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These Are The Exclusions For The Metlife Plans

(The Veterans Plan is Dental Indemnity Insurance, the others are PPO's)

MetLife Dental PPO's Low - Meduim - High Options Exclusions

1. Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which we deem experimental in nature;
2. Services for which You would not be required to pay in the absence of dental insurance;
3. Services or supplies received by a Covered Person before insurance under this policy starts for that person;
4. Services which are neither performed nor prescribed by a Dentist, except for those services of a licensed dental hygienist which are supervised and billed by a Dentist, and which are for:
   
   • • scaling and polishing of teeth; or
   • • fluoride treatments;
   
   
5. Services which are primarily cosmetic, unless required for the treatment or correction of a congenital defect of a newborn Child or for the treatment of a congenital cleft in the lip or palate or both;
6. Services or appliances which restore or alter occlusion or vertical dimension;
7. Restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease;
8. Restorations or appliances used for the purpose of periodontal splinting;
9. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco;
10. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss;
11. Initial installation of a Denture or implant to replace one or more teeth which were missing before such person was insured under this policy, except for congenitally missing teeth;
    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).
    
    
12. Decoration or inscription of any tooth, device, appliance, crown or other dental work;
13. missed appointments;
14. services:
    
    • • Covered under any workers’ compensation or occupational disease law;
      Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.
      
    • • Covered under any employer liability law;
    • • For which the employer of the Covered Person receiving such services is required to pay;
    • • Received at a facility maintained by an employer, labor union, mutual benefit association, or VA hospital;
    
    
15. Temporary or provisional restorations;
16. Temporary or provisional appliances;
17. Prescription drugs;
18. Services for which the submitted documentation indicates a poor prognosis;
19. The following, when charged by the Dentist on a separate basis:
    
    • • claim form completion;
    • • infection control, such as gloves, masks, and sterilization of supplies; or
    • • local anesthesia, non-intravenous conscious sedation or analgesia, such as nitrous oxide;
    
    
20. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food;
21. Caries susceptibility tests;
22. Fixed and removable appliances for correction of harmful habits;
23. Biopsies of hard or soft oral tissue;
24. Precision attachments associated with fixed and removable prostheses, except when theprecision attachment is related to implant prosthetics;
25. Modification of removable prosthodontic and other removable prosthetic services;
26. Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it;
27. Duplicate prosthetic devices or appliances;
28. Replacement of a lost or stolen appliance, Cast Restoration or Denture;
29. Diagnosis and treatment of temporomandibular joint disorders and cone beam imaging cone beam imaging associated with the treatment of temporomandibular joint disorders;
30. Intra and extraoral photographic images;
31. Orthodontic services or appliances except for the PPO High plan;
32. Repair or replacement of an orthodontic device;
33. Any services for which a Waiting Period applies where the Covered Person has not satisfied the Waiting Period requirement on the date of the service;
34. Services delivered outside the United States, except for Emergency Dental Conditions up to a maximum benefit of $100 per calendar year.

Metlife Veterans Affairs Dental Plan

1. Services and treatment not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, we will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law;
2. Services and treatment which are experimental or investigational;
Services and treatment which are for any illness or bodily injury which occurs in the course of employment if a benefit or compensation is available, in whole or in part, under the provision of any law or regulation or any government unit. This exclusion applies whether or not you claim the benefits or compensation;
Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.


3. Services and treatment received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, VA hospital or similar person or group;
4. Services and treatment performed prior to your effective date of coverage;
5. Services and treatment incurred after the termination date of your coverage unless otherwise indicated;
6. Services and treatment which are not dentally necessary or which do not meet generally accepted standards of dental practice;
7. Services and treatment limited by Plan frequency limitations;
8. Services and treatment resulting from your failure to comply with professionally prescribed treatment;
9. Telephone consultations;
10. Any charges for failure to keep a scheduled appointment;
11. Any services that are considered strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;
12. Services related to the diagnosis and treatment of Temporomandibular Joint Disorder (TMJ);
13. Services or treatment provided as a result of intentionally self-inflicted injury or illness;
14. Services or treatment provided as a result of injuries suffered while committing or attempting to commit a felony, engaging in an illegal occupation, or participating in a riot, rebellion or insurrection;
15. Office infection control charges;
16. Charges for copies of your records, charts or x-rays, or any costs associated with forwarding/mailing copies of your records, charts or x-rays;
17. State or territorial taxes on dental services performed;
18. Any charge submitted by a dentist, which is for the same services performed on the same date for the same member by another dentist;
19. Services provided free of charge by any governmental unit, except where this exclusion is prohibited by law;
20. Services for which the member would have no obligation to pay in the absence of this or any similar coverage;
21. Services which are for specialized procedures and techniques;
22. Services performed by a dentist who is compensated by a facility for similar covered services performed for members;
23. Duplicate, provisional and temporary devices, appliances, and services;
24. Plaque control programs, oral hygiene instruction, and dietary instructions;
25. Gold foil restorations;
26. Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan;
27. Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital(inpatient or outpatient);
28. Charges by the provider for completing dental forms;
29. Adjustment of a denture or bridgework which is made within 6 months after installation by the same Dentist who installed it;
30. Use of material or home health aids to prevent decay, such as toothpaste, fluoride gels, dental floss and teeth whiteners;
31. Sealants for teeth other than permanent molars;
32. Precision attachments, personalization, precious metal bases and other specialized techniques;
33. Replacement of dentures that have been lost, stolen or misplaced;
34. Orthodontic services and appliances for a dependent child enrolled in the standard plan.
35. Orthodontic services for members and spouses
36. Orthodontic services for dependent children age 19 and over
37. Orthodontic services provided to a dependent of an enrolled member who has not met the 24 month waiting period requirement.
    34 - 38 can be especially important for anyone in need of braces.
    
    
38. Repair or replacement of an orthodontic device;
39. Replacement of lost or missing appliances;
40. Fabrication of athletic mouth guard;
41. Internal and external bleaching;
42. Nitrous oxide;
43. Oral sedation;
44. Topical medicament center;
45. Bone grafts when done in connection with extractions, apicoetomies or non-covered/non eligible implants;
46. When two or more services are submitted and the services are considered part of the same service to one another the Plan will pay the most comprehensive service (the service that includes the other non-benefited service) as determined by MetLife;
47. When two or more services are submitted on the same day and the services are considered mutually exclusive (when one service contradicts the need for the other service), the Plan will pay for the service that represents the final treatment as determined by MetLife;
48. All out of network services are subject to the Fair Health R&C maximum allowable fee charges as defined by MetLife. The member is responsible for all remaining charges that exceed the allowable maximum.
49. Space Maintainers
50. Fixed and removable appliances for correction of harmful habits
51. Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards
52. Local chemotherapeutic agents