Dental Maintenance Organization (DMO) DeltaCare USA Co-Payment Schedule Effective January 1, 2019

Transcription

1 Dental Maintenance Organization (DMO) DeltaCare USA Co-Payment Schedule Effective January 1, 2019 Raytheon s DMO option is an innovative plan that provides you with comprehensive dental care at significantly lower costs through the DeltaCare USA program from Delta Dental of Massachusetts. Your coverage begins immediately, and there are no pre-existing condition exclusions. There s no annual maximum to your dental coverage either. With DeltaCare USA your benefits are based on this co-payment schedule, so you will always know what services are covered and what your out-of-pocket costs will be. Advantages No surprise costs members know what their out-ofpocket costs will be up front because all services are based on this fixed co-payment schedule. No claim forms participating dentists handle all treatment paperwork, so there are no claim forms for you or your family to fill out. No balance billing participating dentists agree to accept Delta Dental s negotiated fee for services and the patient co-payment as full payment. No pre-existing condition exclusions your coverage begins immediately and there are no pre-existing condition clauses. The only exception would be work in progress dental expenses incurred in connection with any dental procedure started prior to coverage with DeltaCare USA are excluded. Orthodontic coverage braces are covered for you and your family, regardless of age. Everything from initial consultation to follow-up visits is included with your co-payment. Using Your Dental Plan Your Primary Care Dentist (PCD) When you enroll in DeltaCare USA, you and each member of your family will be assigned a Primary Care Dentist (PCD) from the DeltaCare USA directory. Your PCD will be responsible for your overall dental care. Shortly after your enrollment, each member of your family covered by DeltaCare USA will receive two ID cards along with a welcome letter that includes the PCP name and information. You may change your eligibility from one DeltaCare USA participating dentist to another by phoning DeltaCare USA by the 21st day of the month. Our DeltaCare USA Service Team will assist you in the transfer, which will take effect the first day of the following month. How it works There s never any paperwork for you to fill out when you visit your PCD. Simply provide your dentist with the information that is printed on your ID card. Your dentist will collect any applicable co-payments for services you receive and take care of everything else for you. Low out-of-pocket costs Most preventive and diagnostic services are covered at 100%, which means that you won t have any additional out-of-pocket costs for those procedures. Other dental services require co-payments that you ll pay directly to your dentist. And your out-of-pocket costs are completely predictable because they re explained in this fixed co-payment schedule

2 Member Co-Payments for Raytheon s DMO Option Under Raytheon s DMO option, you ll receive comprehensive dental care through the DeltaCare USA program from Delta Dental of Massachusetts. Your dental benefits will be based on this co-payment schedule, and are subject to the limitations, exclusions, and governing administrative policies of the program. I. DIAGNOSTIC GP means General Practitioner SP means Specialty Care Practitioner D0120 Periodic oral evaluation - established patient... $ 0 D0140 Limited oral evaluation - problem focused (GP)... $ 0 D0140 Limited oral evaluation - problem focused (SP)... $ D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver... $ 0 D0150 Comprehensive oral evaluation - new or established patient (GP)... $ 0 D0150 Comprehensive oral evaluation - new or established patient (SP)... $ D0160 Detailed and extensive oral evaluation - problem focused, by report (GP)... $ 0 D0160 Detailed and extensive oral evaluation - problem focused, by report (SP)... $ D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit)... $ 0 D0180 Comprehensive periodontal evaluation - new or established patient (GP)... $ 0 D0180 Comprehensive periodontal evaluation - new or established patient (SP)... $ D0190 Screening of a patient... $ 0 D0191 Assessment of a patient... $ 0 D0210 Intraoral - complete series of radiographic images... $ 0 D0220 Intraoral - periapical first radiographic image... $ 0 D0230 Intraoral - periapical each additional radiographic image... $ 0 D0240 Intraoral - occlusal radiographic image... $ 0 D0270 Bitewing - single radiographic image... $ 0 D0272 Bitewings - two radiographic images... $ 0 D0273 Bitewings - three radiographic images... $ 0 D0274 Bitewings - four radiographic images... $ 0 D0277 Vertical bitewings - 7 to 8 radiographic images... $ 0 D0330 Panoramic radiographic image... $ 0 D0460 Pulp vitality tests... $ 0 D0470 Diagnostic casts... $ 0 II. PREVENTIVE D1110 Prophylaxis cleaning - adult - 2 D1110, D1120 or D4346 per 12 month period... $ 0 D1120 Prophylaxis cleaning - child - 2 D1110, D1120 or D4346 per 12 month period... $ 0 D1206 Topical application of fluoride varnish - child to age 19; 2 per 12 month period... $ 0 D1208 Topical application of fluoride... $ 0 D1330 Oral hygiene instructions... $ 0 D1351 Sealant - per tooth... $ D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth... $ D1510 Space maintainer - fixed - unilateral... $ D1516 Space maintainer - fixed - bilateral, maxillary... $ D1517 Space maintainer - fixed - bilateral, mandibular... $ D1520 Space maintainer - removable - unilateral... $ D1526 Space maintainer - removable - bilateral, maxillary... $ D1527 Space maintainer - removable - bilateral, mandibular... $ D1550 Re-cementation of space maintainer... $ D1555 Removal of fixed space maintainer... $ D1575 Distal shoe space maintainer - fixed - unilateral - child to age 9... $

3 III. RESTORATIVE Includes indirect pulp capping, bases, liners and acid etch procedures. 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... $ D2391 Resin-based composite - one surface, posterior... Optional D2392 Resin-based composite - two surfaces, posterior... Optional D2393 Resin-based composite - three surfaces, posterior... Optional D2394 Resin-based composite - four or more surfaces, posterior... Optional D2410 Gold foil - one surface... Optional D2420 Gold foil - two surfaces... Optional D2430 Gold foil - three surfaces... Optional D2510 Inlay - metallic - one surface 1... $ D2520 Inlay - metallic - two surfaces 1... $ D2530 Inlay - metallic - three or more surfaces 1... $ D2542 Onlay - metallic - two surfaces 1... $ D2543 Onlay - metallic - three surfaces 1... $ D2544 Onlay - metallic - four or more surfaces 1... $ D2610 Inlay - porcelain/ceramic - one surface... Optional D2620 Inlay - porcelain/ceramic - two surfaces... Optional D2630 Inlay - porcelain/ceramic - three or more surfaces... Optional D2642 Onlay - porcelain/ceramic - two surfaces... Optional D2643 Onlay - porcelain/ceramic - three surfaces... Optional D2644 Onlay - porcelain/ceramic - four or more surfaces... Optional D2650 Inlay - resin-based composite - one surface... Optional D2651 Inlay - resin-based composite - two surfaces... Optional D2652 Inlay - resin-based composite - three or more surfaces... Optional D2662 Onlay - resin-based composite - two surfaces... Optional D2663 Onlay - resin-based composite - three surfaces... Optional D2664 Onlay - resin-based composite - four or more surfaces... Optional D2710 Crown - resin-based composite (indirect) 2... $ D2720 Crown - resin with high noble metal 1, 2... $ D2721 Crown - resin with predominantly base metal 2... $ D2722 Crown - resin with noble metal 2... $ D2740 Crown - porcelain/ceramic 2... $ D2750 Crown - porcelain fused to high noble metal 1, 2... $ D2751 Crown - porcelain fused to predominantly base metal 2... $ D2752 Crown - porcelain fused to noble metal 2... $ D2780 Crown - ¾ cast high noble metal 1... $ D2781 Crown - ¾ cast predominantly base metal... $ D2782 Crown - ¾ cast noble metal... $ D2783 Crown - ¾ porcelain/ceramic 2... $ D2790 Crown - full cast high noble metal 1... $ D2791 Crown - full cast predominantly base metal... $ D2792 Crown - full cast noble metal... $ D2794 Crown - titanium 1... $

4 III. RESTORATIVE (Continued) D2910 Recement inlay, onlay or partial coverage restoration... $ D2915 Recement cast or prefabricated post and core... $ D2920 Recement crown... $ D2929 Prefabricated porcelain/ceramic crown - primary tooth... Optional D2930 Prefabricated stainless steel crown - primary tooth... $ D2931 Prefabricated stainless steel crown - permanent tooth... $ D2932 Prefabricated resin crown - anterior teeth only... $ D2933 Prefabricated stainless steel crown with resin window... Optional D2940 Protective restoration... $ D2950 Core buildup, including any pins... $ D2951 Pin retention - per tooth, in addition to restoration... $ D2952 Post and core in addition to crown, indirectly fabricated 1... $ D2953 Each additional indirectly fabricated post - same tooth 1... $ D2954 Prefabricated post and core in addition to crown... $ D2957 Each additional prefabricated post - same tooth... $ D2971 Additional procedures to construct new crown under existing partial denture framework... $ D2980 Crown repair, necessitated by restorative material failure... $ 25+lab D2981 Inlay repair necessitated by restorative material failure... $ 25+lab D2982 Onlay repair necessitated by restorative material failure... $ 25+lab D2990 Resin infiltration of incipient smooth surface lesions... $ IV. ENDODONTICS D3110 Pulp cap - direct (excluding final restoration)... $ 0 D3120 Pulp cap - indirect (excluding final restoration)... $ 0 D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament... $ D3221 Pulpal debridement, primary and permanent teeth... $ D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)... $ D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)... $ D3310 Root canal - endodontic therapy, anterior tooth (excluding final restoration)... $ D3320 Root canal - endodontic therapy, premolar tooth (excluding final restoration)... $ D3330 Root canal - endodontic therapy, molar (excluding final restoration)... $ D3346 Retreatment of previous root canal therapy - anterior... $ D3347 Retreatment of previous root canal therapy - premolar... $ D3348 Retreatment of previous root canal therapy - molar... $ D3410 Apicoectomy/periradicular surgery - anterior... $ D3421 Apicoectomy/periradicular surgery - premolar (first root)... $ D3425 Apicoectomy/periradicular surgery - molar (first root)... $ D3426 Apicoectomy/periradicular surgery (each additional root)... $ D3430 Retrograde filling - per root... $ V. PERIODONTICS Includes preoperative and postoperative evaluations and treatment under a local anesthetic. CODE D4210 D4211 DESCRIPTION Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant... $ Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant... $ D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant... $

5 V. PERIODONTICS (Continued) D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant... $ D4245 Apically positional flap... $ D4249 Clinical crown lengthening - hard tissue... $ D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant... $ D4261 Osseous surgery (including flap entry and closure) - one to 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... $ D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation - 1 D1110, D1120 or D4346 per 6 month period... $ 0 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis on subsequent visit... $ D4910 Periodontal maintenance... $ VI. PROSTHODONTICS (removable) D5110 Complete denture - maxillary 3... $ D5120 Complete denture - mandibular 3... $ D5130 Immediate denture - maxillary 3... $ D5140 Immediate denture - mandibular 3... $ D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) 3... $ D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) 3... $ D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 3... $ D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 3... $ 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... $ D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth) 3... Optional D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) 3... Optional D5282 Removable unilateral partial denture - one piece cast metal (including clasps and teeth), maxillary... $ D5283 Removable unilateral partial denture - one piece cast metal (including clasps and teeth), mandibular... $ D5410 Adjust complete denture - maxillary... $ D5411 Adjust complete denture - mandibular... $ D5421 Adjust partial denture - maxillary... $ D5422 Adjust partial denture - mandibular... $ D5511 Repair broken complete denture base - mandibular... $ D5512 Repair broken complete denture base - maxillary... $ D5520 Replace missing or broken teeth - complete denture (each tooth)... $ D5611 Repair resin partial denture base - mandibular... $ D5612 Repair resin partial denture base - maxillary... $ D5621 Repair cast partial framework - mandibular... $ D5622 Repair cast partial framework - maxillary... $ D5630 Repair or replace broken retentive clasping materials - per tooth... $ D5640 Replace broken teeth - per tooth... $ D5650 Add tooth to existing partial denture... $

6 VI. PROSTHODONTICS (removable) (Continued) D5660 Add clasp to existing partial denture - per tooth... $ D5670 Replace all teeth and acrylic on cast metal framework (maxillary)... $ D5671 Replace all teeth and acrylic on cast metal framework (mandibular)... $ 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)... $ D5731 Reline complete mandibular denture (chairside)... $ D5740 Reline maxillary partial denture (chairside)... $ D5741 Reline mandibular partial denture (chairside)... $ D5750 Reline complete maxillary denture (laboratory)... $ D5751 Reline complete mandibular denture (laboratory)... $ D5760 Reline maxillary partial denture (laboratory)... $ D5761 Reline mandibular partial denture (laboratory)... $ D5820 Interim partial denture (maxillary)... $ 0 D5821 Interim partial denture (mandibular)... $ 0 D5850 Tissue conditioning, maxillary... $ D5851 Tissue conditioning, mandibular... $ D5863 Overdenture - complete maxillary... Optional D5864 Overdenture - partial maxillary... Optional D5865 Overdenture - complete mandibular... Optional D5866 Overdenture - partial mandibular... Optional VII. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge]) D6210 Pontic - cast high noble metal 1... $ D6211 Pontic - cast predominantly base metal... $ D6212 Pontic - cast noble metal... $ D6240 Pontic - porcelain fused to high noble metal 1, 2... $ D6241 Pontic - porcelain fused to predominantly base metal 2... $ D6242 Pontic - porcelain fused to noble metal 2... $ D6250 Pontic - resin with high noble metal 1, 2... $ D6251 Pontic - resin with predominantly base metal 2... $ D6252 Pontic - resin with noble metal 2... $ D6545 Retainer - cast metal for resin bonded fixed prosthesis... Optional D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis... Optional D6600 Retainer inlay - porcelain/ceramic, two surfaces... Optional D6601 Retainer inlay - porcelain/ceramic, three or more surfaces... Optional D6602 Retainer inlay - cast high noble metal, two surfaces 1... $ D6603 Retainer inlay - cast high noble metal, three or more surfaces 1... $ D6604 Retainer inlay - cast predominantly base metal, two surfaces... $ D6605 Retainer inlay - cast predominantly base metal, three or more surfaces... $ D6606 Retainer inlay - cast noble metal, two surfaces... $ D6607 Retainer inlay - cast noble metal, three or more surfaces... $ D6608 Retainer onlay - porcelain/ceramic, two surfaces... Optional D6609 Retainer onlay - porcelain/ceramic, three or more surfaces... Optional D6610 Retainer onlay - cast high noble metal, two surfaces 1... $ D6611 Retainer onlay - cast high noble metal, three or more surfaces 1... $ D6612 Retainer onlay - cast predominantly base metal, two surfaces... $ D6613 Retainer onlay - cast predominantly base metal, three or more surfaces... $

7 VII. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge]) (Continued) D6614 Retainer onlay - cast noble metal, two surfaces... $ D6615 Retainer onlay - cast noble metal, three or more surfaces... $ D6720 Retainer crown - resin with high noble metal 1, 2... $ D6721 Retainer crown - resin with predominantly base metal 2... $ D6722 Retainer crown - resin with noble metal 2... $ D6750 Retainer crown - porcelain fused to high noble metal 1, 2... $ D6751 Retainer crown - porcelain fused to predominantly base metal 2... $ D6752 Retainer crown - porcelain fused to noble metal 2... $ D6780 Retainer crown - ¾ cast high noble metal 1... $ D6781 Retainer crown - ¾ cast predominantly base metal... $ D6782 Retainer crown - ¾ cast noble metal... $ D6790 Retainer crown - full cast high noble metal 1... $ D6791 Retainer crown - full cast predominantly base metal... $ D6792 Retainer crown - full cast noble metal... $ D6930 Recement fixed partial denture... $ D6940 Stress breaker... $ VIII. ORAL AND MAXILLOFACIAL SURGERY Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D7111 Extraction, coronal remnants - primary tooth... $ D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)... $ D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated... $ D7220 Removal of impacted tooth - soft tissue... $ D7230 Removal of impacted tooth - partially bony... $ D7240 Removal of impacted tooth - completely bony... $ D7241 Removal of impacted tooth - completely bony, with unusual surgical complications... $ D7250 Surgical removal of residual tooth roots (cutting procedure)... $ 0 D7286 Biopsy of oral tissue - soft... $ D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant... $ D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant... $ D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant... $ D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant... $ D7471 Removal of lateral exostosis (maxilla or mandible)... $ D7472 Removal of torus palatinus... $ D7473 Removal of torus mandibularis... $ D7510 Incision and drainage of abscess - intraoral soft tissue... $ 0 D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure... $ Base or noble metal is the benefit. If high noble metal (precious) is used for a crown, bridge, indirectly fabricated post and core, inlay or onlay, the Enrollee will be charged the additional laboratory cost of the high noble metal. An additional laboratory charge also applies to a titanium crown. 2 Porcelain on molars is considered optional treatment. 3 Includes any adjustments for six months

8 Orthodontic Services Please contact your local DeltaCare USA Service Team using the phone number listed on the back of your ID card for a detailed breakdown of the following, all inclusive orthodontic fees. Pre-orthodontic treatment visit (applied to treatment fee if patient proceeds with treatment)*...$ Records solely for the purpose of orthodontics (pre-records)**...$ Dependent children to age 19 (comprehensive care up to 24 months)...$ 1, Adults and covered full-time students (comprehensive care up to 24 months)...$ 2, The comprehensive orthodontic treatment includes initial examination, diagnosis, consultation, initial banding, 24 months of active treatment, debanding, and the retention phase of treatment. The retention phase includes the initial construction, placement and adjustments to retainers and office visits for a maximum of two years after the completion of active treatment. For treatment plans extending beyond 24 months of active treatment, the patient will be subject to a monthly office visit fee, not to exceed $75/month. * This fee is built into the all-inclusive orthodontic fees listed, but will be a separate co-payment if you choose not to continue treatment with this dentist. ** This fee includes records solely for the purpose of orthodontics (pre-records), intraoral complete series (including bitewings), cephalometric film, panoramic film, tomographic survey, oral/facial images (includes intra and extra oral images), diagnostic casts. Additional Procedures D9110 Emergency treatment for relief of pain...$ D9211 Regional block anesthesia...$ 0 D9212 Trigeminal division block anesthesia...$ 0 D9215 Local anesthesia...$ 0 D9310 Consultation (a referral from your PCD is required)...$ D9311 Consultation with medical health care professional...$ 0 D9440 After-hours office visit...$ D9450 Case presentation, detailed and extensive treatment planning...$ 0 D9932 Cleaning and inspection of removable complete denture, maxillary...$ 0 D9933 Cleaning and inspection of removable complete denture, mandibular...$ 0 D9934 Cleaning and inspection of removable partial denture, maxillary...$ 0 D9935 Cleaning and inspection of removable partial denture, mandibular...$ 0 D9990 Certified translation or sign language services - per visit...$ 0 D9991 Dental case management - addressing appointment compliance barriers...$ 0 D9992 Dental case management - care coordination...$ 0 D9995 Teledentistry - synchronous; real-time encounter...$ 0 D9996 Teledentistry - asynchronous; information stored and forwarded to dentist for subsequent review...$ 0 D9999 Unspecified adjunctive procedure, by report...$ Failed Appointment without 24-hour notice - per 15 minutes of appointment time...$ Emergency Dental Care If you need emergency care, contact your PCD immediately. He or she will arrange to get you the care you need. If you can t reasonably reach your PCD (for example, you are traveling or you are not in the area) and need emergency care, you should see a local dentist for treatment. Delta Dental will provide coverage for emergency services to reduce swelling, relieve pain and/or reduce the potential for infection until you can see your PCD for treatment. Please contact your local DeltaCare USA Service Team using the phone number listed on the back of your ID card for additional information on Emergency Dental Care. Out-of-Network Benefits Due to insurance legislation requirements, members who reside in Massachusetts may receive care from a nonparticipating dentist. However, we provide benefits at a reduced out-of-network level, and a $100 out-of-network deductible applies. OPT = an alternate benefit. Your plan covers the least expensive method of appropriate care for this condition, yet an alternative procedure can also be applied at the discretion of you and your dentist at a higher out-of-pocket cost to you

9 Frequency Limitations 1. Cleanings twice every 12 months. 2. Dentures up to one set per arch once every five years provided the existing set is no longer serviceable. 3. Partial Dentures are not to be replaced within any five-year period, unless necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible. 4. Denture relines are limited to one per denture during any twelve (12) consecutive months. 5. Periodontic Services are limited to four quadrants during any twelve (12) consecutive months, unless noted differently. 6. Bitewing x-rays are limited to not more than two series of four films in any twelve-month period. 7. Full mouth x-rays are limited to one set every twenty-four (24) consecutive months. 8. Sealants on unrestored permanent molars only, once per tooth for members through age Topical fluoride treatment twice every 12 months for members under age Space maintainers (required due to the premature loss of teeth) For members under age 14 and not for the replacement of primary or permanent anterior teeth. Exclusions 1. General anesthesia, IV sedation, nitrous oxide, and the services of a special anesthesiologist. 2. Cosmetic dental care. 3. Dental conditions arising out of and due to enrollee s employment or for which Worker s Compensation is payable. Services that are provided to the enrollee by state government or agency thereof, or are provided without cost to the enrollee by any municipality, country, or other subdivision. 4. Treatment required by reason of war. 5. Dental services performed in a hospital and related hospital fees. 6. Treatment of fractures and dislocations. 7. Loss or theft of fixed and removable prosthetics (crowns, bridges, full or partial dentures). 8. Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage. 9. Any service that is not specifically listed as a covered expense. 10. Congenital malformation. 11. Cysts and malignancies. 12. Dispensing of drugs not normally supplied in a dental office. 13. Accidental injury. Accidental injury is defined as damage to the hard and soft tissues of the oral cavity resulting from forces external to the mouth. Damages to the hard and soft tissues of the oral cavity from normal masticatory (chewing) function will be covered at the normal schedule of benefits. 14. Cases which in the professional judgment of the attending dentist determines a satisfactory result cannot be obtained or where the prognosis is poor or guarded. 15. Dental services received from any dental office other than the assigned PCD s office, unless expressly authorized in writing from DeltaCare USA. 16. Prophylactic removal of impactions (asymptomatic nonpathological). 17. Specialist consultations for noncovered benefits. 18. Implant placement or removal, appliances placed on or services associated with implants. 19. Dental expenses incurred in connection with any dental procedure started prior to the enrollee s eligibility with the DeltaCare USA program. Example: teeth prepared for crowns, root canals in progress, orthodontic treatment. Orthodontic Limitations and Exclusions 1. Orthodontic treatment must be provided by a member of the DeltaCare USA Orthodontic panel and requires a referral from your PCD. 2. A consultation fee may be charged if treatment is not required or you elect not to start treatment after a diagnosis and consultation has been completed. 3. Lost, stolen, or broken appliances are excluded. 4. Retreatment of orthodontic cases is excluded. 5. Changes in treatment necessitated by an accident of any kind. 6. Surgical procedures incidental to orthodontic treatment. 7. Myofunctional therapy. 8. Surgical procedures related to cleft palate, micrognathia, or macrognathia. 9. Treatment related to temporomandibular joint disturbances and/or hormonal imbalance. 10. Malocclusions that are so severe that they are not amenable to ideal orthodontic therapy. 11. Restorative work caused by orthodontic treatment. 12. Orthodontic examination and records unless you receive comprehensive treatment. 13. Tooth extraction solely for the purpose of orthodontics. 14. Orthodontic treatment started before the effective date of your DeltaCare USA coverage. Please contact the DeltaCare USA Service Team if you have any questions or require detailed information regarding orthodontic services

10 DeltaCare USA Questions and Answers Q. What is DeltaCare USA? A. DeltaCare USA is a national dental HMO covering more than 1.4 million members through a network of participating dentists. Q. My dentist is a Delta Dental dentist, but he is not on the list. Can I still use him? A. Delta Dental has several other dental programs and not all Delta Dental dentists accept all Delta programs. With the DeltaCare USA program, you MUST use only those dentists listed in the directory of participating dentists. If you use a dentist who is not on the list, you will NOT be covered. Q. Will my entire family receive dental care from the same DeltaCare USA provider? A. DeltaCare USA allows up to the three providers within the same state per family unit. Q. How long does it take to get an appointment with a dentist? A. Three to four weeks is a reasonable amount of time to wait for a standard appointment if you can accept the first available appointment. If you require a more specific time you may have to wait longer for an appointment. Q. If I have a pre-existing dental condition, may I join DeltaCare USA? A. YES. Pre-existing conditions are not excluded under the DeltaCare USA program. The only exception would be work in progress dental expenses incurred in connection with any dental procedure started prior to coverage with DeltaCare USA are excluded. Q. Does the DeltaCare USA program provide coverage for specialty services? A. YES. DeltaCare USA maintains a panel of specialists and coordinates all your specialty care needs with your panel dentist. You may select a specialist from the DeltaCare USA network or ask your PCD for a recommendation. Q. How are dentists compensated? A. A participating dentist is compensated by DeltaCare USA through monthly capitation (an amount based on the number of enrollees assigned to the dentist) and by enrollees through required co-payments for treatment received. A specialist is compensated by DeltaCare USA through an agreed-upon amount for each covered procedure, and by the enrollees through applicable co-payments. In no event does DeltaCare USA pay a participating dentist or specialist any incentive as an inducement to deny, reduce, limit, or delay any appropriate treatment. Q. Once I ve selected a participating dentist, may I change dentists? A. YES. You may change your eligibility from one DeltaCare USA participating dentist to another by phoning DeltaCare USA by the 21st day of the month. Our DeltaCare USA Service Team will assist you in the transfer, which will take effect the first day of the following month. Q. Who do I contact if I need assistance? A. The DeltaCare USA Service Team will assist you in all matters pertaining to the DeltaCare USA program. You may reach a DeltaCare USA representative at

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12 NONDISCRIMINATION NOTICE Delta Dental of Massachusetts complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Delta Dental of Massachusetts does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Delta Dental of Massachusetts: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, and accessible electronic formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, visit: com or call the number on your member ID card. If you believe that Delta Dental of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Ugonna Onyekwu Civil Rights Coordinator Compliance Department 465 Medford Street Boston, MA Fax: Phone: FairTreatment@greatdentalplans.com TTY: 711 You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Ugonna Onyekwu is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Complaint forms are available at gov/ocr/office/file/index.html. You can file a complaint electronically through the Office for Civil Rights Complaint Portal, available at jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) FOREIGN LANGUAGE ASSISTANCE ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (TTY: ). كل رفاوتت ةيوغللا ةدعاسملا تامدخ نإف ةغللا ركذا ثدحتت تنك اذإ :ةظوحلم.( (TTY: مقرب لصتا.ناجملاب ប រយ ត ន ប ស នជ អ នកន យ យ ភ ស ខ ម រ, ស វ ជ ន យផ ន កភ ស ដ យម នគ តឈ ន ល គ អ ចម នស រ ប ប រ អ នក ច រ ទ រស ព ទ (TTY: ). ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (TTY: ). ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 번으로전화해주십시오. ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: ). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). ध य न द : यद आप ह द ब लत ह त आपक ल ए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: ). पर क ल कर સ ચન : જ તમ ગ જર ત બ લત હ, ત ન :શ લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: ). (1) Delta Dental of Massachusetts PPO and Premier insurance products are offered by Dental Service of Massachusetts, Inc. (2) DeltaCare insurance products are offered both by Dental Service of Massachusetts, Inc., and DSM Massachusetts Insurance Company, Inc. (3) Total Choice PPO and Delta Dental EPO insurance products are offered by DSM Massachusetts Insurance Company, Inc

13 If you have any questions or need any additional information please call: Delta Dental of Massachusetts DeltaCare USA Service Team Note: This is only a brief summary of the DeltaCare USA plan. If any conflict arises between this description and the plan document, or if any point is not covered, the terms of the plan document will govern in all cases. SP116 (10.18)