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Section 5 Exclusions and Limitations <br />5.1 Exclusions. The Company does not provide benefits for any of the following conditions, <br />treatments, services, or for any direct complications or consequences thereof. The Company does <br />not provide benefits for excluded services even if approved, prescribed, or recommended by a <br />Participating Provider. <br />5.1.1 Bridges, crowns, dentures, or prosthetic devices requiring multiple treatment dates or <br />fittings, if the prosthetic item is installed or delivered more than 60 days after termination <br />of coverage. <br />5.1.2 The completion or delivery of treatments or services performed or initiated prior to the <br />effective date of coverage under this Contract, including the following: <br />a. Endodontic services and prosthodontic services; <br />b. An appliance or modification of one, if an impression for it was made prior to the <br />effective date of coverage under this Contract; or <br />c. A crown, bridge, or cast or processed restoration, if the tooth was prepared prior to the <br />effective date of coverage under this Contract. <br />Such services are the liability of the Enrollee, prior dental plan, and provider. <br />5.1.3 Endodontic therapy completed more than 60 days after termination of coverage. <br />5.1.4 Exams or consultations needed solely in connection with a service that is not covered. <br />5.1.5 Experimental or Investigational services and related exams or consultations. <br />5.1.6 Full mouth reconstruction, including the extensive restoration of the mouth with crowns, <br />bridges, or implants; and occlusal rehabilitation, including crowns, bridges, or implants <br />used for the purpose of splinting altering vertical dimension, restoring occlusions, or <br />correcting attrition, abrasion, or erosion. <br />5.1.7 Hospitalization care outside of a dental office for dental procedures, physician services, or <br />facility fees, except as covered under Section 5.2.5. <br />5.1.8 Maxillofacial prosthetic services. <br />5.1.9 Nightguards. <br />5.1.10 Personalized restorations. <br />5.1.11 Plastic, reconstructive or cosmetic surgery and other services, which are primarily <br />intended to improve, alter, or enhance appearance. <br />5.1.12 Prescription and over-the-counter drugs and pre -medications. <br />5.1.13 Provider charges for a missed appointment or cancelled appointment without 24 hours <br />prior notice. <br />001 L-WA811(5/20) 13 <br />