SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company

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1 SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* COUNTY OF LOS ANGELES D This Schedule of Benefits lists the services available to you under your SafeGuard plan, as well as the co-payments associated with each procedure. There are other factors that impact how your plan works and those are included here in the Exclusions and Limitations. Specialty Care Information: During the course of treatment, your SafeGuard selected general dentist may recommend the services of a dental specialist. Your selected general dentist may refer you directly to a contracted SafeGuard specialty care provider for endodontics, oral surgery, or periodontics; no referral or pre-authorization from SafeGuard is required. * Prior authorization from SafeGuard is required for referrals to participating orthodontists and pediatric specialists. Your SafeGuard selected general dentist will submit all required documentation to SafeGuard and SafeGuard will advise you of the name, address and telephone number of a SafeGuard contracted orthodontist or pediatric specialist in your area. Diagnostic Treatment D0120 Periodic oral evaluation - established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation - new or established patient D0171 Re-evaluation post-operative office visit D0180 Comprehensive periodontal evaluation - new or established patient Office visit - per visit (including all fees for sterilization and/or infection control) Radiographs/Diagnostic Imaging (X-rays) D0210 Intraoral complete series of radiographic images D0220 Intraoral periapical first radiographic image D0230 Intraoral periapical each additional radiographic image D0240 Intraoral occlusal radiographic image D0250 Extra-oral 2D projection radiographic image created using a stationary radiation source, and detector D0270 Bitewing single radiographic image D0272 Bitewings two radiographic images D0273 Bitewings three radiographic images D0274 Bitewings four radiographic images D0330 Panoramic radiographic image D0350 2D oral/facial photographic image obtained intra-orally or extra-orally Tests and Examinations D0460 Pulp vitality tests D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report CA sob 1 01/17

2 SCHEDULE OF BENEFITS (continued) Preventive Services Procedures identified with an asterisk (*) are limited to twice a year, unless medically necessary. D1110 Prophylaxis adult* D1120 Prophylaxis child* D1206 Topical application of fluoride varnish* D1208 Topical application of fluoride excluding varnish D1330 Oral hygiene instructions D1510 Space maintainer fixed unilateral $15 D1515 Space maintainer fixed bilateral $15 D1520 Space maintainer removable unilateral $15 D1525 Space maintainer removable bilateral $15 D1550 Re-cement or re-bond space maintainer D1555 Removal of fixed space maintainer Restorative Treatment D2140 Amalgam one surface, primary or permanent D2150 Amalgam two surfaces, primary or permanent D2160 Amalgam three surfaces, primary or permanent D2161 Amalgam four or more surfaces, primary or permanent D2330 Resin-based composite one surface, anterior D2331 Resin-based composite two surfaces, anterior D2332 Resin-based composite three surfaces, anterior D2335 Resin-based composite four or more surfaces or involving incisal angle (anterior) D2390 Resin-based composite crown, anterior Crowns An additional charge will be applied for any procedure using noble or high noble metal. The cost of porcelain for covered restorations is included in the copayments listed below. D2740 Crown porcelain/ceramic substrate $60 D2750 Crown porcelain fused to high noble metal $60 D2751 Crown porcelain fused to predominantly base metal $60 D2752 Crown porcelain fused to noble metal $60 D2780 Crown ¾ cast high noble metal $60 D2781 Crown ¾ cast predominantly base metal $60 D2782 Crown ¾ cast noble metal $60 D2790 Crown full cast high noble metal $60 D2791 Crown full cast predominantly base metal $60 D2792 Crown full cast noble metal $60 D2794 Crown titanium $60 D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core D2920 Re-cement or re-bond crown D2930 Prefabricated stainless steel crown primary tooth D2931 Prefabricated stainless steel crown permanent tooth D2940 Protective restoration D2950 Core buildup, including any pins when required D2951 Pin retention per tooth, in addition to restoration D2952 Post and core in addition to crown, indirectly fabricated sob 2

3 SCHEDULE OF BENEFITS (continued) D2954 Prefabricated post and core in addition to crown Endodontics All procedures exclude final restoration. D3110 Pulp cap direct (excluding final restoration) D3120 Pulp cap indirect (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament D3310 Endodontic therapy, anterior tooth (excluding final restoration) $45 D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) $45 D3330 Endodontic therapy, molar (excluding final restoration) $45 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $45 D3346 Retreatment of previous root canal therapy anterior $45 D3347 Retreatment of previous root canal therapy bicuspid $45 D3348 Retreatment of previous root canal therapy molar $45 D3351 Apexification/recalcification initial visit (apical closure / calcific repair of perforations, root resorption, etc.) D3352 Apexification/recalcification interim medication replacement D3353 Apexification/recalcification final visit (includes completed root canal therapy apical closure/calcific repair of perforations, root resorption, etc.) D3410 Apicoectomy anterior D3421 Apicoectomy bicuspid (first root) D3425 Apicoectomy molar (first root) D3426 Apicoectomy (each additional root) D3430 Retrograde filling per root Periodontics D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded $55 spaces per quadrant D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded $41 spaces per quadrant D4240 Gingival flap procedure, including root planning-four or more contiguous teeth or $85 tooth bounded spaces per quadrant D4241 Gingival flap procedure, including root planning-one to three contiguous teeth or $64 tooth bounded spaces per quadrant D4260 Osseous surgery (including elevation of a full thickness flap and closure) four or $85 more contiguous teeth or tooth bounded spaces per quadrant D4261 Osseous surgery (including elevation of a full thickness flap and closure) one to $64 three contiguous teeth or tooth bounded spaces per quadrant D4341 Periodontal scaling and root planing four or more teeth per quadrant D4342 Periodontal scaling and root planing one to three teeth per quadrant Removable Prosthodontics Replacement limit 1 every 36 months Denture relines are limited to 1 every 12 months. Includes up to 3 adjustments within 6 months of delivery. D5110 Complete denture maxillary sob 3

4 SCHEDULE OF BENEFITS (continued) D5120 Complete denture mandibular D5130 Immediate denture maxillary D5140 Immediate denture mandibular D5211 Maxillary partial denture resin base (including any conventional clasps, rests and teeth) D5212 Mandibular partial denture resin base (including any conventional clasps, rests and teeth) D5213 Maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5221 Immediate maxillary partial denture resin base (including any conventional clasps, rests and teeth) D5222 Immediate mandibular partial denture resin base (including any conventional clasps, rests and teeth) D5223 Immediate maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5224 Immediate mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5410 Adjust complete denture maxillary D5411 Adjust complete denture mandibular D5421 Adjust partial denture maxillary D5422 Adjust partial denture mandibular D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5620 Repair cast framework D5630 Repair or replace broken clasp - per tooth D5640 Replace broken teeth per tooth D5710 Rebase complete maxillary denture $45 D5711 Rebase complete mandibular denture $45 D5720 Rebase maxillary partial denture $45 D5721 Rebase mandibular partial denture $45 D5730 Reline complete maxillary denture (chairside) $35 D5731 Reline complete mandibular denture (chairside) $35 D5740 Reline maxillary partial denture (chairside) $35 D5741 Reline mandibular partial denture (chairside) $35 D5750 Reline complete maxillary denture (laboratory) $35 D5751 Reline complete mandibular denture (laboratory) $35 D5760 Reline maxillary partial denture (laboratory) $35 D5761 Reline mandibular partial denture (laboratory) $35 D5820 Interim partial denture (maxillary) D5821 Interim partial denture (mandibular) Crowns/Fixed Bridges - Per Unit An additional charge will be applied for any procedure using noble or high noble metal. The cost of porcelain for covered restorations is included in the copayments listed below. D6210 Pontic cast high noble metal $60 D6211 Pontic cast predominantly base metal $60 D6212 Pontic cast noble metal $60 D6214 Pontic titanium $60 sob 4

5 SCHEDULE OF BENEFITS (continued) D6240 Pontic porcelain fused to high noble metal $60 D6241 Pontic porcelain fused to predominantly base metal $60 D6242 Pontic porcelain fused to noble metal $60 D6250 Pontic resin with high noble metal $60 D6251 Pontic resin with predominantly base metal $60 D6252 Pontic resin with noble metal $60 D6720 Retainer crown resin with high noble metal $60 D6721 Retainer crown resin with predominantly base metal $60 D6722 Retainer crown resin with noble metal $60 D6750 Retainer crown porcelain fused to high noble metal $60 D6751 Retainer crown porcelain fused to predominantly base metal $60 D6752 Retainer crown porcelain fused to noble metal $60 D6780 Retainer crown ¾ cast high noble metal $60 D6781 Retainer crown ¾ cast predominantly base metal $60 D6782 Retainer crown ¾ cast noble metal $60 D6790 Retainer crown full cast high noble metal $60 D6791 Retainer crown full cast predominantly base metal $60 D6792 Retainer crown full cast noble metal $60 D6794 Retainer crown titanium $60 D6930 Re-cement or re-bond fixed partial denture D6940 Stress breaker Oral Surgery Includes routine - post operative visits/treatment. Surgical removal of impacted teeth - (not covered unless pathology [disease] exists). Surgical removal of wisdom tooth/third molar for orthodontic reasons only is not covered. D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and $50 including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth soft tissue $50 D7230 Removal of impacted tooth partially bony $50 D7240 Removal of impacted tooth completely bony $50 D7250 Removal of residual tooth roots (cutting procedure) $50 D7285 Incisional biopsy of oral tissue hard (bone, tooth) D7286 Incisional biopsy of oral tissue soft D7510 Incision and drainage of abscess intraoral soft tissue D7511 Incision and drainage of abscess intraoral soft tissue complicated (includes drainage of multiple fascial spaces) D7960 Frenulectomy aka frenectomy or frenotomy separate procedure not incidental to another procedure D7963 Frenuloplasty Orthodontics D8080 Comprehensive orthodontic treatment of the adolescent dentition $1,000 D8090 Comprehensive orthodontic treatment of the adult dentition $1,000 Unspecified orthodontic procedure, by report Orthodontic treatment plan and records (pre/post x-rays (cephalometric, $150 panoramic, etc.), photos, study models) sob 5

6 SCHEDULE OF BENEFITS (continued) Start-up fees shall consist of the initial examination, diagnosis and consultation, study models and the retention phase of treatment up to a maximum of two (2) years. This includes construction, placement, and adjustment of retainers for a maximum period of two (2) years. The maximum cost for such start-up fees shall not exceed one hundred fifty dollars ($150.00). Adjunctive General Services D9110 Palliative (emergency) treatment of dental pain minor procedure $5 D9120 Fixed partial denture sectioning D9215 Local anesthesia in conjunction with operative or surgical procedures D9219 Evaluation for deep sedation or general anesthesia D9223 Deep sedation/general anesthesia each 15 minute increment $15 D9310 Consultation diagnostic service provided by dentist or physician other than requesting dentist or physician D9430 Office visit for observation (during regularly scheduled hours) no other services performed D9440 Office visit after regularly scheduled hours $5 D9952 Occlusal adjustment complete D9986 Missed appointment $10 (less than 24-hr notice) D9987 Cancelled appointment (if less than 24-hr notice, see D9986) Current Dental Terminology American Dental Association sob 6

7 DENTAL BENEFITS: LIMITATIONS AND ADDITIONAL CHARGES 1. Prophylaxis: Limited to two (2) in any twelve (12) consecutive months. 2. Dentures: (full upper and/or lower): Are not to exceed one (1) each in any thirty-six (36) consecutive months. Replacement will be provided for an existing denture or bridge only if it is unsatisfactory and cannot be made satisfactory. 3. Dentures: (partial): Are not to be replaced within any thirty-six (36) consecutive month period unless necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible. 4. Fixed Bridges: Will be authorized only when a partial cannot satisfactorily restore the case. If fixed bridges are used when a partial could satisfactorily restore the case, it is considered optional treatment. Member must pay the difference between the cost of a partial and a fixed bridge. 5. Denture Relines: Are limited to one (1) during any twelve (12) consecutive months. 6. Five periodontal treatments: Are allowed during any twelve (12) consecutive months. 7. Bite-wing x-rays: Are limited to not more than one (1) series of four (4) films in any six (6) month period. 8. Full mouth x-rays: One (1) set every twenty-four (24) consecutive months. 9. Orthodontic treatment is subject to the following: A. Orthodontic treatment must be provided by a member of the SAFEGUARD orthodontic panel. B. Plan benefits shall cover twenty-four (24) months of active, usual and customary orthodontic treatment. Treatment that extends beyond twenty-four (24) months beyond the point of full permanent dentition will be subject to an office visit charge. C. The following are not included as orthodontic benefits: 1. Lost or broken appliances; 2. Retreatment of orthodontic cases; 3. Treatment in progress at inception of eligibility; 4. Changes in treatment necessitated by an accident; 5. Orthodontic treatment that involves: a. Maxillo-facial surgery; b. Treatment involving surgically exposing impacted teeth (i.e., maxillary cuspids); c. Myofunctional therapy; d. Cleft palate; e. Micrognathia; f. Macroglossia; g. Hormonal imbalances causing growth and developmental abnormalities; h. Treatment related to temporomandibular joint disturbances; i. Lingually placed direct bonded appliances and arch wires - invisible braces. D. Should a Member be terminated by the COUNTY for any reason, and at the time of termination be receiving orthodontic treatment, the Member and not SAFEGUARD will be responsible for payment of balance due for treatment performed after termination. The Member s payment shall be based upon a maximum copayment of twelve hundred fifty dollars ($1,250.00) (excluding diagnostic records) and be prorated over the number of months to completion of treatment, and be payable on such terms and conditions as are arranged between the Member and the orthodontist. E. Start-up fees shall consist of the initial examination, diagnosis and consultation, study models and the retention phase of treatment up to a maximum of two (2) years. This includes construction, placement, and adjustment of retainers for a maximum period of two (2) years. The maximum cost for such start-up fees shall not exceed one hundred fifty dollars ($150.00). limit 7

8 DENTAL BENEFITS: LIMITATIONS AND ADDITIONAL CHARGES F. If a Member does not require treatment or chooses not to start treatment after the Provider has completed a diagnosis and consultation, the Member will be charged a consultation fee of twenty-five dollars ($25.00) in addition to the fees for such diagnostic records. G. Orthodontic treatment using removable and/or functional appliances in conjunction with eventual banding shall be considered full treatment. H. Extractions for orthodontic purposes only are not a covered benefit. I. Start-up fees shall consist of diagnostic records, including: 1. Cephalometric X-rays and other X-rays, if needed: 2. Diagnostic tracings of cephalometric X-rays; 3. Photographs. J. Orthodontic copayments are guaranteed by SAFEGUARD for the full term of the Agreement subject to the provisions of this Orthodontic Limitation. limit 8

9 DENTAL BENEFITS: EXCLUSIONS These procedures and services are not included in the Plan: 1. Cosmetic dental care. 2. General anesthesia and services of a special anesthesiologist, except when medically necessary for extractions. 3. Dental conditions arising out of and due to Member s employment or for which Workers Compensation is payable. 4. Treatment required by reason of war. 5. Hospital charges of any kind. 6. Major surgery of fractures and dislocations. 7. Loss or theft of dentures or bridgework. 8. Services which are provided by anyone not specifically authorized by this Plan. 9. Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage under this Plan. 10. Experimental dentistry. exclusions 9

10 LANGUAGE ASSISTANCE As a SafeGuard member you have a right to free language assistance services, including interpretation and translation services. SafeGuard collects and maintains your language preferences, race, and ethnicity so that we can communicate more effectively with our members. If you require language assistance or would like to inform SafeGuard of your preferred language, please contact SafeGuard at (800) Como miembro de SafeGuard usted tiene derecho a recibir servicios gratuitos de asistencia en idiomas. Esto incluye servicios de interpretación y traducción. SafeGuard recaba la información sobre sus preferencias de idioma, raza, y etnia de manera que nos podamos comunicar eficazmente con nuestros afiliados. Si necesita asistencia en su idioma o quiere informarle a SafeGuard sobre su idioma de preferencia, comuníquese con SafeGuard al (800)

Direct Referral Dental Plan* SOC-STANDARD

SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* SOC-STANDARD This Schedule of Benefits lists the services available to you under your