Dental

What Is Not Covered

It is important to understand what your plan covers and how much of your benefits it will pay.

The following is a list of exclusions and limitations under your dental plan. Please refer to the actual plan documents or contact the Employee Benefits Office for more details on limitations and exclusions:

• Services that are not considered reasonable and customary
• Services for care, treatment or supplies that are not prescribed, recommended or approved by an attending physician or dentist
• Routine dental exams or other preventive services and supplies
• Services or supplies determined by Aetna to be experimental or investigational
• Services performed by or for the government unless payment of the charge is required by law
• Services that would have been covered by the government, except for Medicaid
• Services for plastic surgery, reconstructive surgery, cosmetic surgery or other services and supplies which improve, alter or enhance appearance; except to the extent needed to repair an injury suffered while you are covered
• Appliances, services, or supplies ordered while you were not covered
• Services for acupuncture therapy except when it is performed by a physician as a form of anesthesia in connection with covered surgery
• Injuries or diseases covered by workers’ compensation or other occupational laws
• Charges for treatment that is deemed not medically necessary
• Any charge above the copayment percentage based on usual and customary charges. Where benefits are based on a schedule, the dental plans do not pay any amount that exceeds the scheduled benefits.