Noblesville Schools Medical Plan 57 Section 2: Exclusions and Limitations This exclusion does not apply to dental anesthesia for Covered Persons under age 19 or to Covered Persons who are physically or mentally disabled. This exclusion does not apply to dental care (oral exam, X-rays, extractions and non-surgical elimination of oral infection) required for the direct treatment of a medical condition for which Benefits are available under the Plan, limited to: ▪ Transplant preparation. ▪ Prior to the initiation of immunosuppressive drugs. ▪ The direct treatment of acute traumatic Injury, cancer or cleft palate. Dental care that is required to treat the effects of a medical condition, but that is not necessary to directly treat the medical condition, is excluded. Examples include treatment of tooth decay or cavities resulting from dry mouth after radiation treatment or as a result of medication. Endodontics, periodontal surgery and restorative treatment are excluded. 2. Preventive care, diagnosis, treatment of or related to the teeth, jawbones or gums. Examples include: ▪ Removal, restoration and replacement of teeth. ▪ Medical or surgical treatments of dental conditions. ▪ Services to improve dental clinical outcomes. This exclusion does not apply to preventive care for which Benefits are provided under the United States Preventive Services Task Force requirement or the Health Resources and Services Administration (HRSA) requirement. This exclusion also does not apply to accident-related dental services for which Benefits are provided as described under Dental Services - Accident Only in Section 1: Covered Health Care Services. This exclusion does not apply to the extraction of impacted wisdom teeth. 3. Dental implants, bone grafts and other implant-related procedures. This exclusion does not apply to accident-related dental services for which Benefits are provided as described under Dental Services - Accident Only in Section 1: Covered Health Care Services. 4. Dental braces (orthodontics). 5. Treatment of congenitally missing, malpositioned or supernumerary teeth, even if part of a Congenital Anomaly. Devices, Appliances and Prosthetics 1. Devices used as safety items or to help performance in sports-related activities. 2. Orthotic appliances that straighten or re-shape a body part. Examples include foot orthotics and some types of braces, including over-the-counter orthotic braces. This exclusion does not apply to cranial molding helmets and cranial banding that meet clinical criteria. This exclusion does not apply to braces for which Benefits are provided as described under Durable Medical Equipment (DME), Orthotics and Supplies in Section 1: Covered Health Care Services. 3. The following items are excluded, even if prescribed by a Physician: ▪ Blood pressure cuff/monitor. ▪ Enuresis alarm. ▪ Non-wearable external defibrillator. ▪ Trusses.