SHL Dental PPO Plan 29 - SB Adult Only Coverage
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1 SHL Dental PPO Plan 29 - SB Adult Only Coverage Attachment A Benefit Schedule Please read the definition of Eligible Dental Expenses ( EDE ) and SHL Reimbursement Schedule in the Certificate. When accessing a Non-Plan Dentist, you are responsible for any charges over There is no Calendar Year Deductible (CYD) for Services and the CYD for / I Services is combined. The CYD for Plan Dentist /I Services is $50 of EDE per Insured and $150 of EDE per Family. The CYD for Non Plan Dentist /I Services is $50 of EDE per Insured and $150 of EDE per Family. Further, the stated CYD maximum amounts are separate for each tier of benefits and do not accumulate to one another. The Calendar Year plan maximum benefit for Tier II/Tier III Plan and Non-Plan Services is a combined limit of $2,000 per Insured. I Covered Services Waiting Period: You will not be eligible to receive any benefits for I Covered Services until you have been covered under this Certificate for 12 consecutive months. For Group s who meet the following two requirements, Waiting Period Credit will be allowed for the amount of time an Insured had continuous coverage under the Group s previous dental plan. First, the previous plan had been in force at least twelve (12) consecutive months immediately prior to the Effective Date of this plan. And, second, this certificate was issued within sixty (60) days after the date the previous dental plan was discontinued. Credit will be applied only for those Insureds covered under the Group s prior dental plan as of the Effective Date of this Certificate. Predetermination: Predetermination is recommended for all I services. Please see Section 4 of your Dental Certificate for additional information about Predetermination. Deductible Credit: Dental Expenses incurred by an individual on or after January 1 st of the Calendar Year in which this Certificate becomes effective, will apply to the current Calendar Year Deductible for this plan if: 1) proof is furnished to SHL that such dental expenses were covered under the Group s dental insurance policy in force immediately prior to the Effective Date of this Certificate; and 2) such expense would have been considered Covered Services under this Certificate had this Certificate been in force at the time expenses were incurred. 17S_SN_DPPO_PLAN29 Page 1
2 Services: Diagnostic and Preventive Routine Evaluation (exams limited to twice (2) per Calendar Year) Insured pays 0% of Insured pays 20% of Periodic Oral Examination Limited to Oral Evaluation problem-focused/emergency Insured pays 0% of Insured pays 20% of Detailed and Extensive Oral Evaluation problem-focused (exam limited to specialist only, i.e. periodontal Exam) Insured pays 0% of Insured pays 20% of Intraoral Radiograph Complete Series or Panoramic Survey Film (limited to one or the other, once every three (3) Calendar Year Insured pays 0% of Insured pays 20% of Intraoral or Extraoral Radiographs Insured pays 0% of Insured pays 20% of Bitewing Radiographs (limited to twice (2) per Calendar Year) Insured pays 0% of Insured pays 20% of Oral/facial images, Pulp Vitality Tests and Diagnostic Casts Insured pays 0% of Insured pays 20% of Prophylaxis, Adult (limited to twice (2) per Calendar Year) Insured pays 0% of Insured pays 20% of Recementation of Space Maintainer Insured pays 0% of Insured pays 20% of Services: Restorative (Includes local anesthesia and routine postoperative care) Restoration/Amalgam per tooth (anterior & posterior teeth) 20% of 40% of Restoration/Composite per tooth (anterior & posterior teeth) 20% of 40% of Recementation of Inlay, Crown or Bridge 20% of Sedative Filling 20% of Pin Retention per tooth, in addition to restoration 20% of 40% of 40% of 40% of Post Removal (not in conjunction with endodontic therapy) 20% of 40% of 17S_SN_DPPO_PLAN29 Page 2
3 Services: Endodontics Pulp Cap - excluding final restoration 20% of Therapeutic Pulpotomy, excluding final restoration 20% of Pulpal Therapy, per primary tooth 20% of Root Canal Therapy - initial or re-treatment, per tooth - Note: Root Canals include intra-operative radiographs; excludes final restoration. 20% of Retrograde Filling per root 20% of Root Amputation per root 20% of 40% of 40% of 40% of 40% of 40% of 40% of Hemisection (including root removal) not including root canal therapy Services: Periodontics 20% of 40% of Gingivectomy or Gingivoplasty per quadrant 20% of Gingivectomy or Gingivoplasty per tooth 20% of Gingival Curettage, surgical per quadrant 20% of 40% of 40% of 40% of Gingival Flap Procedure (including Root Planing) per quadrant 20% of 40% of Clinical Crown Lengthening 20% of Osseous Surgery (including flap entry and closure) 20% of 40% of 40% of Free Soft Tissue Graft Procedure (including donor site surgery) 20% of 40% of Periodontal Scaling.Root Planing per quadrant (limited to once (1) per quadrant per Calendar Year) 20% of 40% of Full Mouth Debridement (limited to once in three (3) Calendar Years) 20% of 40% of Periodontal Maintenance Procedure following Active Therapy (limited to once in any three (3) month period) 20% of 40% of 17S_SN_DPPO_PLAN29 Page 3
4 Services: Oral Surgery (includes local anesthesia and routine postoperative care) Simple Extraction per tooth 20% of Surgical Extraction per tooth 20% of Alveoloplasty per quadrant 20% of Removal of Exostosis per site 20% of Incision and Drainage of Abscess 20% of Frenulectomy 20% of 40% of 40% of 40% of 40% of 40% of 40% of Services: Adjunctive General Services Excision of hyperplastic tissue per arch 20% of Sectioning of a bridge, to enable extraction of an abutment tooth 20% of Adjustment to Denture of Partial, per appliance, per visit 20% of Repair to Denture of Partial Denture, per repair, per appliance 20% of 40% of 40% of 40% of 40% of Palliative (Emergency) treatment of dental pain minor procedures 20% of 40% of General Anesthesia or Intravenous Sedation when administered by the dentist in the office (when in connection with a surgical extraction or surgical procedure, or when Medically Necessary) 20% of 40% of Professional Consultation (diagnostic service provided by dentist other than dentist providing treatment) 20% of 40% of Office Visit after Regularly Scheduled Office Hours 20% of Therapeutic Drug Injection 20% of Other Drugs and/or Medicaments, by report 20% of Application of Desensitizing Medicaments 20% of 40% of 40% of 40% of 40% of Treatment of Complication (post-surgical), unusual circumstances 20% of 40% of 17S_SN_DPPO_PLAN29 Page 4
5 I Services: Prosthodontics Removable (includes local anesthesia and routine postoperative care) (Subject to 12 month waiting period) I Denture or Partial Denture, per appliance 50% of I Rebase Denture of Partial Denture (limited to once (1) per three (3) Calendar years, per appliance) 50% of 50% of 50% of I Reline Denture or Partial Denture, chairside process (limited to twice (2) per Calendar Year, per appliance) 50% of 50% of I Reline Denture or Partial Denture, laboratory process (limited to twice (2) per Calendar Year, per appliance) 50% of 50% of I Interim Partial Denture, replacing anterior teeth (temporary stayplate/flipper) 50% of 50% of I Tissue Conditioning (limited to twice (2) per Calendar Year per appliance) 50% of 50% of Note: Adjustments are included in the cost of full and immediate dentures, partial dentures, relines and tissues conditionings within the first six (6) months after installation. Relines are allowed twice in a Calendar Year. Precision attachments, overdentures, specialized techniques and characterizations are considered optional and the additional expense shall be borne by the insured. All partials included conventional clasps and rests. I Services: Restorative and Prosthodontics Fixed (includes local anesthesia and routine postoperative care) (Subject to 12 month waiting period) I Inlay or Onlay each 50% of 50% of I Crown per tooth 50% of I Core Buildup, including pins 50% of 50% of 50% of I Post and Core, in addition to crown 50% of I Temporary Crown, fractured tooth 50% of I Crown or Bridge Repair (by report) 50% of I Pontic per tooth 50% of I Retainer (inlay/onlay) per tooth 50% of I Retainer (crown/abutment) per tooth 50% of 50% of 50% of 50% of 50% of 50% of 50% of Note: Refer to the Certificate of Coverage for limitations, exclusions, Managed Care requirements and additional information about the covered services. s. 17S_SN_DPPO_PLAN29 Page 5
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