Arizona disclosures

Individual Dental Insurance disclosures, exclusions and limitations for Arizona residents


TABLE OF CONTENTS

  1. IDN8100-AZ (Individual Dental PPO)
  2. IDN8000-AZ (Individual Dental PPO)
  3. DENTAL-AZ (Fee Schedule)

IDN8100-AZ exclusions and limitations

No benefits are payable under this policy for the procedures and services listed below unless such procedure or service is listed as covered in the Schedule of Covered Procedures. In addition, the procedures listed below will not be recognized toward satisfaction of any deductible.

EXCLUSIONS

We will not pay benefits for any loss that is caused by, contributed to by or occurs as a result of any of the following:

  • federal, state or local taxes are not included as part of a covered dental expense;
  • any procedure or service not shown on the Schedule of Covered Procedures;
  • benefits in excess of the policy year maximum benefit amount;
  • any procedure we determine which is not necessary, does not offer a favorable prognosis or which is experimental in nature based on dental standard of care;
  • services considered inclusive of other procedures billed; the most comprehensive service may be payable;
  • services performed in conjunction with, as part of or related to an applicable associated service (including prior history);
  • any injury or illness when covered under workers’ compensation or similar law or which is work related;
  • any procedure or appliance installed before an insured’s policy effective date, including started but not completed services;
  • any procedure begun after an insured’s insurance under this policy terminates, or for any prosthetic dental appliance finally installed or delivered after an insured’s insurance under this policy terminates;
  • charges for dental services performed by anyone other than a licensed dentist, dental hygienist, dental therapist or denturist;
  • services that are not recommended by a dentist or that are not required for the preservation or restoration of oral health;
  • any adjustment, reline, rebase or repair (including adding or replacing missing or broken teeth) to prosthetic dental work within six months of the initial;
  • retreatment of previous root canal therapy within six months of the initial;
  • replacement of full or partial dentures unless the prior prosthetic appliance is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
  • replacement of implants, crowns, inlays or onlays unless the prior restoration is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
  • any treatment which is elective or primarily cosmetic in nature and not recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations;
  • the correction of congenital malformations, with the exception of newborns, adopted children and children placed for adoption;
  • the replacement of lost or discarded or stolen appliances;
  • replacement of bridges unless the prior bridge is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
  • appliances, services or procedures relating to: (a) the change or maintenance of vertical dimension; (b) restoration of occlusion (unless otherwise noted in the Schedule of Covered Procedures—only for occlusal guards); (c) splinting; (d) correction of attrition, abrasion, erosion or abfraction; (e) bite registration; (f) bite analysis or (g) bruxism;
  • services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain;
  • orthognathic surgery;
  • prescribed medications, premedication or analgesia;
  • any instruction for diet, plaque control and oral hygiene;
  • charges for: implants of any type (except those implants specified in the Schedule of Covered Procedures), 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;
  • 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);
  • for treatment of malignancies, cysts and neoplasms;
  • for orthodontic treatment except those services or treatments provided in the Schedule of Covered Procedures;
  • charges for failure to keep a scheduled visit or for the completion of any claim forms;
  • expenses provided or paid for by any governmental program or law, except Medicaid, and except as to charges which the person is legally obligated to pay or as addressed later under the payment of benefits provision;
  • procedures started but not completed;
  • any duplicate device or appliance;
  • general anesthesia and intravenous sedation except in conjunction with covered complex oral surgery procedures as defined by us, plus the services of anesthetists or anesthesiologists;
  • the replacement of 3rd molars;
  • crowns, inlays and onlays used to restore teeth with micro fractures or fracture lines, undermined cusps or existing large restorations without overt pathology.

LIMITATIONS

See the Schedule of Covered Procedures for all specific procedure limitations.

ALTERNATE BENEFIT

Many dental problems can be resolved in more than one way. If:

  • we determine that a less expensive alternate benefit could be provided for the resolution of a dental problem; and
  • that benefit would produce the same resolution of the diagnosed problem within professionally acceptable limits,

we may use the less expensive alternate benefit to determine the amount payable under this policy. If an alternate benefit is applied, the insured may be responsible for any remaining allowable amount after benefits are paid by the plan.

R-VSN8100

This rider is made a part of the Individual Dental Insurance policy and is subject to all of the provisions, limitations and exclusions of the policy, unless changed or added by this rider.

Each Insured may purchase materials in the form of frames and eyeglass lenses or contact lenses. Purchases are subject to frequency of services and co-pays.

EXCLUSIONS

No benefits are payable for any of the following conditions, procedures and/or materials, unless otherwise specifically listed as a covered benefit on the rider schedule:

  • replacement frames and/or lenses, except at normal intervals when covered services are otherwise available;
  • Plano Lenses or non-prescription lenses or sunglasses;
  • orthoptics, vision training and any associated supplemental testing;
  • frame cases;
  • low (subnormal) vision aids or aniseikonic lenses;
  • medical or surgical treatment of the eyes;
  • charges incurred after (a) the policy to which this rider is attached ends; or (b) the Insured’s
  • coverage under the policy to which this rider is attached ends, except as stated in the policy;
  • experimental or non-conventional treatment or device;
  • any eye examination or corrective eyewear required by an employer as a condition of employment;
  • services for which benefits are paid by Worker’s Compensation;
  • benefits provided under the employee’s medical insurance except in the case of coordination of benefits;
  • blended bifocal lenses;
  • groove, drill or notch, and roll and polish;
  • two pairs of eyeglasses, in lieu of bifocals, trifocals or progressives;
  • coating on lenses (factory scratch coat, anti-reflective, sunglass colors, etc.);
  • cosmetic items;
  • faceted lenses;
  • high-index lenses;
  • laminated lenses;
  • oversize lenses — any lens with an eye size of 61mm or greater;
  • photochromic (Transition) lenses;
  • polaroid lenses;
  • polished bevel lenses;
  • polycarbonate lenses;
  • prism lenses;
  • slab-off lenses;
  • tints;
  • ultraviolet tint or coating;
  • additional cost for any service or material over the allowance;
  • regardless of optical necessity, the Vision Examination Benefit is not available more frequently than specified on the rider schedule;
  • services received before your effective date, including started but not completed services;
  • charges for vision exam rendered by a provider other than ophthalmologist or optometrist acting within the scope of his or her license;
  • federal, state or local taxes.

IDN8000-AZ exclusions and limitations

EXCLUSIONS

  • No benefits are payable under this policy for the procedures and services listed below unless such procedure or service is listed as covered in the Schedule of Covered Dental Procedures. In addition, the procedures listed below will not be recognized toward satisfaction of any policy year deductible.
  • Any procedure or service not shown on the Schedule of Covered Dental Procedures.
  • Amounts in excess of the policy year maximum benefit.
  • Any procedure we determine which is not necessary, does not offer a favorable prognosis or does not have uniform professional endorsement or which is experimental in nature.
  • Any injury or illness when covered under Worker’s Compensation or similar law.
  • Any procedure or appliance installed before a covered person’s effective date, including started but not completed services.
  • Any procedure begun after an covered person’s insurance under the policy terminates, or for any prosthetic dental appliance finally installed or delivered after an covered person’s insurance under the policy terminates.
  • Charges for dental services performed by anyone other than a licensed dentist or dental hygienist.
  • Services that are not recommended by a dentist or that are not required for the preservation or restoration of oral health.
  • Repairs or adjustments to dental work within six months of the initial work.
  • Replacement of full or partial dentures unless the prosthetic appliance is older than the age allowed in the Schedule of Covered Dental Procedures and cannot be made serviceable.
  • Replacement of implants, crowns, inlays or onlays unless the prior restoration is older than the age allowed in the Schedule of Covered Dental Procedures and cannot be made serviceable.
  • Any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations.
  • Service or appliance rendered by someone who is related to a covered person by blood or by law (e.g., sibling, parent, grandparent, child), marriage (e.g., spouse or in-law) or adoption or is normally a member of the covered person’s household.
  • The correction of congenital malformations or congenital missing teeth.
  • The replacement of lost or discarded or stolen appliances.
  • Replacement of bridges unless the bridge is older than the age allowed in the Schedule of Covered Dental Procedures and cannot be made serviceable.
  • Appliances, services or procedures relating to: (a) the change or maintenance of vertical dimension; (b) restoration of occlusion (unless otherwise noted in the Schedule of Covered Dental Procedures-only for occlusal guards); (c) splinting; (d) correction of attrition, abrasion, erosion or abfraction; (e) bite registration; (f) bite analysis or (g) bruxism.
  • Services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain.
  • Orthognathic surgery.
  • Prescribed medications, premedication or analgesia.
  • Any instruction for diet, plaque control and oral hygiene.
  • Charges for: implants of any type (except those implants specified in the Schedule of Covered Dental Procedures), 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.
  • 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).
  • For treatment of malignancies, cysts and neoplasms.
  • For orthodontic treatment except those services or treatments provided in the Schedule of Covered Dental Procedures.
  • Charges for failure to keep a scheduled visit or for the completion of any claim forms.
  • Expenses provided or paid for by any governmental program or law, except as to charges which the person is legally obligated to pay or as addressed later under the “Payment of Claims” provision.
  • Procedures started but not completed.
  • Any duplicate device or appliance.
  • General anesthesia and intravenous sedation except in conjunction with covered complex oral surgery procedures as defined by us, plus the services of anesthetists or anesthesiologists.
  • The replacement of 3rd molars.
  • Crowns, inlays and onlays used to restore teeth with micro fractures or fracture lines, undermined cusps or existing large restorations without overt pathology.

No benefits will be paid for replacement of teeth missing prior to the effective date of coverage.

No benefits will be paid for the initial placement of removable full or partial dentures, unless it includes the replacement of a functioning natural tooth extracted while the covered person is insured under this policy.

No benefits will be paid for the initial placement of a fixed partial denture including a Maryland Bridge, unless it includes the replacement of a functioning natural tooth extracted while the covered person is insured under this policy.

Other limitations: Multiple restorations on one surface are payable as one surface. Multiple surfaces on a single tooth will not be paid as separate restorations. Coverage is limited to two prophylaxis and/or two periodontal maintenance procedures, subject to a maximum total of no more than two (2) procedures per twelve (12) month period. Coverage is limited to one (1) full mouth radiograph or panoramic film per limitation period listed in the Schedule of Covered Dental Procedures. On any given day, more than seven (7) periapical x-rays or a panoramic film in conjunction with bitewings will be paid as a full mouth radiograph. Additional limitations are noted in the Schedule of Covered Dental Procedures.

Federal, state or local taxes are not included as part of a covered dental expense.

See the Schedule of Covered Dental Procedures for all specific procedure limitations.

ALTERNATE BENEFIT PROVISION

Many dental problems can be resolved in more than one way. If:

  • we determine that a less expensive alternative benefit could be provided for the resolution of a dental problem; and
  • that benefit would produce the same resolution of the diagnosed problem within professionally acceptable limits, we may use the less expensive alternative benefit to determine the amount payable under the policy.

For example: When an amalgam filling and a composite filling are both professionally acceptable methods for filling a molar, we may base our benefit on the amalgam filling which is the less expensive alternative benefit. This is the case whether a participating provider or non-participating provider performs the service.

R-VSN8000-AZ

The contact lenses benefit is paid in lieu of eyeglass lenses and frames. A covered person is eligible to receive benefits under the eyeglass lenses benefit or the frame benefit only after the contact lenses benefit frequency has ended.

The eyeglass lenses benefit and the eyeglass frame benefit is paid in lieu of the contact lenses benefit. A covered person is eligible to receive benefits under the contact lenses benefit only after the eyeglass lenses benefit frequency has ended.

Dilation is covered in full under the vision exam benefit ONLY if done for one of the following conditions: central vision loss, photopsia, floaters, high myopia, diabetes or history of ocular surgery, ocular trauma or ocular disease.

EXCLUSIONS

No benefits are payable for any of the following conditions, procedures and/or materials, unless otherwise specifically listed as a covered benefit in vision rider benefits:

  • Replacement frames and/or lenses, except at normal intervals when covered services are otherwise available;
  • Plano or non-prescription lenses or sunglasses;
  • Orthoptics, vision training and any associated supplemental testing;
  • Frame cases;
  • Low (subnormal) vision aids or aniseikonic lenses;
  • Medical and surgical treatment of the eyes;
  • Charges incurred after (a) the policy to which this rider is attached ends; or (b) the covered person’s coverage under the policy to which this rider is attached ends, except as stated in the policy;
  • Experimental or non-conventional treatment or device;
  • Any eye examination or corrective eyewear required by an employer as a condition of employment;
  • Services and materials provided by another vision plan except in the case of coordination of benefits;
  • Services for which benefits are paid by Worker’s Compensation;
  • Benefits provided under the employee’s medical insurance except in the case of coordination of benefits;
  • Blended bifocal lenses;
  • Groove, Drill or Notch, and Roll and Polish;
  • Two pairs of eyeglasses, in lieu of bifocals, trifocals or progressives;
  • Coating on lenses (factory scratch coat, anti-reflective, sunglass colors, etc.)
  • Cosmetic items;
  • Faceted lenses;
  • High-Index lenses;
  • Laminated lenses;
  • Oversize lenses — any lens with an eye size of 61mm or greater;
  • Photochromic (Transition) lenses;
  • Polaroid lenses;
  • Polished bevel lenses;
  • Polycarbonate lenses;
  • Prism lenses;
  • Slab-off lenses;
  • Tints;
  • Ultraviolet tint or coating;
  • Additional cost for contact lenses over the allowance;
  • Additional cost for a frame over the allowance;
  • Regardless of optical necessity, the Vision Examination Benefit is not available more frequently than specified in vision rider benefits;
  • Services received before your effective date, including started but not completed services;
  • Charges for services rendered by a provider other than ophthalmologist or optometrist acting within the scope of his or her license;
  • Treatment or services received while outside the territorial limits of the United States;
  • Any charge for a service required as a result of disease or injury that is due to war or an act of war (whether declared or undeclared); taking part in an insurrection or riot; the commission or attempted commission of a crime; an intentionally self-inflicted injury or attempted suicide while sane or insane;
  • Federal, state or local taxes;
  • Progressive Power Lenses.*

*Progressive Power Lenses: If this type of lens is not a covered benefit under this rider, the provider will apply the retail charge for standard trifocal lenses against the charge for the style of progressive lenses you have selected.

You pay the provider the difference, if any, between the two.

Dental-AZ exclusions and limitations 

GUARANTEED RENEWABLE

This policy is guaranteed renewable as long as you pay the premiums when they are due or within the grace period. Your premium can be changed only if we change it on all policies of this kind in force in the state where the policy was issued.

WHAT IS NOT COVERED BY THIS POLICY

Coding convention errors, misrepresentations or upcoding
A dentist or dental practice’s failure to comply with the current American Dental Association coding convention, including but not limited to upcoding, the overutilization of certain codes and/or the misrepresentation of services, such as unbundling

Crown replacement
Services to treat crowns for a given tooth within five years of last placement, regardless of the type of crown

Inlay or onlay replacement
Services to replace inlays or onlays for a given tooth within five years of last placement

Procedures prior to the effective date
Procedures performed prior to the Policy Coverage Effective Date

Procedures prior to the expiration of the waiting period
Procedures performed prior to expiration of the waiting period, if any, for the specified benefit

Prosthetic replacement
Services to replace prosthetics within five years of last placement

Repairs
Repairs to dental work within six months of the initial procedure

Sealant limitation
Benefits for sealants are limited to secondary molars for dependent children under age 16 and will not be payable more often than every five years.

Teeth missing before the Policy Coverage Effective Date
No benefits will be paid for replacement of teeth that were missing before the Policy Coverage Effective Date.

Treatment outside of the United States
Treatment received outside of the United States or its territories

Unlisted procedures
Procedures not listed on the Policy Schedule or Policy Schedule Addendum, unless the code has been revised or replaced by the American Dental Association

Unrecommended or unrequired services
Services not recommended by a dentist, or services not required for the preservation or restoration of oral health

Orthodontic benefit rider

This benefit is not payable for dental services when the initial treatment occurs prior to the effective date or before the waiting period ended. The $500 initial treatment benefit is not payable for periodic orthodontic treatment visit (CDT Code D8670). Periodic orthodontic treatment visits are payable as continued orthodontic treatment, subject to all other terms.

R-Vision

THIS RIDER DOES NOT COVER:

Examinations not performed by an optometrist or ophthalmologist
Examinations not performed by a licensed optometrist or licensed ophthalmologist;

Non-prescribed vision correction materials
Items available for purchase without a prescription;

Services received outside of the United States
Services received while outside the United States or its territories; or

Surgical procedures
Refractive error-correction surgeries, including but not limited to laser-assisted in-situ keratomileusis (LASIK), photorefractive keratectomy (PRK), radial keratotomy (RK) or intracorneal rings (Intacs).