Charlotte County Public Schools

 

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DHMO CS150
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AVF1 — Advantage
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Elite Preferred 710 w/ortho
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Limitations and Exclusions1

1Select a service below
 
SERVICES
bulletAppointments
bulletDiagnostics
bulletPreventive Care
bulletRestorative
bulletResin Restoration
bulletCrown & Bridge
bulletEndodontics
bulletPeriodontics
bulletProsthodontics
bulletRepairs to Prosthetics
bulletProsthodontics (Fixed)
bulletExtractions
bulletOrthodontics
bulletAdjunctive General Service
 

Limitations and Exclusions
 
  1. No service of any dentist other than a Participating General Dentist or Participating Specialist will be covered by Company, except out-of-area emergency care as provided in Section VIII, Paragraph C of the Certificate.
  2. Whenever any Contributions or Co-payments are delinquent, Member will not be entitled to receive Benefits, transfer Dental Facilities, or enjoy any of the other privileges of a Member in good standing.
  3. Company does not provide coverage for the following services:
a.    Cost of hospitalization and pharmaceuticals, drugs or medications.
 
b.    Services which in the opinion of the Participating General Dentist or Participating Specialist are not Necessary Treatment to establish and/or maintain the Member's oral health.
 
c.    Any service that is not consistent with the normal and/or usual services provided by the Participating General Dentist or Participating Specialist or which in the opinion of the Participating General Dentist or Participating Specialist would endanger the health of the Member.
 
d.    Any service or procedure which the Participating General Dentist or Participating Specialist is unable to perform because of the general health or physical limitations of the Member.
 
e.    Any dental treatment started prior to the Member's effective date for eligibility of benefits.
 
f.    Services for injuries and conditions which are paid or payable under Workers' Compensation or Employers' Liability laws.
 
g.    Treatment for cysts, neoplasms and malignancies.
 
h.    General anesthesia.