California. HumanaDental

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1 California HumanaDental

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3 Feel good about choosing a HumanaDental plan We re happy you are considering a HumanaDental plan. Offering a dental plan not only promotes good dental health, but may also reduce total healthcare costs over time. You can feel good knowing you re offering a highly appreciated employee benefit while helping your employees stay more healthy and fit. Feel even better knowing: 9 out of 10 members would recommend a HumanaDental plan to a friend. * You won t break your budget offer a HumanaDental plan at little or no cost to your business. Your plan will run smoothly. In fact, we have more than 1,000 associates who are experts at servicing dental benefits. Our PPO network is one of the largest with more than 130,000 dentist locations, and growing daily. Your employees will benefit from national network discounts averaging 28 percent. We keep our promises. Humana has never missed a dental service guarantee. * HumanaDental member satisfaction survey,

4 Good health starts with a healthy mouth Education and prevention are top priorities Regular dental cleanings can help manage problems throughout the body such as heart disease, diabetes, and stroke. * HumanaDental plans focus on education, prevention, early diagnosis, and treatment. Healthy employees are good for your business. They are typically more productive, miss less work, and have fewer healthcare costs. Here s what you can expect with your HumanaDental plan: Two regular cleanings and exams, plus two periodontal cleanings and exams for members in a HumanaDental PPO or Traditional Preferred plan Oral cancer screenings for members 40 years and older in a HumanaDental PPO, Traditional Preferred, or Preventive Plus plan BrushUp newsletter provides members with tips on how to keep their mouths healthy, and educates them on the importance of regular dental visits * Prevention and early treatment of dental disease can help people take better care of their overall health as well as improve their oral health. Geoffrey Morris, DDS National Dental Director, Humana Specialty Benefits MyDentalIQ.com, an online dental health assessment delivers a personalized action plan and dental health tips 2

5 You re partnering with a company that has more than three decades experience servicing employers dental insurance needs. Using HumanaDental.com, you can: Enroll employees Update employee information Customize reports Order replacement ID cards Plus, members can find network dentists quickly and check the status of a claim. Personalize your HumanaDental plan You ll work with a team of dental experts to design a plan that best fits you and your employees needs. Choose voluntary or employer-sponsored plans with various deductibles, copayments, and out-of-pocket options. Administrative service only (ASO) plans also are available. You also can: Offer employees a choice of two dental plans (available for groups with 10 or more enrolled employees) Work with us to nominate dentists for our network Talk directly with a Customer Care specialist and/or manage your plan online at HumanaDental.com Choose the enrollment option that works best for you: Web, list enrollment, or paper 3

6 Traditional Preferred and PPO plans Traditional Preferred PPO Deductible options See any dentist See an in-network dentist See an out-of-network dentist Waive deductible option Annual maximum options Extended annual maximum Individual Family Individual Family Individual Family $0 $25 $50 $0 $75 $150 Deductible applies to all services with the option to waive on preventive. $1,000 $1,250 $1,500 $2,000 $2,500 $0 $25 $50 $50 $0 $75 $150 $150 $25 $50 $50 $100 $75 $150 $150 $300 Deductible applies to all services with the option to waive on out-of-network preventive. Deductible does not apply to in-network preventive. $1,000 $1,250 $1,500 $2,000 You will receive 30 percent coinsurance on preventive, basic, and major services for the rest of the year after you reach your annual maximum. (Implants and orthodontia excluded) Coinsurance options Coinsurance options Coinsurance options $2,500 See any dentist in network out of network in network out of network in network out of network in network out of network Preventive services Oral examinations, X-rays, cleanings, topical fluoride treatment (through age 14, one per calendar year), sealants (through age 14) 100% 100% 100% 100% 100% 100% 100% 100% 80% 100% 80% Basic services Space maintainers (through age 14), emergency care for pain relief, non-surgical extractions, fillings (amalgams, composite for anterior teeth), appliances for children (through age 14), prefabricated stainless steel crowns Major services Crowns, inlays and onlays, bridgework, dentures, denture relines and rebases, denture repair and adjustments, oral surgery, periodontics (gum therapy), endodontics (root canals) 80% 50% 50% 100% 80% 90% 80% 90% 80% 80% 50% 50% 50% 30% 60% 50% 60% 50% 50% 50% 50% 50% Plan options Periodontics/Endodontics Complex oral surgery Composite fillings for molars Implants Orthodontia If you do not choose orthodontia coverage, employees may be able to receive up to a 20 percent savings by visiting participating orthodontists and asking for the discount. Periodontics and endodontics available as a basic service for an additional cost. Complex oral surgery available as a basic service for an additional cost. Composite fillings for molars can be added to basic services for groups with 10 or more enrolled employees for an additional cost. Implants can be added to major services for groups with 10 or more enrolled employees for an additional cost. $1,500 maximum implant benefit, subject to the annual maximum. Child orthodontia Available for groups with 10 or more enrolled employees. Plan pays 50 percent (no deductible) of the covered child orthodontia services up to: $1,000 $1,500 $2,000 Adult/child orthodontia Available for groups with 25 or more enrolled employees. Plan pays 50 percent (no deductible) of the covered adult/child orthodontia services up to: $1,000 $1,500 $2,000 4

7 Preventive Plus plans Deductible Waive deductible option Preventive Plus Individual Annual maximum $1,000 Preventive services Oral examinations, X-rays, cleanings, topical fluoride treatment (through age 14, one per calendar year), sealants (through age 14) Basic services Emergency care for pain relief, nonsurgical extractions, fillings (amalgams, composite for anterior teeth) Discount services Basic services Space maintainers (through age 14), appliances for children, prefabricated stainless steel crowns Major services Crowns, inlays and onlays, bridgework, dentures, denture relines and rebases, denture repair and adustments, oral surgery, periodontics (gum therapy), endodontics (root canals) Orthodontia services Adult and child orthodontia See any dentist Family $50 $150 Deductible applies to all services with the option to waive on preventive. Coinsurance options See any dentist 100% 100% 80% 50% You may be able to receive a discount on these services if you see participating dentists. These services are not covered under this plan. Out-ofpocket expenses do not apply to deductible and annual maximum. Additional plan options Out-of-network reimbursement options Based on maximum allowable fee (MAF): If a member sees an out-of-network dentist, the coinsurance level will apply to the maximum allowable fee. Based on in-network fee schedule (INFS): If a member sees an out-of-network dentist, the coinsurance level will apply to the average negotiated in-network fee schedule in your area. If a member visits a participating network dentist, the member will not receive a bill for charges more than the negotiated fee schedule. Funding options Employer sponsored: Your business only needs to contribute 25 percent of the single rate. Voluntary: Same group benefits to your employees at no cost to your business. Dual choice: Combine any two employersponsored or any two voluntary plans. (Available for groups with 10 or more enrolled employees.) Administrative services only (ASO): Your business funds the plan. HumanaDental carefully manages your plan through our industry-leading claims system and nationwide PPO network. Enrollment options for employees joining late Open enrollment: Employees without a qualifying event can only join during the annual open enrollment period. Additional late applicant waiting periods do not apply (plan waiting periods may apply). Late applicants: Employees can join at any time during the plan year without a qualifying event. Late applicant waiting periods apply. Policy number: GN HD 5/06 Insured or administered by HumanaDental Insurance Company Genuine customer care Call , Monday through Friday, 8 a.m. to 6 p.m. (TDD: ) 5

8 LIBERTY Dental plans The DHMO plan focuses on maintaining oral health with low or no-cost preventive procedures and includes restorative care at fees considerably lower than those charged by non-participating dentists. A member may see a primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet, and no waiting periods. Members must select, and be assigned to, a LIBERTY Dental Plan contracted dental office to utilize covered benefits. Your assigned office will initiate a treatment plan or will initiate the specialty referral process with LIBERTY Dental Plan if the services are dentally necessary and outside the scope of general dentistry. Member Co-payments are payable to the dental office at the time services are rendered. This Schedule does not guarantee benefits. All services are subject to eligibility and dental necessity at the time of service. Dental procedures not listed as covered benefits are available at the dental office s usual and customary fee. For a complete description of your Plan, please refer to the Evidence of Coverage in addition to this Schedule. Summary of services Diagnostic services LS100 LS200 LS300 D0120 Periodic oral evaluation no charge no charge no charge D0140 Limited oral evaluation no charge no charge no charge D0145 Oral Evaluation under age no charge no charge no charge D0150 Comprehensive oral evaluation no charge no charge no charge D0160 Oral evaluation, problem focused no charge no charge no charge D0170 Re-evaluation, limited, problem focused no charge no charge no charge D0180 Comprehensive periodontal evaluation no charge no charge no charge D0210 Intraoral, complete series (includes bitewings) no charge no charge no charge D0220 Intraoral, periapical, first film no charge no charge no charge D0230 Intraoral, periapical, each additional film no charge no charge no charge D0240 Intraoral, occlusal film no charge no charge no charge D0250 Extraoral, first film no charge no charge no charge D0260 Extraoral, each additional film no charge no charge no charge D0270 Bitewing, single film no charge no charge no charge D0272 Bitewings, 2 films no charge no charge no charge D0273 Bitewings, 3 films no charge no charge no charge D0274 Bitewings, 4 films no charge no charge no charge D0277 Vertical bitewings, 7 to 8 films no charge no charge no charge D0330 Panoramic Film no charge no charge no charge D0415 Collection of microorganisms for culture no charge no charge no charge D0425 Caries susceptibility tests no charge no charge no charge D0460 Pulp vitality tests no charge no charge no charge D0470 Diagnostic casts no charge no charge no charge D0472 Accession of tissue, gross exam, prep & report no charge no charge no charge D0474 Accession of tissue, gross/micro. exam, report no charge no charge no charge Preventive services D1110 Prophylaxis, adult no charge no charge $ 8.00 Prophylaxis, adult (3rd or more per 12 months) $ $ $ D1120 Prophylaxis, child no charge no charge $ 7.00 Prophylaxis, child (3rd or more per 12 months) $ $ $ D1203 Topical application of fluoride, child no charge no charge $ 8.00 Topical application fluoride, child (3rd + in 12 mo.) $ $ $ D1204 Topical application of fluoride, adult no charge no charge $ 9.00 D1206 Topical fluoride varnish no charge no charge $ 9.00 D1310 Nutritional counseling for control of dental disease no charge no charge no charge D1320 Tobacco counseling, control/prevention oral disease no charge no charge no charge D1330 Oral hygiene instruction no charge no charge no charge D1351 Sealant, per tooth $ $ $ D1352 Preventive resin restoration permanent tooth $ $ $ D1510 Space maintainer, fixed, unilateral $ $ $ D1515 Space maintainer, fixed, bilateral $ $ $ D1520 Space maintainer, removable, unilateral $ $ $ CDT-2011/2012: Current Dental Terminology, 2010 American Dental Association. All rights reserved. 6

9 Preventive services continued LS100 LS200 LS300 D1525 Space maintainer, removable, bilateral $ $ $ D1550 Recementation of space maintainer $ $ $ D1555 Removal of fixed space maintainer $ $ $ Restorative D2140 Amalgam, 1 surface, primary or permanent no charge......$ $ D2150 Amalgam, 2 surfaces, primary or permanent no charge......$ $ D2160 Amalgam, 3 surfaces, primary or permanent no charge......$ $ D2161 Amalgam, 4 or more surfaces, primary/permanent no charge......$ $ D2330 Resin-based composite, 1 surface, anterior no charge......$ $ D2331 Resin-based composite, 2 surfaces, anterior no charge......$ $ D2332 Resin-based composite, 3 surfaces, anterior no charge......$ $ D2335 Resin-based composite, 4+ surfaces/incisal angle no charge......$ $ D2390 Resin-based composite crown, anterior $ $ $ D2391 Resin-based composite, 1 surface, posterior $ $ $ D2392 Resin-based composite, 2 surfaces, posterior $ $ $ D2393 Resin-based composite, 3 surfaces, posterior $ $ $ D2394 Resin-based composite, 4+ surfaces, posterior $ $ $ *GUIDELINES for Inlays, Onlays, and Single Crowns: The total maximum amount chargeable to the member for elective upgraded procedures (explained below) is $ per tooth. Providers are required to explain covered benefits as well as any elective differences in materials and fees prior to providing an elective upgraded procedure. 1. Brand name restorations (e.g. Sunrise, Captek, Vitadur-N, Hi-Ceram, Optec, HSP, In-Ceram, Empress, Cerec, AllCeram, Procera, Lava, etc.) may be considered elective upgraded procedures if their related CDT procedure codes are not listed as covered benefits. 2. Benefits for anterior and bicuspid teeth: Resin, porcelain and any resin to base metal or porcelain to base metal crowns are covered benefits for anterior and bicuspid teeth. Adding a porcelain margin may be considered an elective upgraded procedure Benefits for molar teeth: Cast base metal restorations are covered benefits for molar teeth. Resin-based composite and porcelain/ceramic crowns are not covered benefits on molar teeth. Any resin to metal or porcelain to metal crowns may be considered elective upgraded procedures. Adding a porcelain margin may be considered an elective upgraded procedure. 4. Base metal is the benefit. If elected, the member may be charged additional lab costs for a) noble metal, b) high noble metal, or c) titanium. D2510 Inlay, metallic, 1 surface $ 80.00*......$ * $ * D2520 Inlay, metallic, 2 surfaces $ 85.00*.....$ * $ * D2530 Inlay, metallic, 3 or more surfaces $ 90.00*.....$ * $ * D2542 Onlay, metallic, 2 surfaces $ 90.00*.....$ * $ * D2543 Onlay, metallic, 3 surfaces $ 95.00*.....$ * $ * D2544 Onlay, metallic, 4 or more surfaces $ *.....$ * $ * D2610 Inlay, porcelain/ceramic, 1 surface $ 80.00*.....$ * $ * D2620 Inlay, porcelain/ceramic, 2 surfaces $ 85.00*.....$ * $ * D2630 Inlay, porcelain/ceramic, 3 or more surfaces $ 90.00*.....$ * $ * D2642 Onlay, porcelain/ceramic, 2 surfaces $ 95.00*.....$ * $ * D2643 Onlay, porcelain/ceramic, 3 surfaces $ *.....$ * $ * D2644 Onlay, porcelain/ceramic, 4 or more surfaces $ *.....$ * $ * D2650 Inlay, resin-based composite, 1 surface $ 80.00*.....$ * $ * D2651 Inlay, resin-based composite, 2 surfaces $ 85.00*.....$ * $ * D2652 Inlay, resin-based composite, 3 or more surfaces $ 90.00*.....$ * $ * D2662 Onlay, resin-based composite, 2 surfaces $ 90.00*.....$ * $ * D2663 Onlay, resin-based composite, 3 surfaces $ 95.00*.....$ * $ * D2664 Onlay, resin-based composite, 4 or more surfaces $ *.....$ * $ * D2710 Crown, resin-based composite (indirect) $ 60.00*.....$ 85.00*..... $ * D2712 Crown, 3/4 resin-based composite (indirect) $ 60.00*.....$ 85.00*..... $ * D2720 Crown, resin with high noble metal $ 70.00*.....$ 90.00*..... $ * D2721 Crown, resin with predominantly base metal $ 70.00*.....$ 90.00*..... $ * D2722 Crown, resin with noble metal $ 70.00*.....$ 90.00*..... $ * D2740 Crown, porcelain/ceramic substrate $ 70.00*.....$ * $ * D2750 Crown, porcelain fused to high noble metal $ 70.00*.....$ * $ * D2751 Crown, porcelain fused to predominantly base metal $ 70.00*.....$ * $ * D2752 Crown, porcelain fused to noble metal $ 70.00*.....$ * $ * D2780 Crown, 3/4 cast high noble metal $ 70.00*.....$ * $ * D2781 Crown, 3/4 cast predominantly base metal $ $ $ D2782 Crown, 3/4 cast noble metal $ 70.00*.....$ * $ * CDT-2011/2012: Current Dental Terminology, 2010 American Dental Association. All rights reserved. 7

10 LIBERTY Dental plans Restorative continued LS100 LS200 LS300 D2783 Crown, 3/4 porcelain/ceramic $ 70.00*.....$ * $ * D2790 Crown, full cast high noble metal $ 70.00*.....$ * $ * D2791 Crown, full cast predominantly base metal $ $ $ D2792 Crown, full cast noble metal $ 70.00*.....$ * $ * D2794 Crown, titanium $ 70.00*.....$ *..... $ * D2799 Provisional crown $ $ $ D2910 Recement inlay, onlay, partial coverage restoration no charge......$ $ D2915 Recement cast or prefabricated post & core no charge......$ $ D2920 Recement crown no charge......$ $ D2930 Prefabricated stainless steel crown, primary tooth no charge......$ $ D2931 Prefabricated stainless steel crown, permanent tooth $ $ $ D2932 Prefabricated resin crown $ $ $ D2933 Prefabricated stainless steel crown, resin window $ $ $ D2934 Prefabricated esthetic coated SS crown, primary $ $ $ D2940 Protective restoration (temporary) no charge no charge no charge D2950 Core build-up, including any pins $ $ $ D2951 Pin retention, per tooth, in addition to restoration $ $ $ D2952 Post & core in addition to crown, indirect fabric $ 20.00*.....$ 30.00*..... $ 50.00* D2953 Each additional indirect fabric. post, same tooth $ 20.00*.....$ 25.00*..... $ 30.00* D2954 Prefabricated post & core in addition to crown $ $ $ D2955 Post removal (not in conj. with endodontic therapy) $ $ $ D2957 Each additional prefabricated post, same tooth $ $ $ D2960 Labial veneer (resin laminate), chairside $ $ $ D2961 Labial veneer (resin laminate), laboratory $ $ $ D2962 Labial veneer (porcelain laminate), laboratory $ $ $ D2970 Temporary crown (fractured tooth) $ $ $ D2971 Add l procedure/new crown, existing partial denture $ $ $ D2980 Crown repair, by report $ $ $ Endodontics D3110 Pulp cap direct (excluding final restoration) no charge no charge $ 5.00 D3120 Pulp cap indirect (excluding final restoration) no charge no charge $ 5.00 D3220 Therapeutic pulpotomy (excluding final restoration) no charge......$ $ D3221 Pulpal debridement, primary & permanent teeth $ $ $ D3230 Pulpal therapy (resorbable filling), anterior, primary $ $ $ D3240 Pulpal therapy (resorbable filling), posterior, primary $ $ $ D3310 Anterior (excluding final restoration) $ $ $ D3320 Bicuspid (excluding final restoration) $ $ $ D3330 Molar (excluding final restoration) $ $ $ D3331 Treatment of root canal obstruction; non-surgical $ $ $ D3332 Incomplete endodontic therapy, inoperable $ $ $ D3333 Internal root repair of perforation defects $ $ $ D3346 Retreatment of previous root canal anterior $ $ $ D3347 Retreatment of previous root canal bicuspid $ $ $ D3348 Retreatment of previous root canal molar $ $ $ D3351 Apexification/recalcification/pulp reg. initial visit $ $ $ D3352 Apexification/recalcification/pulp reg. interim med $ $ $ D3353 Apexification/recalcification final visit $ $ $ D3410 Apicoectomy/periradicular surgery anterior $ $ $ D3421 Apicoectomy/periradicular surgery bicuspid $ $ $ D3425 Apicoectomy/periradicular surgery molar $ $ $ D3426 Apicoectomy/periradicular surgery ea. add. root $ $ $ D3430 Retrograde filling per root $ $ $ D3450 Root Amputation per root $ $ $ D3910 Surgical procedure for isolation with rubber dam $ $ $ D3920 Hemisection (incl. root removal), not incl. root canal $ $ $ D3950 Canal prep. & fitting of preformed dowel/post no charge......$ $ Periodontics D4210 Gingivectomy/gingivoplasty, 4+ teeth per quadrant $ $ $ D4211 Gingivectomy/gingivoplasty, 1-3 teeth per quadrant $ $ $ CDT-2011/2012: Current Dental Terminology, 2010 American Dental Association. All rights reserved. 8

11 Periodontics continued LS100 LS200 LS300 D4240 Ging. flap procedure, 4+ teeth per quadrant $ $ $ D4241 Ging. flap procedure, 1-3 teeth per quadrant $ $ $ D4245 Apically positioned flap $ $ $ D4249 Clinical crown lengthening, hard tissue $ $ $ D4260 Osseous surgery, 4+ teeth per quadrant $ $ $ D4261 Osseous surgery, 1-3 teeth per quadrant $ $ $ D4263 Bone replacement graft, 1st site in quadrant $ $ $ D4264 Bone replacement graft, ea. additional site, quad $ $ $ D4265 Biologic materials to aid soft osseous tissue $ $ $ D4266 Guided tissue regeneration-resorbable, per site $ $ $ D4267 Guided tissue regeneration- non resorbable, per site $ $ $ D4270 Pedicle soft tissue graft procedure $ $ $ D4271 Free soft tissue graft procedure (incl. donor site) $ $ $ D4273 Subepithelial connective tissue graft, per tooth $ $ $ D4274 Distal/proximal wedge procedure $ $ $ D4275 Soft tissue allograft $ $ $ D4320 Provisional splinting - intracoronal $ $ $ D4321 Provisional splinting - extracoronal $ $ $ GUIDELINE: No more than two (2) quadrants of periodontal scaling and root planing per appointment/per day are allowable. D4341 Periodontal scaling & root planing, 4+ teeth/quad $ $ $ D4342 Periodontal scaling & root planing, 1-3 teeth/quad $ $ $ D4355 Full mouth debridement $ $ $ D4381 Localized delivery of antimicrobial agent/per tooth $ $ $ D4910 Periodontal maintenance $ $ $ D4920 Unscheduled dressing change/non-treating dentist no charge......$ $ Prosthodontics removable D5110 Complete denture, maxillary $ $ $ D5120 Complete denture, mandibular $ $ $ D5130 Immediate denture, maxillary $ $ $ D5140 Immediate denture, mandibular $ $ $ D5211 Maxillary partial denture, resin base $ $ $ D5212 Mandibular partial denture, resin base $ $ $ D5213 Maxillary partial denture, cast metal/resin base $ $ $ D5214 Mandibular partial denture, cast metal/resin base $ $ $ D5225 Maxillary partial denture, flexible base $ $ $ D5226 Mandibular partial denture, flexible base $ $ $ D5281 Removable unilateral partial denture, 1 pc. cast $ $ $ D5410 Adjust complete denture, maxillary no charge no charge $ D5411 Adjust complete denture, mandibular no charge no charge $ D5421 Adjust partial denture, maxillary no charge no charge $ D5422 Adjust partial denture, mandibular no charge no charge $ D5510 Repair broken complete denture base no charge......$ $ D5520 Replace missing/broken teeth, complete denture $ $ $ D5610 Repair resin denture base no charge......$ $ D5620 Repair cast framework no charge......$ $ D5630 Repair or replace broken clasp $ $ $ D5640 Replace broken teeth, per tooth $ $ $ D5650 Add tooth to existing partial denture $ $ $ D5660 Add clasp to existing partial denture $ $ $ D5670 Replace all teeth & acrylic/cast metal frame, max $ $ $ D5671 Replace all teeth & acrylic/cast metal frame, mand $ $ $ D5710 Rebase complete maxillary denture $ $ $ D5711 Rebase complete mandibular denture $ $ $ D5720 Rebase maxillary partial denture $ $ $ D5721 Rebase mandibular partial denture $ $ $ D5730 Reline complete maxillary denture, chairside no charge......$ $ D5731 Reline complete mandibular denture, chairside no charge......$ $ CDT-2011/2012: Current Dental Terminology, 2010 American Dental Association. All rights reserved. 9

12 LIBERTY Dental plans Prosthodontics removable continued LS100 LS200 LS300 D5740 Reline maxillary partial denture, chairside no charge......$ $ D5741 Reline mandibular partial denture, chairside no charge......$ $ D5750 Reline complete maxillary denture, laboratory $ $ $ D5751 Reline complete mandibular denture, laboratory $ $ $ D5760 Reline maxillary partial denture, laboratory $ $ $ D5761 Reline mandibular partial denture, laboratory $ $ $ D5810 Interim complete denture, maxillary $ $ $ D5811 Interim complete denture, mandibular $ $ $ D5820 Interim partial denture, maxillary $ $ $ D5821 Interim partial denture, mandibular $ $ $ D5850 Tissue conditioning, maxillary no charge no charge $ D5851 Tissue conditioning, mandibular no charge no charge $ Implant services GUIDELINE: Implants and all services associated with implants are listed at the actual member co-payment amount. No additional fee is allowable for porcelain, noble metal, high noble metal, or titanium for implants and procedures associated with implants. D6010 Surgical placement of implant body, endosteal $ $ $ D6056 Prefabricated abutment, includes placement $ $ $ D6058 Abutment supported porcelain/ceramic crown $ $ $ D6059 Abutment supported porcelain/high noble crown $ $ $ D6060 Abutment supported porcelain/base metal crown $ $ $ D6061 Abutment supported porcelain/noble metal crown $ $ $ D6062 Abutment supported cast metal crown, high noble $ $ $ D6063 Abutment supported cast metal crown, base metal $ $ $ D6064 Abutment supported cast metal crown, noble metal $ $ $ D6094 Abutment supported crown, titanium $ $ $ D6065 Implant supported porcelain/ceramic crown $ $ $ D6066 Implant supported porcelain/metal crown $ $ $ D6067 Implant supported metal crown $ $ $ D6068 Abutment supported retainer, porcelain/ceramic FPD $ $ $ D6069 Abutment supported retainer, metal FPD, high noble $ $ $ D6070 Abut. support. retainer, porc./metal FPD, base metal $ $ $ D6071 Abut. support. retainer, porc./metal FPD, noble $ $ $ D6072 Abut. support. retainer, cast metal FPD, high noble $ $ $ D6073 Abut. support. retainer, cast metal FPD, base metal $ $ $ D6074 Abut. support. retainer, cast metal FPD, noble $ $ $ D6194 Abut. supported retainer crown, FPD, titanium $ $ $ D6075 Implant supported retainer for ceramic FPD $ $ $ D6076 Implant supported retainer for porc./metal FPD $ $ $ D6077 Implant supported retainer for cast metal FPD $ $ $ D6092 Recement implant/abutment supported crown $ $ $ D6093 Recement implant/abutment supported FPD $ $ $ Prosthodontics - fixed * GUIDELINES for Pontics and Abutment Inlays, Onlays and Crowns The total maximum amount chargeable to the member for elective upgraded procedures (explained below) is $ per tooth. Providers are required to explain covered benefits as well as any elective differences in materials and fees prior to providing an elective upgraded procedure. 1. Brand name restorations (e.g. Sunrise, Captek, Vitadur-N, Hi-Ceram, Optec, HSP, In-Ceram, Empress, Cerec, AllCeram, Procera, Lava, etc.) may be considered elective upgraded procedures if their related CDT procedure codes are not listed as covered benefits. 2. Benefits for anterior and bicuspid teeth: Resin, porcelain and any resin to base metal or porcelain to base metal crowns are covered benefits for anterior and bicuspid teeth. Adding a porcelain margin may be considered an elective upgraded procedure. 3. Benefits for molar teeth: Cast base metal restorations are covered benefits for molar teeth. Resin-based composite and porcelain/ceramic crowns are not covered benefits on molar teeth. Any resin to metal or porcelain to metal crowns may be considered elective upgraded procedures. Adding a porcelain margin may be considered an elective upgraded procedure. 4. Base metal is the benefit. If elected, the member may be charged additional lab costs for a) noble metal, b) high noble metal, or c) titanium. D6205 Pontic, indirect resin based composite $ 60.00*.....$ 85.00*..... $ * D6210 Pontic, cast high noble metal $ 70.00*.....$ *..... $ * CDT-2011/2012: Current Dental Terminology, 2010 American Dental Association. All rights reserved. 10

13 Prosthodontics - fixed continued LS100 LS200 LS300 D6211 Pontic, cast predominantly base metal $ $ $ D6212 Pontic, cast noble metal $ 70.00*.....$ *..... $ * D6214 Pontic, titanium $ 70.00*.....$ *..... $ * D6240 Pontic, porcelain fused to high noble metal $ 70.00*.....$ *..... $ * D6241 Pontic, porcelain fused to predominantly base metal $ 70.00*.....$ *..... $ * D6242 Pontic, porcelain fused to noble metal $ 70.00*.....$ *..... $ * D6245 Pontic, porcelain/ceramic $ 70.00*.....$ *..... $ * D6250 Pontic, resin with high noble metal $ 70.00*.....$ 90.00*..... $ * D6251 Pontic, resin with predominantly base metal $ 70.00*.....$ 90.00*..... $ * D6252 Pontic, resin with noble metal $ 70.00*.....$ 90.00*..... $ * D6253 Provisional pontic $ $ $ D6545 Retainer, cast metal for resin bonded fixed prosth $ 70.00*.....$ 90.00*..... $ * D6548 Retainer, proc./ceramic, resin bonded fixed prosth $ $ $ D6600 Inlay, porcelain/ceramic, 2 surfaces $ 90.00*.....$ *..... $ * D6601 Inlay, porcelain/ceramic, 3 or more surfaces $ *......$ * $ * D6602 Inlay, cast high noble metal, 2 surfaces $ 85.00*.....$ * $ * D6603 Inlay, cast high noble metal, 3 or more surfaces $ 90.00*.....$ * $ * D6604 Inlay, cast base metal, 2 surfaces $ $ $ D6605 Inlay, cast base metal, 3 or more surfaces $ $ $ D6606 Inlay, cast noble metal, 2 surfaces $ 60.00*.....$ * $ * D6607 Inlay, cast noble metal, 3 or more surfaces $ 85.00*.....$ * $ * D6624 Inlay, Titanium $ $ $ D6608 Onlay, porcelain/ceramic, 2 surfaces $ *......$ * $ * D6609 Onlay, porcelain/ceramic, 3 or more surfaces $ *......$ * $ * D6610 Onlay, cast high noble metal, 2 surfaces $ *......$ * $ * D6611 Onlay, cast high noble metal, 3 or more surfaces $ *......$ * $ * D6612 Onlay, cast base metal, 2 surfaces $ $ $ D6613 Onlay, cast base metal, 3 or more surfaces $ $ $ D6614 Onlay, cast noble metal, 2 surfaces $ 90.00*.....$ * $ * D6615 Onlay, cast noble metal 3 or more surfaces $ 95.00*.....$ * $ * D6634 Onlay, titanium $ 95.00*.....$ * $ * D6710 Crown, indirect resin based composite $ 60.00*.....$ 85.00*..... $ * D6720 Crown, resin with high noble metal $ 70.00*.....$ 90.00*..... $ * D6721 Crown, resin with predominantly base metal $ 70.00*.....$ 90.00*..... $ * D6722 Crown, resin with noble metal $ 70.00*.....$ 90.00*..... $ * D6740 Crown, porcelain/ceramic $ 70.00*.....$ * $ * D6750 Crown, porcelain fused to high noble metal $ 70.00*.....$ * $ * D6751 Crown, porcelain fused to predominantly base metal $ 70.00*.....$ * $ * D6752 Crown, porcelain fused to noble metal $ 70.00*.....$ * $ * D6780 Crown, 3/4 cast high noble metal $ 70.00*.....$ * $ * D6781 Crown, 3/4 cast predominantly base metal $ $ $ D6782 Crown, 3/4 cast noble metal $ 70.00*.....$ * $ * D6783 Crown, 3/4 porcelain/ceramic $ 70.00*.....$ * $ * D6790 Crown, full cast high noble metal $ 70.00*.....$ * $ * D6791 Crown, full cast predominantly base metal $ $ $ D6792 Crown, full cast noble metal $ 70.00*.....$ * $ * D6793 Provisional retainer crown $ $ $ D6794 Crown, titanium $ 70.00*.....$ * $ * D6930 Recement fixed partial denture no charge no charge $ D6940 Stress breaker $ $ $ D6970 Post & core in addition to FPD retainer, indirect $ 20.00*.....$ 30.00*..... $ 50.00* D6972 Prefabricated post & core in add. to FPD retainer $ $ $ D6973 Core buildup for retainer, including any pins $ $ $ D6976 Each additional indirectly fabricated post/same tooth $ 20.00*.....$ 50.00*..... $ 55.00* D6977 Each additional prefabricated post, same tooth $ $ $ D6980 Fixed partial denture repair, by report $ $ $ Oral and maxillofacial surgery D7111 Extraction, coronal remnants, deciduous tooth no charge no charge $ 5.00 D7140 Extraction, erupted tooth or exposed root no charge......$ $ D7210 Surgical removal of erupted tooth $ $ $ D7220 Removal of impacted tooth, soft tissue $ $ $ D7230 Removal of impacted tooth, partially bony $ $ $ CDT-2011/2012: Current Dental Terminology, 2010 American Dental Association. All rights reserved. 11

14 LIBERTY Dental plans Oral and maxillofacial surgery continued LS100 LS200 LS300 D7240 Removal of impacted tooth, completely bony $ $ $ D7241 Removal impacted tooth, complete bony,complication $ $ $ D7250 Surgical removal residual tooth roots, cutting proc $ $ $ D7261 Primary closure of a sinus perforation $ $ $ D7270 Tooth reimplantation/stabilization, accident $ $ $ D7280 Surgical access of an unerupted tooth $ $ $ D7282 Mobilization of erupted/malpositioned tooth $ $ $ D7283 Placement, device to facilitate eruption, impaction $ $ $ D7285 Biopsy of oral tissue, hard (bone, tooth) no charge......$ $ D7286 Biopsy of oral tissue, soft no charge......$ $ D7287 Exfoliative cytological sample collection $ $ $ D7288 Brush biopsy, tranepithelial sample collection $ $ $ D7310 Alveoloplasty with extractions, 4+ teeth, quadrant $ $ $ D7311 Alveoloplasty with extractions, 1-3 teeth, quadrant $ $ $ D7320 Alveoloplasty, w/o extractions, 4+ teeth, quadrant $ $ $ D7321 Alveoloplasty, w/o extractions, 1-3 teeth, quadrant $ $ $ D7340 Vestibuloplasty, ridge extension (2nd epithelialization) $ $ $ D7350 Vestibuloplasty, ridge extension $ $ $ D7450 Removal, benign odotogenic cyst/tumor, up to $ $ $ D7451 Removal, benign odotogenic cyst/tumor, over $ $ $ D7460 Removal, benign nonodontogenic cyst/tumor, to $ $ $ D7461 Removal, benign nonodontogenic cyst/tumor, $ $ $ D7471 Removal of lateral exostosis, maxilla or mandible $ $ $ D7472 Removal of torus palatinus $ $ $ D7473 Removal of torus mandibularis $ $ $ D7485 Surgical reduction of osseous tuberosity $ $ $ D7510 Incision & drainage of abscess, intraoral soft tissue $ $ $ D7511 Incision/drainage, abscess, intraoral soft, complicated $ $ $ D7520 Incision & drainage, abscess, extraoral soft tissue $ $ $ D7521 Incision/drainage, abscess, extraoral soft, complicate $ $ $ D7530 Remove foreign body, mucosa, skin, tissue $ $ $ D7560 Maxillary sinusotomy, remove th. frag./foreign body $ $ $ D7960 Frenulectomy (frenectomy or frenotomy), sep. proc no charge no charge $ D7963 Frenuloplasty no charge no charge $ D7970 Excision of hyperplastic tissue, per arch $ $ $ D7971 Excision of pericoronal gingival $ $ $ Adjunctive general services D9110 Palliative (emergency) treatment, minor procedure $ $ $ D9120 Fixed partial denture sectioning no charge no charge $ 5.00 D9210 Local anesthesia not with operative/surgical proced no charge no charge no charge D9211 Regional block anesthesia no charge no charge no charge D9212 Trigeminal division block anesthesia no charge no charge..... no charge D9215 Local anesthesia with operative/surgical procedure no charge no charge no charge ** GUIDELINE: Deep sedation/general anesthesia is a covered benefit only when in conjunction with covered oral surgery and pedodontic procedures when dispensed in a dental office by a practitioner acting within the scope of his/her licensure; and when warranted by documented conditions that local anesthetic is contraindicated. General anesthesia, as used for dental pain control, means the elimination of all sensations accompanied by a state of unconsciousness. Patient apprehension and/or nervousness are not of themselves sufficient justification for deep sedation/general anesthesia or intravenous conscious sedation/ analgesia. D9220 Deep sedation/general anesthesia, 1st 30 minutes $ **.....$ **..... $ ** D9221 Deep sedation/general anesthesia, each add. 15 min $ **.....$ **..... $ ** D9230 Inhalation of nitrous oxide/analgesia, anxiolysis $ $ $ D9241 Intravenous conscious sedation/analgesia, 1st 30 min $ **.....$ **..... $ ** D9242 IV conscious sedation/analgesia, each add. 15 min $ 70.00**.....$ 90.00**..... $ ** D9248 Non-intravenous conscious sedation $ $ $ D9310 Consultation, other than requesting dentist no charge no charge $ D9430 Office visit, observation, regular hrs., no other serv no charge no charge no charge D9440 Office visit, after regularly scheduled hours $ $ $ D9450 Case presentation, detailed & extensive treatment no charge no charge no charge CDT-2011/2012: Current Dental Terminology, 2010 American Dental Association. All rights reserved. 12

15 Adjunctive general services continued LS100 LS200 LS300 D9630 Other drugs and/or medicaments, by report $ $ $ D9910 Application of desensitizing medicament no charge no charge $ 5.00 D9911 Application of desensitizing resin, per tooth no charge no charge $ 5.00 D9930 Treatment of complications, post surgical, unusual no charge......$ $ D9940 Occlusal guard, by report $ $ $ D9942 Repair and/or reline of occlusal guard $ $ $ D9950 Occlusion analysis, mounted case no charge no charge no charge D9951 Occlusal adjustment, limited $ $ $ D9952 Occlusal adjustment, complete $ $ $ D9971 Odontoplasty 1-2 teeth $ $ $ D9972 External bleaching per arch $ $ $ Broken appointment, less than 24 hour notice $ $ $ Office visit, per visit no charge no charge no charge Orthodontic Services D0340 Cephalometric x-ray and tracings for orthodontic puposes $ $ $ D0470 Diagnostic casts for orthodontic purposes $ $ $ D9310 Initial consultation for orthodontic purposes $ $ $ 0.00 D8010 Limited orthodontic treatment of the primary dentition $ 1, $ 1, $ 1, D8020 Limited orthodontic treatment of the transitional dentition $ 1, $ 1, $ 1, D8030 Limited orthodontic treatment of the adolescent dentition $ 1, $ 1, $ 1, D8040 Limited orthodontic treatment of the adult dentition $ 1, $ 1, $ 1, D8050 Interceptive orthodontic treatment of the primary dentition $ $ $ D8060 Interceptive orthodontic treatment of the transitional dentition $ $ $ D8070 Comprehensive orthodontic treatment of the transitional dentition $ 1, $ 1, $ 1, D8080 Comprehensive orthodontic treatment of the adolescent dentition $ 1, $ 1, $ 1, D8090 Comprehensive orthodontic treatment of the adult dentition $ 1, $ 1, $ 1, D8210 Removable appliance therapy $ $ $ D8220 Fixed appliance therapy $ $ $ D8660 Pre-orthodontic treatment visits $ $ $ 0.00 D8670 Periodic orthodontic visits (as part of contract) $ $ $ 0.00 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $ $ $ Broken appointment (less than 24 hour notice) $ $ $ LIBERTY Dental Plan will arrange for you to receive services from a contracted Dental Specialist if the necessary treatment is outside the scope of General Dentistry. Your General Dentist will initiate the referral process with LIBERTY Dental Plan. When you receive services from a Dental Specialist utilizing the proper referral process, the Member Co-Payments listed in this Copayment Schedule will apply. Underwritten by LIBERTY Dental Plan of California, Inc. For more information on participation, eligibility, and waiting periods, see the Plan Guidelines section. CDT-2011/2012: Current Dental Terminology, 2010 American Dental Association. All rights reserved. 13

16 HumanaDental plan guidelines Eligibility Traditional Preferred, PPO, Preventive Plus, and DHMO 2+ eligible employees Traditional Preferred, PPO, Preventive Plus, and DHMO Employer pays 100 percent of premium Employer contributes at least 25 percent of premium For groups with two or more eligible employees, HumanaDental will lower the participation requirement to 50 percent if 25 percent or more of the eligible employees waive due to other credible coverage. Voluntary Traditional Preferred, PPO, and Preventive Plus Voluntary DHMO Participation 100 percent 75 percent Two enrolled employees or 25 percent, whichever is greater Two or more enrolled employees Waiting periods Traditional Preferred, PPO, and Preventive Plus HumanaDental reimburses most services in your plan as of your effective date. There are no waiting periods for preventive services. There are no waiting periods for endodontics unless you are a late applicant. In some circumstances, benefits are available after 12 months. Please see the chart below. Enrollment type Group size Preventive Basic Major 1 Orthodontia 1 Initial enrollment, open enrollment, and timely add-on Initial enrollment, open enrollment, and timely add-on 2-9 enrolled employees No No 12 months 2 Not available 10 or more enrolled employees No No No 12 months 2 (No waiting period for employer-sponsored) Late applicant 3 All group sizes No 12 months 12 months 12 months 4 1 Preventive Plus does not cover major and orthodontia services. 2 The 12-month waiting period may be decreased or waived based on the number of months the member had dental coverage immediately before joining the HumanaDental plan. Members must have prior orthodontic coverage to reduce or waive the waiting period under orthodontia. 3 Late applicants not allowed with open enrollment option. 4 Orthodontia is not available for groups with 2-9 enrolled employees. If the oral surgery rider is selected for groups with 2-9 enrolled employees, there is a 12 month waiting period for the oral surgery rider. 14 This is not a complete disclosure of the plan qualifications and limitations. Specific limitations and exclusions as contained in the Regulatory and Technical Information Guide will be provided by the agent/broker. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the plan selection.

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18 thank you for considering HumanaDental.