VIRGINIA
PLAN LIMITATIONS.The following exclusions and limitations shall apply:
Services for injuries and conditions which are covered under Workers’ CompensationorEmployers’LiabilityLaws;
Services which are provided without cost to the Covered Individual and/or Dependent(s) by any municipality,county or otherpolitical subdivision (withthe exceptionof Medicaid);
Services which, in the opinion of the Participating DENTIST, are not necessary for the Covered Individual and/or Dependent(s) health;
Payment of any claim or bill will not be made for prohibited referrals; Cosmetic, elective, or aesthetic dentistry, which in the opinion of the Participating DENTIST are not necessary for the patient’s dental health; Oral surgery requiring the setting of fractures or dislocations; Services with respect to malignancies, cystsorneoplasms, or hereditary, congenital or developmental malformations; Dispensing of drugs, except those used as a localanesthetic; Hospitalization for any dental procedure; Loss or theft of bridgework or dentures previously supplied under the PLAN; Replacement of a bridge, crown, or denture within five (5) years after the date it was originally installed;
Any implantation; General anesthesia; Services that cannot be performed because of the general health of the patient; Teeth Cleaning (Prophylaxis) limited to twice per Coverage Period; Unlisted procedures will be provided at the dentist’s charge; Services which are obtained outside the dental office in which enrolled and
which are not pre-authorized by the PLAN. This does not apply to out-of-area emergency dental services;
Services rendered by a Pedodontist (PediatricDentist) are considered Specialty Care and must be approved by the Covered Individual and / or Dependent(‘s) Personal Participating DENTIST; all services listed on the Schedule of Benefits and Copayments will be provided by a general Participating DENTIST or an Approved Specialist ; provided, however, that a general DENTIST will refer the Covered Individual or Dependent to an Approved Specialist or recommend that the Covered Individual or Dependent contact an Approved Specialist if it is the judgment of the DENTIST that the service or procedure must be provided by an Approved Specialist, with an exception for out-of-area emergencycare, and a referral to a non-participating general dentist or specialist;
Services which cannot be performed in the dental office of the “Personal Participating DENTIST ”or“ Approved Specialist” due to the special needs or health related conditions of the Covered Individual and/or Dependent(s).
OUT-OF-AREA EMERGENCY CARE: Covered Individuals and/or Dependents are covered for emergency dental treatment to alleviate acutepain, along with treatment arising from accidental injury or illness while temporarily more than fifty (50) miles from their “Personal ParticipatingDENTIST. ”Limited to $50 per Covered Individual or Dependent per emergency, minus member’scopay.
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