed the customary and reasonable charge as determined by UniCare.
Experimental or investigative procedures: Services or supplies that we consider to be experimental or investigative.
Expenses before coverage begins: Services received before your effective date.
End of coverage: Services received after your coverage ends, except as specifically stated under Extension of Benefits.
Services for which you are not legally obligated to pay: Services for which no charge would be made to you in the absence of insurance coverage.
Workers’ compensation: Any condition for which benefits could be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if you donot claim those benefits.
War: Diseases contracted or injuries sustained as result of war declared or undeclared, conditions caused by the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy.
Government services: Any services provided by a local, state, county or federal government agency including any foreign government.
Services from relatives: Professional services received from a person who lives in the insured person’s home or who is related to the insured person by blood or marriage.
Cosmetic dentistry: Any services performed for cosmetic purposes are not covered under this plan, unless they are for the correction of functional disorders or as a result of an accidental injury occurring while you were covered under this plan.
Charges for treatment by other than a licensed dentist or physician, except charges for dental prophylaxis performed by a licensed dental hygienist, under the supervision and direction of a dentist.
Replacement of an existing prosthesis which has been lost or stolen; or which in the opinion of the dentist is or can be made satisfactory.
Replacement of a fixed or removable prosthesis if such replacement occurs within five years of the original placement, unless the denture is a stayplate used during the healing period for recently extracted anterior teeth.
Diagnosis or treatment of the joint of the jaw and/or occlusion (the way upper and lower teeth meet) services, supplies or appliances provided in connection with: 1) any treatment to alter, correct, fix, improve, remove, replace, reposition, restore or otherwise treat the joint of the jaw (temporomandibular joint) or associated musculature, nerves and other tissues for any reason or by any means; or 2)any treatment, including crowns, caps and/or bridges to change the way the upper and lower teeth meet (occlusion); or 3) treatment to change vertical dimension (the space between the upper and lower jaw) for any reason or by any means including the restoration of vertical dimension because teeth have worn down.
Procedures requiring appliances or restorations (other than those for replacement of structureloss from caries) that are necessary to alter, restore or maintain occlusions. These include but are not limited to: 1) changing the vertical dimension; 2) replacing or stabilizing lost tooth structure by attrition, abrasion, or erosion; 3) realignment of teeth; 4) gnathological recording; 5) occlusal equilibration; 6) periodontal splinting.
Services not included as a covered procedure, unless they are similar in nature to an included procedure; in such event the benefit payable will be based on the most nearly comparable services included.
Oral examinations exceeding two per insured person per year.
Sealants: Sealants are limited to one treatment every 36 months per insured person per tooth for children under 15 years of age for permanent first and second molars, unrestored.
Fluoride applications are limited to once per insured person per calendar year up to the age of 18.
Prophylaxis treatments, exceeding two treatments per insured person per year.
More than one set of full-mouth x-rays or its equivalent in a three year period per insured person.
Correction of congenital or development malformation for an insured person, including but not limited to: cleft palate, maxillary or mandibular(upper and lower jaw) malformations, enamel hypoplasia (lack of development),fluorosis (a type of discoloration of the teeth), and anodontia (congenitally missing teeth).
Adjustment, repairs or relines to prostheses for a period of six months from initial placement.
Fixed bridges, removable cast partials and/or cast crown with or without veneers and inlays for patients under sixteen years of age.
Replacement of crowns and cast restorations including porcelain inlays and porcelain crowns, if such replacement occurs within five years of the original placement.
Transfer of care: If an insured person transfers from the care of one dentist to that of another dentist during the course of treatment, or if more than one dentist renders services for one dental procedure, UniCare shall be liable only for the amount it would have been liable for had one dentist rendered the services.
Prescribed drugs, pre-medication or analgesia.
Oral hygiene instruction.
Malignancies and neoplasms: Services for treatment of malignancies and neoplasms are not covered services.
Implants (materials implanted into or on bone or soft tissue) or the removal of implants are not benefits under this certificate. However, if implants are provided in association with a covered prosthetic appliance, UniCare will allow the benefit for a standard complete or partial denture or a bridge toward the cost of implants and the prosthetic appliances.
Services or supplies that are not medically necessary: Medically necessary services or supplies are those UniCare determines to be appropriate and necessary for the symptoms, diagnosis or treatment of the dental condition, and within standards of good dental practice within the organized dental community.
Replacement of teeth missing prior to the effective date of coverage.