In addition to the limitations and exclusions shown in the “Schedule of Benefits” section, Delta Dental does not pay for the following:

1. Treatment of injury or illness covered by Workers' Compensation or employer liability laws.

2. Services received without cost from any federal, state or local agency. This exclusion will not apply if prohibited by law.

3. Cosmetic surgery or procedures for purely cosmetic reasons.

4. Services for congenital (hereditary) or developmental malformations. Such malformations include, but are not limited to, cleft palate or upper and lower jaw malformations. This does not exclude those services provided under Orthodontic benefits, if covered.

5. Treatment to restore tooth structure lost from wear.

6. Treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion or treatment to stabilize the teeth. For example: equilibration, periodontal splinting and double abutments on bridges.

7. Oral hygiene and dietary instructions, treatment for desensitizing teeth, prescribed drugs or other medication, experimental procedures, conscious sedation and extra oral grafts (grafting of tissues from outside the mouth to oral tissues).

8. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the dentist for treatment in any such facility.

9. Diagnosis or treatment for any disturbance of the temporomandibular joints (jaw joints) or myofacial pain dysfunction.

10. Services by a dentist beyond the scope of his or her license.

11. Dental services for which the patient incurs no charge.

12. Dental services where charges for such services exceed the charge that would have been made and actually collected if no coverage existed.

13. Delta Dental will apply the limitations and exclusions of this benefit plan based upon the member’s complete and prior history as reflected in Delta Dental’s records.

In the event a member transfers from one dentist to another during the course of treatment, payment by Delta Dental will be limited to the amount that would have been paid had only one dentist rendered the service.