— Any drugs or medicines, even if they are prescribed. This includes analgesics (medications to relieve pain) and patient management drugs, such as pre-medication and nitrous oxide; — Cases which in the professional judgment of the attending dentist a satisfactory result cannot be obtained or where the prognosis is poor or guarded; — Prophylactic removal of impactions (asymptomatic, nonpathological); — Specialist consultations for non-covered benefits; — Orthodontic treatment which involves therapy for myofunctional problems, TMJ, dysfunctions, micrognathia, macroglossia, or hormonal imbalances causing growth and developmental abnormalities; — All other services not specifically included on the patient’s copayment schedule as a Covered Dental Benefit; — Treatment of fractures and dislocations to the jaw; — Dental services received from any dental office other than the assigned dental office, unless expressly authorized in writing by DeltaCare or as cited under “Emergency Care or Urgent Care”. Governing Administrative Policies The following guidelines are an integral part of the dental program and are consistent with the principles of accepted dental practice and the continued maintenance of good dental health. In all cases in which the patient selects a more expensive plan of treatment that is not a covered benefit, the more expensive treatment is considered optional. The patient must pay the difference in cost between the dentist’s DDWA filed fees for the covered benefit and the optional treatment plus any co-payment for covered benefits. Failure to pay a scheduled co-payment at the time of service may prevent future dental services from being rendered with the exception of emergency services. Replacement of prosthetic appliances (crowns, bridges, partials and full dentures) shall be considered only if the existing appliance is no longer functional or cannot be made functional by repair or adjustment and meets the five year limitation for replacement. Partial Dentures 1. A removable cast metal partial denture is considered the covered benefit in cases where one or more posterior teeth is missing in a dental arch or a combination of one or more posterior and anterior teeth are missing in a dental arch. A three unit bridge is considered the covered benefit if only one anterior tooth is missing in a dental arch. If the patient selects another course of treatment, the patient must pay the difference in cost between the dentists’ DDWA filed fees for the covered benefit and the optional treatment, plus any co-payment for the covered benefit. 2. If a cast metal partial denture will restore the case, the Primary Care Dentist will apply the difference of the cost of such procedure toward any alternative treatments which the patient and dentist may choose to use. The patient must pay the difference in cost between the dentist’s DDWA filed fees for the covered benefit and the optional treatment plus any co-payment for the covered benefit. 3. An acrylic partial denture may be considered a covered benefit in cases involving extensive periodontal disease. Patients will pay the applicable co-payment for a cast metal partial denture. Complete Dentures 4. If, in the construction of a denture, the patient and the Primary Care Dentist decide on personalized restorations or employ specialized techniques as opposed to standard procedures, the patient must pay the difference in cost between the dentist’s DDWA filed fees for the covered benefit (a standard denture) and optional treatment (a personalized denture or a denture that employed specialized techniques), plus any co-payment for the covered benefit. 2024-01-03100-BB 21 DCL 20240101