Summary of Exclusions Coverage does not include: Conscious sedation/general anesthesia | Any condition resulting from military service or war | Injuries sustained while practicing or competing in a professional athletic contest | Bleaching of a tooth | Cast dowel post | Endodonics, bridges, crowns or other services or prosthetic devices or fittings if treatment was ordered prior to the Patient's effective date or if the item was installed or delivered more than 60 days after the Patient's coverage under the Policy has terminated | Charges by any person other than a licensed dentist, licensed denturist, or licensed hygienist | Charges that the patient would have had no obligation to pay in the absence of this Policy | Charges incurred to comply with Occupational Safety and Health Administration (OSHA) requirements | Any benefits paid or payable by Medicare unless required by law | Full-mouth reconstruction | Cosmetic dentistry or surgery | Dental implants or implant supported prosthetics | Excision of a tumor; biopsy of soft or hard tissue; removal of a cyst or exostosis | Dental services started prior to coverage under the Policy | Extraction of permanent teeth for tooth guidance procedures; procedures for tooth movement; correction of malocclusion, preventive orthodontic procedures, or other orthodontic treatment | Habit or stress breaking appliances. | Dental procedures in a hospital. | Intentionally self-inflicted injuries | Investigational services or supplies | Materials not approved by American Dental Association | For occupational injury or disease | Occlusal guards | Personalized restoration, precision attachments, and special techniques | Prescription drugs, medications or supplies.| Accidental injury to teeth more than 12 months after date of accident | Repair or replacement of lost, stolen or broken items | Replacements of an existing denture, crown, or bridge less than 5 years from the most recent placement | Replacement of sound restorations | Services or supplies that are not listed as covered | Services not necessary or not approved by Licensed Dentist | Services for Temporomandibular Joint Disorders (TMJ) | Veneers; composite surfaces on posterior teeth | Splints, nightguards, and other appliances used to increase vertical dimension and restore bite | Orthognathic surgery To receive the benefits under this plan you must receive services from a Willamette Dental Office. If you elect to go to a non-Willamette Dental Office, then you will be responsible for any charges exceeding $10. Dental Plus Customer Service Number 877-329-7965 This dental plan is provided by Willamette Dental of Idaho, Inc. 8950 W. Emerald St., Suite 108, Boise, ID 83704 www.WillametteDental.com THE POLICY PROVIDES DENTAL BENEFITS ONLY. PLEASE REFER TO YOUR POLICY FOR A COMPLETE DESCRIPTION OF EXCLUSIONS AND LIMITATIONS. Form No. 1921-DP (7/09) Policy No. 1918-ID (1/1/02)
