No benefits will be provided for the following. You will be responsible for the charges for these services:

1. Services for injuries or conditions payable under Workers' Compensation or Employer's Liability laws; benefits or services that are available from or payable by any federal or state government agency (including Medicare), from any municipality, county, other political subdivision or community agency; or from any foundation or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX Social Security Act (Medicaid).
2. Services or appliances including, but not limited to, prosthodontics (including crowns and bridges), started before an individual became eligible under this plan.
3. Prescription drugs, laboratory tests and/or examinations, premedications and/or relative analgesia; charges for hospitalization; general anesthesia and/or intravenous sedation for restorative dentistry; general anesthesia and/or intravenous sedation for surgical procedures, unless medically necessary; and preventive control programs, including home care items.
4. Charges for failing to keep a dental appointment.
5. Replacement, repair, relines or adjustments of occlusal guards.
6. Charges for completion of claim forms. Such charges are not to be made by a member dentist or a contracting dentist to a person covered by Delta Dental.
7. Charges for replacement of lost, missing or stolen appliances of any type and charges for replacement or repair of orthodontic appliances.
8. Appliances, surgical procedures and restorations for increasing vertical dimension; for restoring occlusion; for replacing tooth structure loss resulting from attrition, abrasion or erosion; for correcting congenital or developmental malformations; for cosmetic surgery, including dentistry for cosmetic reasons. This exclusion does not apply to the provision of orthodontic benefits as limited by the terms and conditions of the plan.
9. Treatment by other than a dentist, except for the scaling or cleaning of teeth and topical application of fluoride by a licensed dental hygienist under the supervision and guidance of a dentist in accordance with generally accepted dental standards.
10. Implants (except for re-implants that are covered under Oral Surgery benefits).
11. Inlays are not a covered benefit.
12. Services or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of dental coverage under the Plan.
13. Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared.
14. Services that are covered under a hospital, surgical/medical or prescription drug program.
15. Appliances, restorations or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ).
16. The State Dental Plan will not honor a claim for services if such claim is received by Delta Dental more than twelve months following the year in which the services were completed.
17. Those services excluded by the rules and regulations of Delta Dental, as the Plan’s agent, including processing policies, which may change periodically.
18. Services for injuries or conditions that are compensable under any Michigan automobile personal injury protection (no-fault) insurance, unless you or your dependent has made your automobile personal injury protection insurance secondary coverage (as permitted by Public Act No. 72 of 1974, being Section 500.3109 (a) of the Compiled Laws of 1970).
19. Services that are not necessary and/or customary as determined by the standards of generally accepted dental practice, for which no valid dental need can be demonstrated, that are specialized techniques or that are experimental in nature.
20. Services that are not within the classes of dental benefits as defined by the Plan in this book.