Schedule of Covered Services and Copayments CA SmartSmile Plan

Transcription

1 Schedule of Covered Services and Copayments CA SmartSmile Plan D431 adjunctive pre-diagnostic test that aids in 1 D9543 Office Visit 4 detection of mucosal abnormalities D9986 missed appointment Per office including premalignant and malignant policy lesions, not to include cytology or biopsy D9987 cancelled appointment Per office procedures policy D46 pulp vitality tests covered Diagnostic D47 diagnostic casts with a finding of low risk 5 D61 caries risk assessment and documentation, 1 D12 periodic oral evaluation - established with a finding of moderate risk patient D63 caries risk assessment and documentation, 1 D14 limited oral evaluation - problem focused with a finding of high risk D62 caries risk assessment and documentation, 1 D15 comprehensive oral evaluation - new or established patient Preventive D16 detailed and extensive oral evaluation - problem focused, by report D111 prophylaxis - adult (limited to 1 per 6 15 D17 re-evaluation - limited, problem focused months & additional at higher copayments) (established patient; not post-operative D111+ Prophylaxis - adult (additional beyond 1 in 8 visit) 6 months) D171 re-evaluation post-operative office visit D112 prophylaxis - child (limited to 1 per 6 15 D18 comprehensive periodontal evaluation - months & additional at higher copayments) new or established patient D112+ Prophylaxis - child (additional beyond 1 in 8 D21 intraoral - complete series of radiographic 6 months) images D126 topical application of fluoride varnish 12 D22 intraoral - periapical first radiographic D128 topical application of fluoride excluding 15 image varnish D23 intraoral - periapical each additional D131 nutritional counseling for control of dental radiographic image disease D24 intraoral - occlusal radiographic image D132 tobacco counseling for the control and D25 extra-oral 2D projection radiographic prevention of oral disease image created using a stationary radiation D133 oral hygiene instructions source, and detector D1351 sealant - per tooth 1 D27 bitewing - single radiographic image D1352 preventive resin restoration in a moderate 2 D272 bitewings - two radiographic images to high caries risk patient permanent D273 bitewings - three radiographic images tooth D274 bitewings - four radiographic images D1353 sealant repair per tooth 1 D277 vertical bitewings - 7 to 8 radiographic D1354 interim caries arresting medicament 2 images application D33 panoramic radiographic image D34 2D cephalometric radiographic image 1 Space Maintainers acquisition, measurement and analysis D151 space maintainer - fixed - unilateral 1 D35 2D oral/facial photographic image D1515 space maintainer - fixed - bilateral 15 obtained intra-orally or extra-orally D152 space maintainer - removable - unilateral 1 D391 interpretation of diagnostic image by a 5 D1525 space maintainer - removable - bilateral 15 practitioner not associated with capture of the image, including report D155 re-cement or re-bond space maintainer 2 D415 collection of microorganisms for culture 2 D1555 removal of fixed space maintainer and sensitivity D425 caries susceptibility tests 15 Amalgam Restorations - Primary or Permanent amalgam - one surface, primary or permanent 115M254 Current Dental Terminology 215 American Dental Association. All rights reserved Effective Date: 1/1/216 D214 32

2 D215 amalgam - two, primary or 42 D2664 onlay - resin-based composite - four or 35 permanent D216 amalgam - three, primary or permanent 5 D271 D2712 crown - resin-based composite (indirect) crown - ¾ resin-based composite (indirect) D2161 amalgam - four or, primary 6 D272 * crown - resin with high noble 4 or permanent D2721 crown - resin with predominantly base 25 Resin-Based Composite Restorations D2722 * crown - resin with noble 375 D233 resin-based composite - one surface, 44 D274 crown - porcelain/ceramic substrate 34 anterior D274SPC crown- ceramic specialty upgrade 2 D2331 resin-based composite - two, 6 D275 * crown - porcelain fused to high noble 49 anterior D2332 resin-based composite - three, anterior 8 D27BM D27MOL crown-butt margin crown- porcelain on molar 5 1 D2335 resin-based composite - four or more 12 D275SPC crown- specialty upgrade 2 or involving incisal angle (anterior) D2751 crown - porcelain fused to predominantly 34 D239 resin-based composite crown, anterior 12 base D2391 resin-based composite - one surface, 6 D2752 * crown - porcelain fused to noble 465 posterior D278 * crown - 3/4 cast high noble 46 D2392 resin-based composite - two, 8 D2781 crown - 3/4 cast predominantly base 31 posterior D2782 * crown - 3/4 cast noble 435 D2393 resin-based composite - three, 1 D2783 crown - 3/4 porcelain/ceramic 34 posterior D279 D2394 resin-based composite - four or more 13 * crown - full cast high noble 46, posterior D2791 crown - full cast predominantly base 31 D2792 * crown - full cast noble 435 Crowns - Single Restoration Only D2794 * crown - titanium 46 D2799 provisional crown further treatment or 2 *Copayment already includes fees of $125 for noble and $15 for completion of diagnosis necessary prior to high noble /titanium. Additional copayments may be charged for final impression specialized/upgraded products such as: porcelain butt margin- (D27BM) $5, specialized crowns such as Lava, Captek, Empress, E-Max, Procera, etc.- (D274SPC or D275SPC) $2, and porcelain on molar crowns Other Restorative Services (D27MOL) $1. D291 re-cement or re-bond inlay, onlay, veneer 25 D251 inlay - lic - one surface 31 or partial coverage restoration D252 inlay - lic - two 31 D2915 re-cement or re-bond indirectly fabricated 25 D253 inlay - lic - three or 31 or prefabricated post and core D2542 onlay - lic - two 31 D292 re-cement or re-bond crown 25 D2543 onlay - lic - three 31 D2921 reattachment of tooth fragment, incisal 35 D2544 onlay - lic - four or 31 edge or cusp D261 inlay - porcelain/ceramic - one surface 41 D2929 prefabricated porcelain/ceramic crown 75 primary tooth D262 inlay - porcelain/ceramic - two 41 D293 prefabricated stainless steel crown - 75 D263 inlay - porcelain/ceramic - three or more 41 primary tooth D2931 prefabricated stainless steel crown - 75 D2642 onlay - porcelain/ceramic - two 41 permanent tooth D2643 onlay - porcelain/ceramic - three 41 D2932 prefabricated resin crown 8 D2644 onlay - porcelain/ceramic - four or more 41 D2933 prefabricated stainless steel crown with 1 resin window D265 inlay - resin-based composite - one surface 33 D2934 prefabricated esthetic coated stainless steel 1 D2651 inlay - resin-based composite - two 35 crown - primary tooth D294 protective restoration 2 D2652 inlay - resin-based composite - three or 35 D2941 interim therapeutic restoration primary 12 dentition D2662 onlay - resin-based composite - two 35 D2949 restorative foundation for an indirect 2 D2663 onlay - resin-based composite - three 35 restoration core buildup, including any pins when required 115M254 Current Dental Terminology 215 American Dental Association. All rights reserved Effective Date: 1/1/216 D295 75

3 D2951 pin retention - per tooth, in addition to restoration 25 D3348 retreatment of previous root canal therapy - molar 5 D2952 post and core in addition to crown, 11 D3351 apexification/recalcification initial visit 23 indirectly fabricated (apical closure / calcific repair of D2953 each additional indirectly fabricated post - perforations, root resorption, etc.) same tooth D3352 apexification/recalcification interim 155 D2954 prefabricated post and core in addition to crown 8 D3353 medication replacement apexification/recalcification - final visit 26 D2955 post removal 55 (includes completed root canal therapy - D2957 each additional prefabricated post - same apical closure/calcific repair of tooth perforations, root resorption, etc.) D296 labial veneer (resin laminate) - chairside 2 D3355 pulpal regeneration - initial visit 23 D2961 labial veneer (resin laminate) - laboratory 31 D3356 pulpal regeneration - interim medication 155 replacement D2962 labial veneer (porcelain laminate) - 34 laboratory D3357 pulpal regeneration - completion of 2 treatment D2971 additional procedures to construct new 25 crown under existing partial denture D341 apicoectomy - anterior 2 framework D3421 apicoectomy - bicuspid (first root) 225 D2975 coping 31 D3425 apicoectomy - molar (first root) 25 D299 resin infiltration of incipient smooth surface lesions 1 D3426 D3427 apicoectomy (each additional root) periradicular surgery without apicoectomy 1 2 D343 retrograde filling - per root 8 Endodontics D392 hemisection (including any root removal), 2 not including root canal therapy D311 pulp cap - direct (excluding final 15 D395 canal preparation and fitting of preformed dowel or post D312 pulp cap - indirect (excluding final 15 6 D322 therapeutic pulpotomy (excluding final 45 Periodontics - removal of pulp coronal to D421 gingivectomy or gingivoplasty - four or 15 the dentinocemental junction and more contiguous teeth or tooth bounded application of medicament spaces per quadrant D3221 D3222 D323 D324 D331 D332 D333 D3331 D3332 D3333 D3346 D3347 pulpal debridement, primary and permanent teeth partial pulpotomy for apexogenesis - permanent tooth with incomplete root development pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final endodontic therapy, anterior tooth (excluding final endodontic therapy, bicuspid tooth (excluding final endodontic therapy, molar (excluding final treatment of root canal obstruction; nonsurgical access incomplete endodontic therapy; inoperable, unrestorable or fractured tooth internal root repair of perforation defects retreatment of previous root canal therapy - anterior retreatment of previous root canal therapy - bicuspid D4211 D4212 D423 D4231 D424 D4241 D4245 D4249 D426 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth anatomical crown exposure - four or more contiguous teeth per quadrant anatomical crown exposure - one to three teeth per quadrant gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant apically positioned flap clinical crown lengthening hard tissue osseous surgery (including elevation of a full thickness flap and closure) four or more contiguous teeth or tooth bounded spaces per quadrant osseous surgery (including elevation of a full thickness flap and closure) one to three contiguous teeth or tooth bounded spaces per quadrant bone replacement graft - first site in quadrant 115M254 Current Dental Terminology 215 American Dental Association. All rights reserved Effective Date: 1/1/216 D4261 D

4 D4264 bone replacement graft - each additional 155 D5222 immediate mandibular partial denture 49 site in quadrant resin base (including any conventional D4266 guided tissue regeneration - resorbable barrier, per site 28 D5223 clasps, rests immediate maxillary partial denture cast 49 D4267 guided tissue regeneration - nonresorbable 35 framework with resin denture bases barrier, per site (includes membrane removal) D4268 D427 D4274 D4277 D4278 D4341 D4342 D4355 D4381 D491 D491+ D4921 Dentures surgical revision procedure, per tooth pedicle soft tissue graft procedure distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site periodontal scaling and root planing - four or more teeth per quadrant periodontal scaling and root planing - one to three teeth per quadrant full mouth debridement to enable comprehensive evaluation and diagnosis localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth periodontal maintenance (first 2 cleanings within calendar year) Periodontal maintenance (3rd and 4th cleaning within calendar year) gingival irrigation per quadrant Dentures and partials include four months free adjustments. Add lab cost of any gold. D511 complete denture - maxillary 44 D512 complete denture - mandibular 44 D513 immediate denture - maxillary 44 D514 immediate denture - mandibular 44 D5211 maxillary partial denture - resin base 44 D5212 mandibular partial denture - resin base 44 D5213 maxillary partial denture - cast 48 framework with resin denture bases D5214 mandibular partial denture - cast 48 framework with resin denture bases D5221 immediate maxillary partial denture resin base (including any conventional clasps, rests D5224 D5225 D5226 D5281 immediate mandibular partial denture cast framework with resin denture bases (including any conventional clasps, rests maxillary partial denture - flexible base (including any clasps, rests mandibular partial denture - flexible base (including any clasps, rests removable unilateral partial denture - one piece cast (including clasps Denture Adjustments & Repairs D541 D5411 D5421 D5422 D551 D552 D561 D562 D563 D564 D565 D566 D567 D5671 D571 D5711 D572 D5721 D573 D5731 D574 D5741 D575 D5751 D576 D5761 D581 D5811 adjust complete denture - maxillary adjust complete denture - mandibular adjust partial denture - maxillary adjust partial denture - mandibular repair broken complete denture base replace missing or broken teeth - complete denture (each tooth) repair resin denture base repair cast framework repair or replace broken clasp - per tooth replace broken teeth - per tooth add tooth to existing partial denture add clasp to existing partial denture - per tooth replace all teeth and acrylic on cast framework (maxillary) replace all teeth and acrylic on cast framework (mandibular) rebase complete maxillary denture rebase complete mandibular denture rebase maxillary partial denture rebase mandibular partial denture reline complete maxillary denture (chairside) reline complete mandibular denture (chairside) reline maxillary partial denture (chairside) reline mandibular partial denture (chairside) reline complete maxillary denture (laboratory) reline complete mandibular denture (laboratory) reline maxillary partial denture (laboratory) reline mandibular partial denture (laboratory) interim complete denture (maxillary) interim complete denture (mandibular) 115M254 Current Dental Terminology 215 American Dental Association. All rights reserved Effective Date: 1/1/

5 D582 interim partial denture (maxillary) 18 D674 * abutment supported retainer for cast 1125 D5821 interim partial denture (mandibular) 18 FPD (noble ) D585 tissue conditioning, maxillary 5 D675 implant supported retainer for ceramic 1 D5851 tissue conditioning, mandibular 5 FPD D5863 overdenture complete maxillary 36 D676 * implant supported retainer for porcelain 115 fused to FPD (titanium, titanium D5864 overdenture partial maxillary 36 alloy, or high noble ) D5865 overdenture complete mandibular 36 D677 * implant supported retainer for cast 115 D5866 overdenture partial mandibular 36 FPD (titanium, titanium alloy, or high noble ) Implants D692 re-cement or re-bond implant/abutment 3 supported crown *Copayment already includes fees of $125 for noble and $15 for high noble /titanium. Implant services are covered only when performed by a D693 re-cement or re-bond implant/abutment 4 participating general dentist. supported fixed partial denture D61 surgical placement of implant body: 15 D694 * abutment supported crown - (titanium) 65 endosteal implant D614 bone graft at time of implant placement 26 D611 second stage implant surgery 2 D611 implant /abutment supported removable 23 D651 interim abutment 2 denture for edentulous arch maxillary D652 semi-precision attachment abutment 2 D6111 implant /abutment supported removable 23 denture for edentulous arch mandibular D656 prefabricated abutment includes 45 modification and placement D6112 implant /abutment supported removable 23 denture for partially edentulous arch D657 custom fabricated abutment includes 45 maxillary placement D6113 implant /abutment supported removable 23 D658 abutment supported porcelain/ceramic 1 denture for partially edentulous arch crown mandibular D659 * abutment supported porcelain fused to 115 D6194 * abutment supported retainer crown for 65 crown (high noble ) FPD (titanium) D66 abutment supported porcelain fused to 1 crown (predominantly base ) D661 * abutment supported porcelain fused to 1125 crown (noble ) Bridges *Copayment already includes fees of $125 for noble and $15 for D662 * abutment supported cast crown 115 high noble /titanium. Additional copayments may be charged for (high noble ) specialized/upgraded products such as: porcelain butt margin- (D62BM or D663 abutment supported cast crown 1 D67BM) $5, porcelain on molar crowns (D62MOL or D67MOL) $1, (predominantly base ) and specialized crowns such as Lava, Captek, Empress, E-Max, Procera, etc.- (D624SPC, D625SPC, D674SPC or D675SPC) $2. D664 * abutment supported cast crown 1125 (noble ) D625 pontic - indirect resin based composite 25 D665 implant supported porcelain/ceramic 1 D621 * pontic - cast high noble 46 crown D6211 pontic - cast predominantly base 31 D666 * implant supported porcelain fused to 115 D6212 * pontic - cast noble 435 crown (titanium, titanium alloy, high D6214 * pontic - titanium 46 noble ) D624 * pontic - porcelain fused to high noble 49 D667 * implant supported crown (titanium, 115 titanium alloy, high noble ) D624SPC pontic - ceramic specialty upgrade 2 D668 abutment supported retainer for 1 D6241 pontic - porcelain fused to predominantly porcelain/ceramic FPD base 34 D669 * abutment supported retainer for porcelain 115 D6242 * pontic - porcelain fused to noble 465 fused to FPD (high noble ) D6245 pontic - porcelain/ceramic 34 D67 abutment supported retainer for porcelain 1 D625 * pontic - resin with high noble 4 fused to FPD (predominantly base ) D62BM pontic- butt margin 5 D671 * abutment supported retainer for porcelain 1125 D62MOL pontic- porcelain on molar 1 fused to FPD (noble ) D625SPC pontic- specialty upgrade 2 D672 * abutment supported retainer for cast 115 D6251 pontic - resin with predominantly base 25 FPD (high noble ) D673 abutment supported retainer for cast 1 D6252 * pontic - resin with noble 375 FPD (predominantly base ) D6253 provisional pontic - further treatment or completion of diagnosis necessary prior to final impression 2 115M254 Current Dental Terminology 215 American Dental Association. All rights reserved Effective Date: 1/1/216

6 D6545 retainer - cast for resin bonded fixed 17 D6781 retainer crown - 3/4 cast predominantly 31 prosthesis base D6548 retainer - porcelain/ceramic for resin 34 D6782 * retainer crown - 3/4 cast noble 435 bonded fixed prosthesis D6783 retainer crown - 3/4 porcelain/ceramic 34 D6549 resin retainer for resin bonded fixed 17 D679 * retainer crown - full cast high noble 46 prosthesis D6791 retainer crown - full cast predominantly 31 D66 inlay - porcelain/ceramic, two 24 base D661 retainer inlay - porcelain/ceramic, three or 24 D6792 * retainer crown - full cast noble 435 D6793 provisional retainer crown - further 2 D662 * retainer inlay - cast high noble, two 46 treatment or completion of diagnosis necessary prior to final impression D663 * retainer inlay - cast high noble, three 46 D6794 * retainer crown - titanium 46 or D693 re-cement or re-bond fixed partial denture 3 D664 retainer inlay - cast predominantly base 31, two D665 retainer inlay - cast predominantly base 31 Oral Surgery, three or D7111 extraction, coronal remnants - deciduous 35 D666 * retainer inlay - cast noble, two 435 tooth D714 extraction, erupted tooth or exposed root 4 D667 * retainer inlay - cast noble, three or 435 (elevation and/or forceps removal) D721 surgical removal of erupted tooth 7 D668 retainer onlay - porcelain/ceramic, two 34 requiring removal of bone and/or sectioning of tooth, and including D669 retainer onlay - porcelain/ceramic, three 34 elevation of mucoperiosteal flap if or indicated D661 * retainer onlay - cast high noble, two 46 D722 removal of impacted tooth - soft tissue 85 D723 removal of impacted tooth - partially bony 16 D6611 * retainer onlay - cast high noble, 46 D724 removal of impacted tooth - completely 235 three or bony D6612 retainer onlay - cast predominantly base 31 D7241 removal of impacted tooth - completely 275, two bony, with unusual surgical complications D6613 retainer onlay - cast predominantly base 31 D725 surgical removal of residual tooth roots 8, three or (cutting procedure) D6614 * retainer onlay - cast noble, two 435 D7251 coronectomy intentional partial tooth 235 removal D6615 * retainer onlay - cast noble, three or 435 D727 tooth reimplantation and/or stabilization 25 of accidentally evulsed or displaced tooth D6624 * retainer inlay - titanium 46 D728 surgical access of an unerupted tooth 2 D6634 * retainer onlay - titanium 46 D7282 mobilization of erupted or malpositioned 275 D671 retainer crown - indirect resin based 25 tooth to aid eruption composite D7285 incisional biopsy of oral tissue-hard (bone, 95 D672 * retainer crown - resin with high noble 4 tooth) D7286 incisional biopsy of oral tissue-soft 95 D6721 retainer crown - resin with predominantly 25 D7288 brush biopsy - transepithelial sample 5 base collection D6722 * retainer crown - resin with noble 375 D7311 alveoloplasty in conjunction with 7 D674 retainer crown - porcelain/ceramic 34 extractions - one to three teeth or tooth spaces, per quadrant D674SPC abutment crown- ceramic specialty upgrade 2 D732 alveoloplasty not in conjunction with 9 D675 * retainer crown - porcelain fused to high 49 extractions - four or more teeth or tooth noble spaces, per quadrant D67BM abutment crown- butt margin 5 D7321 alveoloplasty not in conjunction with 7 D67MOL abutment crown-porcelain on molar 1 extractions - one to three teeth or tooth D675SPC abutment crown- specialty upgrade 2 spaces, per quadrant D6751 retainer crown - porcelain fused to 34 D7471 removal of lateral exostosis (maxilla or 2 predominantly base mandible) D6752 * retainer crown - porcelain fused to noble 465 D751 incision and drainage of abscess - intraoral 5 soft tissue D678 * retainer crown - 3/4 cast high noble M254 Current Dental Terminology 215 American Dental Association. All rights reserved Effective Date: 1/1/216

7 D7511 incision and drainage of abscess - intraoral 1 D9974 internal bleaching - per tooth 1 soft tissue - complicated (includes drainage D9975 external bleaching for home application, 2 of multiple fascial spaces) per arch; includes materials and fabrication D796 frenulectomy - also known as frenectomy or frenotomy - separate procedure not 175 of custom trays incidental to another procedure Orthodontics D7963 frenuloplasty 2 D797 excision of hyperplastic tissue - per arch 2 removable orthodontic retainer adjustment D7971 excision of pericoronal gingiva 5 Consultation 25 Failed/no-show appointment without Other Services hour notice Full banded - child, up to age D911 palliative (emergency) treatment of dental 25 Full banded - adult 2175 pain - minor procedure Partial banded - child, up to age D912 fixed partial denture sectioning 4 Partial banded - adult 155 D921 local anesthesia not in conjunction with Mixed dentition - phase 1 6 operative or surgical procedures Palatal expansion 45 D9211 regional block anesthesia Rapid palatal expansion 6 D9212 trigeminal division block anesthesia Retention appliance - after orthodontic 25 D9215 local anesthesia in conjunction with treatment operative or surgical procedures Functional appliance (Bionator-Frankel) 6 D931 consultation - diagnostic service provided 2 Headgear 4 by dentist or physician other than requesting dentist or physician Simple crossbite 4 D943 office visit for observation (during Copying records 4 regularly scheduled hours) - no other Please call your Dental Health Services Member Service Specialist at services performed 6453 for a referral to a conveniently located participating orthodontist. D944 office visit - after regularly scheduled hours 5 Orthodontic models, x-rays, photographs and records are not covered. There may D945 case presentation, detailed and extensive be additional copayments depending on treatment needs. treatment planning D961 therapeutic parenteral drug, single 15 administration D9612 therapeutic parenteral drugs, two or more 3 administrations, different medications D963 other drugs and/or medicaments, by report 25 D991 application of desensitizing medicament 2 D9911 application of desensitizing resin for 2 cervical and/or root surface, per tooth D9932 cleaning and inspection of removable 25 complete denture, maxillary D9933 cleaning and inspection of removable 25 complete denture, mandibular D9934 cleaning and inspection of removable 25 partial denture, maxillary D9935 cleaning and inspection of removable 25 partial denture, mandibular D994 occlusal guard, by report 18 D9941 fabrication of athletic mouthguard 1 D9942 repair and/or reline of occlusal guard 9 D9943 occlusal guard adjustment 15 D9951 occlusal adjustment - limited 35 D9952 occlusal adjustment - complete 75 D997 enamel microabrasion 2 D9971 odontoplasty 1-2 teeth; includes removal 2 of enamel projections D9972 external bleaching - per arch - performed 2 in office D9973 external bleaching - per tooth 1 115M254 Current Dental Terminology 215 American Dental Association. All rights reserved Effective Date: 1/1/216

8 Exclusions and Limitations of Coverage CA SmartSmile SM Plan Orthodontic exclusions The following services are not covered by your dental plan: A. Retreatment of orthodontic cases. B. Treatment of a case in progress at inception of eligibility. C. Surgical procedures (including extraction of teeth) incidental orthodontic treatment. D. Surgical procedures related to cleft palate, micrognathia or macrognathia. E. Treatment related to temporomandibular joint (TMJ) disturbances and/ or hormonal imbalances. F. Any dental procedure considered within the field of general dentistry including but not limited to: myofunctional therapy; general anesthetics, including intravenous and inhalation sedation dental services of any nature performed in a hospital. G. Cephalometric x-rays, dental x-rays. H. Tracings and photographs. I. Study models. J. Replacement of lost or broken appliances. K. Changes in treatment necessitated by an accident of any kind. L. Services which are compensable under worker s compensation or employer liability laws. M. Malocclusions so severe or mutilated they are not amenable to ideal orthodontic therapy. Orthodontic limitations The following are subject to additional charges: A. Full banded treatments are based on a 24-month standard treatment plan..additional treatment, or treatment that extends beyond that time may be subject to additional charges. B. If the member should terminate coverage, they are no longer eligible for the plan s orthodontic rate. C. Should the contract between Dental Health Services and the orthodontist terminate, any Dental Health Services members in treatment would not be subject to proration. Dental exclusions The following services are not covered by your dental plan: A. Services that are not consistent with professionally recognized standards of practice. B. Cosmetic services, for appearance only, unless specifically listed. C. Myofunctional therapy-procedures for training, treating or developing muscles in and around the jaw or mouth including T.M.J. and related diseases, except for occlusal guard. D. Treatment for malignancies, neoplasms (tumors) and cysts as well as hereditary, congenital and/or developmental malformations. E. Dispensing of drugs not normally supplied in a dental office. F. Hospitalization charges, dental procedures or services rendered while patient is hospitalized. G. Procedures, appliances or restorations (other than fillings) that are necessary for full mouth rehabilitation, to increase arch vertical dimension, or crown/bridgework requiring more than 1 crowns/ pontics. Replacement or stabilization of tooth structure lost through attrition, abrasion or erosion. H. Procedures performed by a prosthodontist. I. Fixed bridges for patients under the age of sixteen, in the presence of non-supportive periodontal tissue, when edentulous spaces are bilateral in the same arch, when replacement of more than four teeth in an arch, replacement of missing third molars, or when the prognosis is poor. J. General anesthesia, including intravenous and inhalation sedation. K. Dental procedures that cannot be performed in the dental office due to the general health and/or physical limitations of the member. L. Expenses incurred for dental procedures initiated prior to member s eligibility with Dental Health Services, or after termination of eligibility. M. Services that are reimbursed by a third party (such as the medical portion of an insurance/health plan or any other third party indemnification). N. Extractions of non-pathologic, asymptomatic teeth, including extractions and/or surgical procedures for orthodontic reasons. O. Setting of a fracture or dislocation, surgical procedures related to cleft palate, micrognathia or macrognathia, and surgical grafting procedures. P. Coordination of benefits with another prepaid managed care dental plan. Q. Orthodontic treatment of a case in progress and/or retreatment of ortho cases. R. Cephalometric x-rays, tracings, photographs and orthodontic study models. S. Replacement of lost or broken orthodontic appliances. T. Changes in orthodontic treatment necessitated by an accident of any kind. U. Malocclusions so severe or mutilated which are not amenable to ideal orthodontic therapy. V. Services not specifically listed on the Schedule of Covered Services and Copayments. W. Specialty services. Dental limitations Restrictions on benefits are applied to the following services: A. Treatment of dental emergencies is limited to treatment that will alleviate acute symptoms and does not cover definitive restorative treatment including, but not limited to root canal treatment and crowns. B. Optional services: when the patient selects a plan of treatment that is considered optional or unnecessary by the attending dentist, the additional cost is the responsibility of the patient. C. Routine teeth cleaning (prophylaxis) is limited to once every six months and full mouth x-rays are limited to one set every three years if needed. D. Periodontal surgical procedures are limited to four quadrants every two years. E. There are additional charges for precious/noble s (gold). F. Replacement will be made of any existing appliance (denture, etc.) only if it is unsatisfactory and cannot be made satisfactory. Prosthetic appliances will be replaced only after five years have elapsed from the time of delivery. Lost or stolen removable appliances are the responsibility of the enrollee. G. Relines are limited to once per twelve months, per appliance. H. Single unit inlays and crowns are a benefit as provided above only when the teeth cannot be adequately restored with other restorative materials. 215 Dental Health Services. All rights reserved.

9 Health plan benefits and coverage matrix This matrix is intended to be used to help you compare coverage benefits and is a summary only. The evidence of coverage and plan contract should be consulted for a detailed description of coverage benefits and limitations. Deductibles: None Lifetime maximums: There are no maximums. Professional services - exam & preventive services: No charge for most services. Full mouth x-rays limited to every three years. Prophylaxis (cleanings) limited to every six months. Professional services - restorative, crowns, endodontics and oral surgery services: Copayments for fillings, caps, root canals and extractions vary by procedure in the enclosed Schedule of Covered Services and Copayments. Professional services - periodontic services: Copayments for gum treatments vary by procedure in the enclosed Schedule of Covered Services and Copayments. Surgical procedures are limited to four quads every two years. Professional services - dentures and partial dentures: Copayments vary by procedure and appear in the enclosed Schedule of Covered Services and Copayments. Replacements limited to every five years. Relines limited to every 12 months. Outpatient office visits: $4 Hospitalization services: Not covered Prescription drug coverage: Not covered Emergency health services: Not covered Ambulance services: Not covered Durable medical equipment: Not covered Mental health services: Not covered Chemical dependency services: Not covered Home health services: Not covered Dental Health Services A Great Reason to Smile sm 3833 Atlantic Avenue, Long Beach, CA Dental Health Services