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A separate charge for anesthesia is not covered when used for restorative procedures
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Benefits will be limited to one sealant per tooth during any five-year period
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If a tooth can be restored with a material such as amalgam, silicate or plastic, but another type of restoration is selected, covered expense will be limited to the cost of amalgam, silicate or plastic
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Oral surgery benefits are limited to minor surgical procedures and do not allow payment for services such as vestibuloplasty
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Replacement of an existing prosthetic device is covered only if it cannot be made satisfactory. Replacement is never covered if the existing device is less than seven years old. Specialized or personalized prosthetics are limited to the cost of standard devices
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Replacement of necessary crowns, jackets, and gold or cast restorations, including onlays, is covered only if seven years have elapsed since the last prior crown, jacket, and gold or cast restoration was furnished on the tooth. Inlays are not covered. Alternative benefits may apply
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Sealant benefits for the occlusal surfaces of unrestored permanent bicuspids and first and second molars are limited to children under age 19
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The obligation of the plan to make payments for orthodontic treatment will cease upon termination of treatment for any reason prior to completion of the case
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The obligation of the plan to make payments for orthodontic treatment begun prior to the patient's eligibility date will be calculated on the balance of a dentist's normal payment pattern remaining at the patient's initial eligibility date. The maximum orthodontic benefit amount will apply fully to this amount
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The plan's obligation to make monthly or other periodic payments for orthodontics shall cease on termination of eligibility.
