Limitations and Exclusions
The benefits described in this Dental Blue Freedom Benefit Description are limited or excluded as follows.
Multi-Stage Dental Procedures
Your dental benefits for procedures that require more than one visit (for example, root canals and crowns) will be provided as long as you are enrolled for benefits under Dental Blue Freedom on the date the procedure is completed. This means that you do not have to be enrolled under Dental Blue Freedom on the date the procedure is started in order to receive benefits for the covered service. However, if your membership under Dental Blue Freedom is terminated prior to the completion date of the procedure, no benefits are provided for the entire procedure. (If you have an Orthodontic Endorsement that provides supplemental coverage for orthodontic services, this provision does not apply to those orthodontic services.)
Non-Covered Dental Services
No benefits are provided by Dental Blue Freedom for:
- Services, supplies, procedures or appliances to treat an illness or injury for which you have the right to benefits under government programs. These include the Veterans Administration for an illness or injury connected to military service. They also include programs set up by other local, state, federal or foreign laws or regulations that provide or pay for health care services and supplies or that require care or treatment to be furnished in a public facility. No benefits are provided if you could have received governmental benefits by applying for them on time. This exclusion does not include Medicaid or Medicare.
- Charges that are received for or related to dental care that Blue Cross and Blue Shield considers to be experimental. The care must be documented by controlled studies that determine its merits (such as its safety) and include sufficient follow-up studies.
- Charges for appointments that you do not keep. Dentists may charge you for failing to keep your scheduled appointments. They may do so if you do not give reasonable notice to the office. Appointments that you do not keep are not counted against any benefit limits described in this Dental Blue Freedom Benefit Description.
- A service, supply, procedure or appliance that is not described as a covered dental service in this Dental Blue Freedom Benefit Description.
- Orthodontic services unless your group has purchased an Orthodontic Endorsement to provide supplemental coverage to help pay for these services.
- Services, supplies, procedures or appliances that do not conform to Blue Cross and Blue Shield dental policy guidelines.
- Any service or supply furnished along with, in preparation for, or as a result of a non-covered dental service.
- Services, supplies, procedures and appliances that are not considered necessary and appropriate by Blue Cross and Blue Shield.
- A method of treatment more costly than is customarily provided. If Blue Cross and Blue Shield determines that your treatment is more costly than another acceptable alternative treatment, Dental Blue Freedom will provide benefits for the least expensive but acceptable alternative treatment that meets your needs. (In this case, you pay any balance.)
- Services, supplies, procedures and appliances that are furnished to someone other than the patient.
- Treatment and related services that are required by third parties.
- Free care or care for which you are not required to pay or for which you would not be required to pay if you were not covered under Dental Blue Freedom.
- A service rendered by someone other than a licensed dentist or hygienist who is employed by the dentist.
- Nutrition counseling or instructions in dental hygiene, including proper methods of tooth brushing, the use of dental floss, plaque control programs and caries (cavity) susceptibility tests.
- Incomplete procedures.
- Laboratory or bacteriological tests.
- Consultations when the dentist who renders the consultation provides treatment.
- Restorations for reasons other than decay or fracture of teeth, such as erosion, abrasion or attrition.
- Sealants applied to permanent premolar or molar surfaces that have decay or fillings.
- Fillings on tooth surfaces where a sealant was applied within the last 12 months.
- Replacement of a filling within 12 months of the date of the prior restoration.
- Labial veneers.
- Stainless steel crowns on permanent (adult) teeth, other than on first permanent (adult) molars for members under age 16.
- Fixed or removable prosthodontics or major restorative procedures for members under age 16. (Dental Blue Freedom provides the benefit for a temporary partial denture for replacement of a lost or missing tooth. You pay any balance.)
- Temporary complete dentures or temporary fixed bridges.
- Replacement of dentures, bridges or space maintainers for reasons such as theft, abuse, misuse, misplacement, loss, improper fit, allergies, breakage or ingestion.
- Duplicate dentures or bridges.
- Transplants or any related surgical or restorative procedures.
- Any procedure to save a tooth when there is a poor statistical probability (less than a 70% chance) that the tooth will last for 60 months (for example, surgical periodontal regenerative procedures to stabilize a tooth loosened due to extensive periodontal disease).
- Services, supplies, procedures or appliances to stabilize teeth when required due to periodontal disease (periodontal splinting).
- Cast restorations, copings or attachments for installing overdentures, including associated endodontic procedures such as root canals.
- Precision attachments, semiprecision attachments or copings.
- A service to diagnose or treat temporomandibular joint (TMJ) disorders or myofascial (muscular) pain, including bruxism (grinding of the teeth).
- A service, supply or procedure when its sole purpose is to increase the height of teeth (vertical dimension) or to restore occlusion.
- Athletic mouth guards
- Occlusal guards.
- A separate charge for occlusal analysis, pulp vitality testing or pulp capping since these services are usually performed as part of another covered procedure.
- Services and supplies that are cosmetic in nature or meant primarily to change or improve your appearance.
- Services and supplies for the treatment of congenital anomalies, except for covered orthodontic services when you have an Orthodontic Endorsement that provides supplemental coverage for orthodontic services.
- Drugs, pharmaceuticals, biologicals or other prescription agents or products.
- Analgesia (nitrous oxide) or sedation.
- A dentist’s charge for shipping and handling or taxes.
- A dentist’s charge to file a claim. Also, a dentist’s charge to transcribe or copy your dental records.
- Services and supplies furnished before your effective date, except for a multi-stage procedure that begins before your effective date and is completed date while you are enrolled under Dental Blue Freedom. See “Multi-Stage Dental Procedures” above.
- Services and supplies furnished after your termination date under Dental Blue Freedom. (If your membership under Dental Blue Freedom is terminated prior to the completion date of a procedure that requires more than one visit, no benefits are provided for the entire procedure. See “Multi-Stage Dental Procedures” above.)
- Services and supplies furnished by a dentist to himself or herself or to a member of his or her immediate family. “Immediate family” means any of the following members of a dentist’s family: spouse or spousal equivalent; parent, child, brother or sister (by birth or adoption); stepparent, stepchild, stepbrother or stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law or sister-in-law (for purposes of providing covered dental services, an in-law relationship does not exist between the dentist and the spouse of his or her wife’s (or husband’s) brother or sister); and grandparent or grandchild. For the purposes of this exclusion, the immediate family members listed above will still be considered immediate family after the marriage which created the relationship is ended (by divorce or death).