For Eligible Participants of the UFCW Local 1776 and Participating
Employers Health and Welfare Fund

The Dental Plan does not cover expenses for the following services:
Cosmetic or aesthetic services including cosmetic bonding

Replacement of lost or stolen appliances within five years

Replacement of a bridge or denture which meets commonly held dental standards of functional acceptability

Appliances or restorations, other than full dentures, whose primary purpose is to alter vertical dimension, stabilize periodontally involved teeth or restore occlusion

Treatment of Temporomandibular joint syndrome (TMJ)

Extraction of wisdom teeth for which no symptoms exist

Sealants for patients over age 16

Services deemed necessary as a result of an accident when such services are payable under another insurance carrier

Services payable under Workers' Compensation

Services payable by a third party, such as another health plan, in accordance with established COB procedures