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These Exclusions Are For The Following Madison Dental Plans

(This Includes Indemnity and PPO's)

1. Treatment, services or supplies which:
   • A. Are not Medically Necessary;
   • B. Are not prescribed by a Dentist;
   • C. Are determined to be Experimental/Investigational in nature by Us;
   • D. Are received without charge or legal obligation to pay;
   • E. Would not routinely be paid in the absence of insurance;
   • F. Are received from any Family Member;
   • G. Are not Covered Procedures.
2. Self inflicted injuries.
3. War or an act of war, whether or not declared.
4. A Covered Person's commission of a felony or an assault on another person.
5. Riot, nuclear accident, or a major disaster.
6. Employment; whether caused by, related to, or as a condition of employment, including self employment. This exclusion applies even if Workers' Compensation or any Occupational Disease or similar law does not cover the charges.
   Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.


7. Treatment which began, before the Covered Person's Effective Date of coverage or after the Covered Person's termination of coverage.
8. Congenital or development malformations existing on the Covered Person's effective date as shown on the Schedule of Benefits.
9. Cosmetic procedures, unless the coverage is elected by the Insured Person and the required premium is paid.
10. Implants of any type, and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments, unless the coverage is elected by the Insured Person and the required premium is paid.
11. Periodontal splinting.
12. Porcelain on crowns, or pontics posterior to the 2nd bicuspid.
13. Replacement of partial or full dentures, fixed bridge work, crowns, gold restorations and jackets more often than once in any 5 year period.
14. Relining of dentures more often than once in any 2 year period.
15. Lost, stolen, or missing dentures or bridges or for duplicates.
16. Fixed or removable bridgework involving replacement of a natural tooth or teeth which was lost prior to the Covered Persons Effective Date of coverage as shown on the Schedule of Benefits. Benefits may be payable for bridgework required for loss of teeth while covered under the Policy, if such bridgework is not an abutment for non covered bridgework.
    Unless you have a tooth extracted while insured by this company, there is no benefit for any prosthetic appliance (dentures or partials) or fixed partial denture (bridges).


17. Prescription Drugs and analgesia pre medication.
18. Telephone consultations, failure to keep a scheduled appointment, to complete claim forms or attending Dentist statements, and any other services or supplies which are not part of the direct treatment of the Covered Person.
19. Dental education or training programs including oral hygiene or plaque control programs.
20. Counseling on diet and nutrition.
21. Military service, including service in a military reserve unit.
22. Orthodontia, unless this coverage is elected by the Insured Person and the required premium is paid.
    This is especially important for anyone in need of braces.


23. Prosthodontics, unless this coverage is elected by the Insured Person and the required premium is paid.
24. Charges payable under any medical insurance.
25. Charges made by any government entity unless the Covered Person is required to pay; or by any public entity from which coverage could have been obtained by application or enrollment even if application or enrollment was not actually made.
26. Use of materials, other than fluorides or sealants, to prevent tooth decay.
27. Bite registrations.
28. Bacteriologic cultures in connection with a covered dental service.
29. Therapeutic injections administered by a Dentist.
30. Cast restorations, inlays, onlays and crowns for teeth that are not broken down by extensive decay or accidental injury or for teeth that can be restored by other means (such as an amalgam or composite filling).
31. Replacement of 3rd molars.
32. Composites on teeth posterior to the 2nd bicuspid.
33. Crowns, inlays and onlays used to restore teeth with micro fractures or fracture lines, undermined cusps, or existing large restorations without overt pathology.
34. Temporomandibular joint syndrome.