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  |      | Dallas     Independent School District Dental Member
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  Texas Dental Plan (TDP) Limitations and Exclusions1
 
 
          | 1Select a service below |       |  |       | SERVICES |       |  |       |  |      |  |  |  |       |  |       |        |  | Limitations and Exclusions |  |       |  |                        | Plan Exclusions and Limitations 
 
             The following exclusions apply:
 
             Member's dental fees apply only when treatment is performed at a             participating dental office.             If the services of a non-participating specialist            or non-participating general dentist are required, these dental fees            do not apply and the patient will be responsible to the non-participating             dentist for his usual, customary and reasonable fee.            | a. | Services for injuries or conditions that are covered under Workman's             Compensation, Employer's Liability Laws, or similar coverage; |              | b. | Services which are provided without cost to the member by any municipality,             county or other political subdivision; |              | c. | Cost of dental care which is covered under automobile, medical, no fault,             or similar type insurance; |              | d. | General anesthesia (put to sleep), I.V. sedation, Nitrous Oxide, and             hospitalization or hospital or medical charges of any kind; and |              | e. | Osseointegrated implants. |  Reduced fees will not be honored if dental treatment is already             in progress or if the patient is no longer covered under the             dental plan.
 Any member accepted for orthodontic treatment must remain a             member of the dental plan for the full duration of their treatment             or risk additional charges from their participating Orthodontist or             General Dentist.
 A patient's existing dental or medical condition may necessitate             extra precautionary procedures and require additional charges.             Please discuss all fees with your dentist prior to treatment.
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