Platinum Plan

EXCEPTIONS, REDUCTIONS, AND LIMITATIONS OF THE POLICY:

LIMITATIONS:
Dental Expenses will not include, and benefits will not be payable, for any of the following.

1. Covered Dental Expenses for Type 3 Procedures in the first 6 months the person is covered under this contract unless you qualify for Takeover benefits as defined. 
   
2. Covered Dental Expenses in the first 12 months that a person is insured if the person is a Late Entrant; except for evaluations, prophylaxis (cleanings), and fluoride application.
3. Covered Dental Expenses for initial placement of any prosthetic crown, appliance, or fixed partial denture unless such placement is needed because of the extraction of one or more teeth while the insured person is covered under this contract.  But the extraction of a third molar (wisdom tooth) will not qualify under the above.  Any such prosthetic crown, appliance, or fixed partial denture must include the replacement of the extracted tooth or teeth..
4. Covered Dental Expenses for appliances, restorations, or procedures to do any of the following.
1. Alter vertical dimension.
2. Restore or maintain occlusion.
3. Splint or replace tooth structure lost as a result of abrasion or attrition.
5. Covered Dental Expenses for any procedure begun after the insured person's insurance under this contract terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the Insured's insurance under this contract terminates.
6. Covered Dental Expenses to replace lost or stolen appliances.
7. Covered Dental Expenses for any treatment which is for cosmetic purposes.
8. Covered Dental Expenses for any procedure not shown in the Table of Dental Procedures.  (Frequency and other limitations may apply.  Please see the Table of Dental Procedures for details.)
9. Covered Dental Expenses for orthodontic treatment unless orthodontic expense benefits have been included in this policy.  Please refer to the Schedule of Benefits and Orthodontic Expense Benefits provision.
10. Covered Dental Expenses for which the Insured person is entitled to benefits under any workers' compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of  employment.
11. Covered Dental Expenses for charges which the Insured person is not liable or which would not have been made had no insurance been in force, except for those benefits paid under Medicaid.
12. Covered Dental Expenses for services that are not required for necessary care and treatment or are not within the generally accepted parameters of care.
13. Covered Dental Expenses because of war or any act of war, declared or not.

LIMITATIONS:
Covered Expenses for Orthodontics will not include and benefits will not be payable for expenses incurred:

1. for a Program begun on or after the Insured's 17th birthday.
2. for a Program begun before the Insured became covered under this section.
3. in the first 12 months that a person is insured if the person is a Late Entrant.
4. before the Insured has been insured under this section for at least 12 consecutive months.
   
5. if the Insured's insurance under this section terminates.
6. for which the Insured is entitled to benefits under any workers' compensation or similar law, or for charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit.
7. for charges the Insured is not legally required to pay or would not have been made had no insurance been in force.
8. for services not required for necessary care and treatment or not within the generally accepted parameters of care.
9. because of war or any act of war, declared or not.
10. to replace lost or stolen appliances.

LIMITATIONS:
Covered Expenses for EyeCare Insurance will not include and no benefits will be payable for expenses incurred for:

1. Examinations performed or frames or lenses ordered before the Insured was covered under this section.
2. Any examination performed or frame or lens ordered after the Insured's coverage under this section ceases, subject to Extension of Benefits.
3. Sub-normal vision aids; orthoptic or vision training or any associated testing.
4. Non-prescription lenses.
5. Replacement or repair of lost or broken lenses or frames except at normal intervals.
6. Any eye examination or corrective eyewear required by an employer as a condition of employment.
7. Medical or surgical treatment of the eyes.
8. Any service or supply not shown on the Schedule of Eye Care Services.
9. Coated lenses; oversize lenses (exceeding 71 mm); photo-gray lenses; polished edges; UV-400 coating and facets, and tints other than solid.

LIMITATIONS:
Covered Expenses for Hearing Care Benefits will not include and no benefits will be payable for expenses incurred for:

1. examinations performed or supplies furnished before the Insured was covered under this section.
2. any examination performed or supply furnished after the Insured's coverage under this section ceases.
3. any hearing examination or supply required by an employer as a condition of employment, including but not limited to, any mandatory worksite programs designed to satisfy OSHA hearing conservation programs.
4. medical or surgical treatment of any part of the ear, including but not limited to, cochlear implants, or tubes in the ears.
5. which the Insured person is entitled to benefits under any workers' compensation or similar law, or charges for services or supplies received as a result of any hearing loss caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit, including an occupational hearing loss.
6. charges for which the Insured person is not liable or which would not have been made had no insurance been in force.
7. any procedure not shown in the Schedule of Hearing Care Services.
8. any treatment which is for cosmetic purposes.
9. assistive hearing devices not listed in the Schedule of Hearing Care Services, such as phone amplification, cellular phone amplifier, hearing aid dehumidifier, loop system, etc.
10. charges for services not provided by a licensed provider, such as an audiologist, hearing aid specialist, otolaryngologist (ENT) or otologist (ear doctor), within the scope of that license.
11. services or supplies which are not related to a conductive or sensorineural hearing loss, such as any nonorganic hearing loss or occupational hearing loss.
12. charges for a hearing screening performed as a part of or in the course of any non-hearing routine examination.
13. a hearing aid dispensed without the direction and supervision of a provider licensed to perform hearing aid examinations and/or hearing aid dispensing.
14. because of war or any act of war, declared or not.
15. removal of foreign bodies or ear wax from the ear or any part of the ear.

LIMITATIONS:
For Laser Vision:

• No benefit will be payable for any HCPCS Level II codes not listed below in the definition of Covered Procedures.
• No benefit will be payable for any Insured under the age of 18.
• No benefit will be payable in the first 12 months that a person is insured if the person is a Late Entrant.  After this 12 month waiting period, the Maximum Amount Payable per Insured Person will begin at the 1st Benefit Period as shown in the schedule.
• Each Insured Person is eligible for only one Covered Procedure benefit payment per eye.  No benefit will be payable for multiple laser vision correction treatments on the same eye.
  

Please note:  This listing of exclusions and limitations may vary by state.  Please refer to the policy for the most complete listing of exclusions and limitations by state.