The benefits provided by the State Dental Plan are limited as shown in the Dental Plan Features and as follows. For the purpose of this Plan, all time limitations are measured from the date on which those services were last supplied under the State Dental Plan.

1. Benefits for oral exams are payable only twice in a Plan year.
2. Benefits for prophylaxes (cleanings) are payable only three times in a Plan year and only two times in a Plan year for the Scientific and Engineering Unit.
3. Benefits for bitewing X-rays are payable only once in a Plan year. Benefits for full mouth X-rays (which include bitewing X-rays) are payable only once in any five-year period, unless necessary for the diagnosis and treatment of a specific disease or injury. A panographic X-ray (including bitewings) is considered a full mouth X-ray and is paid as such. A panographic film in conjunction with a full mouth X-ray is not a separate benefit when performed by the same dentist.
4. Benefits for space maintainers are payable only for dependent children until their 14th birthday.
5. Benefits for topically applied fluorides are payable only for dependent children until their 19th birthday, except where special need is shown by the attending dentist.
6. Benefits for cast restorations on the same tooth, including jackets, crowns, onlays and associated procedures, such as cores and post substructures, are payable only once in any five-year period.
7. Benefits for porcelain, porcelain substrate and cast restorations are not payable for enrolled dependents under 12 years of age.
8. An occlusal guard is payable once in a lifetime.
9. Prosthodontic benefit limitations:
   

a)Benefits for one complete upper and one complete lower denture are payable only once in any five-year period for any individual.

b)Benefits for a partial denture, fixed bridge or removable bridge for any individual are payable only once in any five-year period unless the loss of additional teeth requires the construction of a new appliance.

c) Benefits for fixed bridges and removable cast partials are not payable for people under 16 years of age.

d) Benefits for a reline or the complete replacement of denture base material are payable only once in any three-year period for any individual.

10. Optional treatment: In all cases in which the employee or eligible dependent selects a more expensive service than is customarily provided, the Plan will pay only the applicable percentage of the fee for the service if any, that is customarily provided. The employee or eligible dependent will be responsible for the difference in cost.
11. Benefits for root planing are payable only once in any two-year period. Benefits for periodontal surgery, including sub-gingival curettage, are payable only once in any three-year period.
12. Orthodontic benefit limitations:
    

a) Orthodontic benefits are payable for enrolled dependent children until their 19th birthday, or until their 25th birthday if they are a full-time college student.
b) If the orthodontic treatment plan is terminated before completion of the case for any reason, the State Dental Plan’s obligation will cease with payment to the date of termination.
c) Orthodontic treatment may be terminated by the dentist, with written notification to Delta Dental and to the patient, for lack of patient interest and cooperation. The State Dental Plan’s obligation for payment of benefits in those cases ends on the last day of the month in which the patient was last treated.
d) Any charge for the replacement or repair of an orthodontic appliance furnished under any Delta Dental plan will not be paid by the Plan and will be the responsibility of the patient.


13. When services in progress are interrupted and completed later by another dentist, claims will be reviewed to determine the payment under the Plan, if any, to each dentist.
14. Care terminated due to the death of an employee or dependent will be paid in full, to the limit of the Plan’s liability, for the services completed or in progress.
15. Delta Dental processing policies, which may change periodically, may limit treatment.
16. Maximum payment:
    
    a) The maximum benefit payable in any Plan year (October - September) will be limited to $1,000 for each covered person. The following services, if approved by Delta Dental, are exempt from the annual maximum: apicoectomy/periaradicular surgery; retrograde filling; gingivectomy or gingivoplasty; gingival flap procedure; crown lengthening; osseous surgery and graft; pedicle soft tissue graft procedure; free soft tissue graft procedure (including donor site); extraction of soft tissue impaction, partial bony impaction and complete bony impaction; surgical removal of residual roots; surgical exposure of impacted or unerupted tooth for orthodontic reasons; surgical exposure of impacted or unerupted tooth to aid eruption; alveoloplasty; frenulectomy (frenectomy or frenotomy); excision of hyperplastic tissue and excision of periocoronial gingiva.
    
    b) Delta Dental's payment for orthodontic (Class III) benefits will be limited to a lifetime maximum of $1,500 for each eligible person.
    
17. The amount payable under the State Dental Plan will take into account any coverage the employee or eligible dependent has under any other employment-connected plan. Benefits will be coordinated to provide maximum reimbursement for expenses covered in part under either plan. Such coordination will be consistent with the Michigan Coordination of Benefit Act or any other applicable Michigan law for coordination of group health insurance benefits. This provision applies only to employment-connected plans. Benefits available through homeowner's liability coverage or individual non-employment connected plans will not be subject to coordination.