Schedule of Covered Services and Copayments CA SmartSmile Plan

Transcription

1 Schedule of Covered Services and Copayments CA SmartSmile Plan Code Description Copayment Code Description Copayment 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 Diagnostic D47 diagnostic casts 5 D61 caries risk assessment and documentation, 1 with a finding of low risk D62 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 D145 oral evaluation for a patient under three years of age and counseling with primary caregiver Preventive D comprehensive oral evaluation - new or D111 prophylaxis - adult (limited to 1 every 6 established patient months) D16 detailed and extensive oral evaluation - D112 prophylaxis - child (limited to 1 every 6 problem focused, by report months) D17 re-evaluation - limited, problem focused D11AX prophylaxis - adult (additional beyond 1 in 8 (established patient; not post-operative 6 months) visit) D11CX prophylaxis - child (additional beyond 1 in 8 D171 re-evaluation post-operative office visit 6 months) D18 comprehensive periodontal evaluation - D126 topical application of fluoride varnish 12 new or established patient D128 topical application of fluoride excluding D21 intraoral - complete series of radiographic varnish images D131 nutritional counseling for control of dental D22 intraoral - periapical first radiographic disease image D132 tobacco counseling for the control and D23 intraoral - periapical each additional prevention of oral disease radiographic image D133 oral hygiene instructions D24 intraoral - occlusal radiographic image D1351 sealant - per tooth 1 D extra-oral 2D projection radiographic D1352 preventive resin restoration in a moderate 2 image created using a stationary radiation source, and detector to high caries risk patient permanent tooth D27 bitewing - single radiographic image D1353 sealant repair per tooth 1 D272 bitewings - two radiographic images D1354 interim caries arresting medicament 2 D273 bitewings - three radiographic images application- per tooth D274 bitewings - four radiographic images D277 vertical bitewings - 7 to 8 radiographic Space Maintainers images D1 space maintainer - fixed - unilateral 1 D33 panoramic radiographic image D space maintainer - fixed - bilateral D34 2D cephalometric radiographic image 1 D2 space maintainer - removable - unilateral 1 acquisition, measurement and analysis D space maintainer - removable - bilateral D35 2D oral/facial photographic image obtained intra-orally or extra-orally D5 re-cement or re-bond space maintainer 2 D391 D4 D4 interpretation of diagnostic image by a practitioner not associated with capture of the image, including report collection of microorganisms for culture and sensitivity caries susceptibility tests 5 2 D55 D removal of fixed space maintainer distal shoe space maintainer fixed unilateral Amalgam Restorations - Primary or Permanent 117M241 Current Dental Terminology 218 American Dental Association. All rights reserved Effective Date: 1/1/218 1

2 D214 amalgam - one surface, primary or 32 D2664 onlay - resin-based composite - four or 35 permanent more D2 amalgam - two, primary or permanent 42 D271 D2712 crown - resin-based composite (indirect) crown - ¾ resin-based composite (indirect) D216 amalgam - three, primary or 5 D272 * crown - resin with high noble 4 permanent D2721 crown - resin with predominantly base D2161 amalgam - four or more, primary 6 or permanent D2722 * crown - resin with noble 3 Resin-Based Composite Restorations D274 crown - porcelain/ceramic 49 D2 * crown - porcelain fused to high noble 49 D233 resin-based composite - one surface, 44 anterior D21 crown - porcelain fused to predominantly 34 D2331 resin-based composite - two, 6 base anterior D22 * crown - porcelain fused to noble 465 D2332 resin-based composite - three, anterior 8 D278 D2781 * crown - 3/4 cast high noble crown - 3/4 cast predominantly base D2335 resin-based composite - four or more 12 D2782 * crown - 3/4 cast noble 435 or involving incisal angle (anterior) D2783 crown - 3/4 porcelain/ceramic 34 D239 resin-based composite crown, anterior 12 D279 * crown - full cast high noble 46 D2391 resin-based composite - one surface, 6 D2791 crown - full cast predominantly base 31 posterior D2792 * crown - full cast noble 435 D2392 resin-based composite - two, 8 D2794 posterior * crown - titanium 46 D2799 provisional crown further treatment or 2 D2393 resin-based composite - three, 1 completion of diagnosis necessary prior to posterior final impression D2394 resin-based composite - four or more 13 D27BM crown-butt margin 5, posterior D27ML crown- porcelain on molar 1 Crowns - Single Restoration Only D27SC crown- specialty upgrade 2 *Copayments include charges for noble and high noble /titanium. D27SC is an optional upgrade charge added to the standard base crown copayment for specialized porcelain such as Lava, Captek, Cercon, Empress, E- Max, etc. and D27BM is an optional benefit for porcelain butt margin. D27ML is an additional copayment for porcelain crowns on molar teeth. D1 inlay - lic - one surface 31 D2 inlay - lic - two 31 D3 inlay - lic - three or more 31 D42 onlay - lic - two 31 D43 onlay - lic - three 31 D44 onlay - lic - four or more 31 D261 inlay - porcelain/ceramic - one surface 41 D262 inlay - porcelain/ceramic - two 41 D263 inlay - porcelain/ceramic - three or more 41 D2642 onlay - porcelain/ceramic - two 41 D2643 onlay - porcelain/ceramic - three 41 D2644 onlay - porcelain/ceramic - four or more 41 D265 inlay - resin-based composite - one surface 33 D2651 inlay - resin-based composite - two 35 D2652 inlay - resin-based composite - three or 35 more D2662 onlay - resin-based composite - two 35 D2663 onlay - resin-based composite - three 35 Other Restorative Services D291 D29 D292 D2921 D2929 D293 D2931 D2932 D2933 D2934 D294 D2941 re-cement or re-bond inlay, onlay, veneer or partial coverage restoration re-cement or re-bond indirectly fabricated or prefabricated post and core re-cement or re-bond crown reattachment of tooth fragment, incisal edge or cusp prefabricated porcelain/ceramic crown primary tooth prefabricated stainless steel crown - primary tooth prefabricated stainless steel crown - permanent tooth prefabricated resin crown prefabricated stainless steel crown with resin window prefabricated esthetic coated stainless steel crown - primary tooth protective restoration interim therapeutic restoration primary dentition restorative foundation for an indirect restoration core buildup, including any pins when required pin retention - per tooth, in addition to restoration 117M241 Current Dental Terminology 218 American Dental Association. All rights reserved Effective Date: 1/1/218 D2949 D295 D

3 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 5 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 5 replacement D2962 labial veneer (porcelain laminate) - 34 laboratory D3357 pulpal regeneration - completion of 2 treatment D2971 additional procedures to construct new crown under existing partial denture D341 apicoectomy - anterior 2 framework D3421 apicoectomy - premolar (first root) 2 D29 coping 31 D34 apicoectomy - molar (first root) 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 D345 root amputation - per root D311 pulp cap - direct (excluding final D392 hemisection (including any root removal), 2 restoration) not including root canal therapy D312 pulp cap - indirect (excluding final D395 canal preparation and fitting of preformed 6 restoration) dowel or post D322 therapeutic pulpotomy (excluding final 45 restoration) - removal of pulp coronal to Periodontics the dentinocemental junction and D421 gingivectomy or gingivoplasty - four or application of medicament more contiguous teeth or tooth bounded D3221 pulpal debridement, primary and 45 spaces per quadrant D3222 D323 D324 D331 D332 D333 D3331 D3332 D3333 D3346 D3347 D3348 permanent teeth partial pulpotomy for apexogenesis - permanent tooth with incomplete root development pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) endodontic therapy, anterior tooth (excluding final restoration) endodontic therapy, premolar tooth (excluding final restoration) endodontic therapy, molar tooth (excluding final restoration) 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 - premolar retreatment of previous root canal therapy - molar 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 or bounded spaces per quadrant anatomical crown exposure - one to three teeth or bounded spaces 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 retained natural tooth first site in quadrant 117M241 Current Dental Terminology 218 American Dental Association. All rights reserved Effective Date: 1/1/218 D4261 D

4 D4264 bone replacement graft retained natural tooth each additional site in quadrant 5 D5214 mandibular partial denture - cast framework with resin denture bases 48 D4266 guided tissue regeneration - resorbable 28 barrier, per site D4267 guided tissue regeneration - nonresorbable 35 D5221 immediate maxillary partial denture resin 49 barrier, per site (includes membrane base (including any conventional clasps, removal) rests D4268 surgical revision procedure, per tooth 445 D5222 immediate mandibular partial denture 49 D427 pedicle soft tissue graft procedure 445 resin base (including any conventional D4274 D4277 D4278 D4341 D4342 D4346 D4355 D4381 D491 D4921 D49XC Dentures mesial/distal wedge procedure, single tooth (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 scaling in presence of generalized moderate or severe gingival inflammation full mouth, after oral evaluation full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth periodontal maintenance (1st and 2nd in year) gingival irrigation per quadrant periodontal maintenance (3rd and 4th in year) Dentures and partials include four months free adjustments. D511 complete denture - maxillary D512 complete denture - mandibular D513 immediate denture - maxillary D514 immediate denture - mandibular D5211 maxillary partial denture - resin base D5212 mandibular partial denture - resin base D5213 maxillary partial denture - cast framework with resin denture bases D5223 D5224 D52 D5226 D5281 clasps, rests immediate maxillary partial denture cast framework with resin denture bases 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 and teeth) Denture Adjustments & Repairs D541 D5411 D5421 D5422 D5511 D5512 D552 D5611 D5612 D5621 D5622 D563 D564 D565 D566 D567 D5671 D571 D5711 D572 D5721 D573 adjust complete denture - maxillary adjust complete denture - mandibular adjust partial denture - maxillary adjust partial denture - mandibular repair broken complete denture base, mandibular repair broken complete denture base, maxillary replace missing or broken teeth - complete denture (each tooth) repair resin partial denture base, mandibular repair resin partial denture base, maxillary repair cast partial framework, mandibular repair cast partial framework, maxillary 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) M241 Current Dental Terminology 218 American Dental Association. All rights reserved Effective Date: 1/1/218

5 D5731 reline complete mandibular denture 8 D661 retainer inlay - porcelain/ceramic, three or 24 (chairside) more D574 reline maxillary partial denture (chairside) 8 D662 * retainer inlay - cast high noble, two 46 D5741 reline mandibular partial denture 8 (chairside) D663 * retainer inlay - cast high noble, three 46 D5 reline complete maxillary denture 14 or more (laboratory) D664 retainer inlay - cast predominantly base 31 D51 reline complete mandibular denture 14, two D576 (laboratory) reline maxillary partial denture (laboratory) 14 D665 retainer inlay - cast predominantly base, three or more 31 D5761 reline mandibular partial denture 14 D666 * retainer inlay - cast noble, two 435 (laboratory) D581 interim complete denture (maxillary) 18 D667 * retainer inlay - cast noble, three or 435 D5811 interim complete denture (mandibular) 18 more D582 interim partial denture (maxillary) 18 D668 retainer onlay - porcelain/ceramic, two 34 D5821 interim partial denture (mandibular) 18 D669 retainer onlay - porcelain/ceramic, three 34 D585 tissue conditioning, maxillary 5 or more D5851 tissue conditioning, mandibular 5 D661 * retainer onlay - cast high noble, two 46 D5863 overdenture complete maxillary 36 D5864 overdenture partial maxillary 36 D6611 * retainer onlay - cast high noble, D5865 overdenture complete mandibular 36 three or more 46 D5866 overdenture partial mandibular 36 D6612 retainer onlay - cast predominantly base 31, two Bridges D6613 retainer onlay - cast predominantly base 31, three or more *Copayments include charges for noble and high noble /titanium. D6614 * retainer onlay - cast noble, two 435 D62SC and D67SC are ore optional upgrade charges to the standard crown copayment for specialized porcelain such as Lava, Captek, Cercon, Empress, E- Max, etc. and D67BM is an optional benefit for porcelain butt margin. D62ML D66 * retainer onlay - cast noble, three or 435 and D67ML have an additional copayment for porcelain crowns on molar teeth. more D6 pontic - indirect resin based composite D6624 * retainer inlay - titanium 46 D621 * pontic - cast high noble 46 D6634 * retainer onlay - titanium 46 D6211 pontic - cast predominantly base 31 D671 retainer crown - indirect resin based composite D6212 * pontic - cast noble 435 D672 * retainer crown - resin with high noble 4 D6214 * pontic - titanium 46 D624 * pontic - porcelain fused to high noble 49 D6721 retainer crown - resin with predominantly base D6241 pontic - porcelain fused to predominantly 34 D6722 * retainer crown - resin with noble 3 base D674 retainer crown - porcelain/ceramic 34 D6242 * pontic - porcelain fused to noble 465 D6 * retainer crown - porcelain fused to high 49 D6245 pontic - porcelain/ceramic 34 noble D6 * pontic - resin with high noble 4 D61 retainer crown - porcelain fused to 34 D61 pontic - resin with predominantly base predominantly base D62 * retainer crown - porcelain fused to noble 465 D62 * pontic - resin with noble 3 D63 provisional pontic - further treatment or 2 D678 * retainer crown - 3/4 cast high noble 46 completion of diagnosis necessary prior to D6781 retainer crown - 3/4 cast predominantly 31 final impression base D62ML pontic- porcelain on molar 1 D6782 * retainer crown - 3/4 cast noble 435 D62SC pontic - specialty upgrade 2 D6783 retainer crown - 3/4 porcelain/ceramic 34 D6545 retainer - cast for resin bonded fixed 17 D679 * retainer crown - full cast high noble 46 prosthesis D6791 retainer crown - full cast predominantly 31 D6548 retainer - porcelain/ceramic for resin 34 base bonded fixed prosthesis D6792 * retainer crown - full cast noble 435 D6549 resin retainer for resin bonded fixed 17 prosthesis D6793 provisional retainer crown - further 2 treatment or completion of diagnosis D66 inlay - porcelain/ceramic, two 24 necessary prior to final impression 117M241 Current Dental Terminology 218 American Dental Association. All rights reserved Effective Date: 1/1/218

6 D6794 * retainer crown - titanium 46 D676 * implant supported retainer for porcelain 1 D67BM abutment crown- butt margin 5 fused to FPD (titanium, titanium D67ML abutment crown-porcelain on molar 1 alloy, or high noble ) D67SC abutment crown- specialty upgrade 2 D677 * implant supported retainer for cast FPD (titanium, titanium alloy, or high D693 re-cement or re-bond fixed partial denture 3 noble ) 1 Implants D681 scaling and debridement in the presence 6 of inflammation or mucositis of a single *Copayments include charges for noble and high noble /titanium. implant, including cleaning of the implant Implant services are covered only when performed by a participating general dentist., without flap entry and closure D61 surgical placement of implant body: D685 provisional implant crown 2 endosteal implant D692 re-cement or re-bond implant/abutment 3 D611 second stage implant surgery 2 supported crown D651 interim abutment 2 D693 re-cement or re-bond implant/abutment 4 supported fixed partial denture D652 semi-precision attachment abutment 2 D694 * abutment supported crown - (titanium) 65 D656 prefabricated abutment includes 45 modification and placement D614 bone graft at time of implant placement 26 D657 custom fabricated abutment includes 45 D611 implant /abutment supported removable 23 placement denture for edentulous arch maxillary D658 abutment supported porcelain/ceramic 1 D6111 implant /abutment supported removable 23 crown denture for edentulous arch mandibular D659 * abutment supported porcelain fused to 1 D6112 implant /abutment supported removable 23 crown (high noble ) denture for partially edentulous arch maxillary D66 abutment supported porcelain fused to 1 crown (predominantly base ) D6113 implant /abutment supported removable 23 denture for partially edentulous arch D661 * abutment supported porcelain fused to 11 mandibular crown (noble ) D6194 * abutment supported retainer crown for 65 D662 * abutment supported cast crown 1 FPD (titanium) (high noble ) D663 abutment supported cast crown 1 (predominantly base ) Oral Surgery D664 * abutment supported cast crown 11 D7111 extraction, coronal remnants - primary 35 (noble ) tooth D665 implant supported porcelain/ceramic 1 D714 extraction, erupted tooth or exposed root 4 crown (elevation and/or forceps removal) D666 * implant supported porcelain fused to 1 D721 extraction, erupted tooth requiring 7 D667 * crown (titanium, titanium alloy, high noble ) implant supported crown (titanium, 1 removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated titanium alloy, high noble ) D722 removal of impacted tooth - soft tissue 85 D668 abutment supported retainer for 1 D723 removal of impacted tooth - partially bony 16 porcelain/ceramic FPD D724 removal of impacted tooth - completely 235 D669 * abutment supported retainer for porcelain 1 bony D67 fused to FPD (high noble ) abutment supported retainer for porcelain 1 D7241 removal of impacted tooth - completely bony, with unusual surgical complications 2 fused to FPD (predominantly base D7 removal of residual tooth roots (cutting ) procedure) 8 D671 * abutment supported retainer for porcelain 11 D71 coronectomy intentional partial tooth fused to FPD (noble ) removal 235 D672 * abutment supported retainer for cast 1 D727 tooth reimplantation and/or stabilization FPD (high noble ) of accidentally evulsed or displaced tooth D673 abutment supported retainer for cast 1 D728 exposure of an unerupted tooth 2 FPD (predominantly base ) D7282 mobilization of erupted or malpositioned 2 D674 * abutment supported retainer for cast 11 tooth to aid eruption FPD (noble ) D7285 incisional biopsy of oral tissue-hard (bone, 95 D6 implant supported retainer for ceramic 1 tooth) FPD D7286 incisional biopsy of oral tissue-soft M241 Current Dental Terminology 218 American Dental Association. All rights reserved Effective Date: 1/1/218

7 D7288 brush biopsy - transepithelial sample 5 D9933 cleaning and inspection of removable collection complete denture, mandibular D731 alveoloplasty in conjunction with 9 D9934 cleaning and inspection of removable D7311 extractions - four or more teeth or tooth spaces, per quadrant alveoloplasty in conjunction with 7 D9935 partial denture, maxillary cleaning and inspection of removable partial denture, mandibular extractions - one to three teeth or tooth D994 occlusal guard, by report 18 spaces, per quadrant D9941 fabrication of athletic mouthguard 1 D732 alveoloplasty not in conjunction with 9 D9942 repair and/or reline of occlusal guard 9 extractions - four or more teeth or tooth spaces, per quadrant D9943 occlusal guard adjustment D7321 alveoloplasty not in conjunction with 7 D9951 occlusal adjustment - limited 35 extractions - one to three teeth or tooth D9952 occlusal adjustment - complete spaces, per quadrant D997 enamel microabrasion 2 D7471 removal of lateral exostosis (maxilla or 2 D9971 odontoplasty 1-2 teeth; includes removal 2 mandible) of enamel projections D1 incision and drainage of abscess - intraoral 5 D9972 external bleaching - per arch - performed 2 soft tissue in office D11 incision and drainage of abscess - intraoral 1 D9973 external bleaching - per tooth 1 soft tissue - complicated (includes D9974 internal bleaching - per tooth 1 drainage of multiple fascial spaces) D99 external bleaching for home application, 2 D796 frenulectomy - also known as frenectomy 1 per arch; includes materials and or frenotomy - separate procedure not fabrication of custom trays incidental to another procedure D9991 dental case management addressing D7963 frenuloplasty 2 appointment compliance barriers D797 excision of hyperplastic tissue - per arch 2 D9992 dental case management care D7971 Other Services excision of pericoronal gingiva 5 D9993 coordination dental case management motivational interviewing D911 D9994 dental case management patient palliative (emergency) treatment of dental education to improve oral health literacy pain - minor procedure D912 fixed partial denture sectioning 4 D921 local anesthesia not in conjunction with Orthodontics operative or surgical procedures Removable orthodontic retainer D9211 regional block anesthesia adjustment D9212 trigeminal division block anesthesia Consultation D92 local anesthesia in conjunction with Failed/no-show appointment without 24- operative or surgical procedures hour notice D931 consultation - diagnostic service provided 2 Full banded - child, up to age by dentist or physician other than Full banded - adult 21 requesting dentist or physician Partial banded - child, up to age 19 1 D943 office visit for observation (during Partial banded - adult 5 regularly scheduled hours) - no other Mixed dentition - phase 1 6 services performed Palatal expansion 45 D944 office visit - after regularly scheduled hours 5 Rapid palatal expansion 6 D945 case presentation, detailed and extensive Retention appliance - after orthodontic treatment planning treatment D961 therapeutic parenteral drug, single Functional appliance (Bionator-Frankel) 6 administration Headgear 4 D9612 therapeutic parenteral drugs, two or more 3 administrations, different medications Simple crossbite 4 D963 drugs or medicaments dispensed in the Copying records 4 office for home use Please call your Dental Health Services Member Service Specialist at D991 application of desensitizing medicament for a referral to a conveniently located participating orthodontist. D9911 application of desensitizing resin for 2 Orthodontic models, x-rays, photographs and records are not covered. There may cervical and/or root surface, per tooth be additional copayments depending on treatment needs. D9932 cleaning and inspection of removable complete denture, maxillary 117M241 Current Dental Terminology 218 American Dental Association. All rights reserved Effective Date: 1/1/218

8 Exclusions & Limitations of Coverage CA SmartSmile 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 contract between the group and Dental Health Services is terminated, service is subject to a pro-rated fee based on current market value for the balance of orthodontic treatment. If the member should terminate group coverage, they are no longer eligible for the group 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 218 Dental Health Services. All rights reserved. 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; additional cleanings beyond the 6 months are available at a higher copayment. D. Periodontal maintenance (D491) has a shared frequency with prophylaxis (D111 or D112) cleanings of 1 in 6 months. E. Full mouth x-rays (D21) are limited to one set every three years if needed and have a shared frequency limitation with a

9 panoramic film (D33). Panoramic films may be covered regardless of full mouth x-ray history when wisdom teeth extractions have been approved. F. Caries risk assessments (D61-D63) are covered for members 18 years of age and younger. 1. D61 & D62 are covered once every 6 months. 2. D63 is covered once every 3 months. G. Periodontal surgical procedures are limited to four quadrants every two years. H. Scaling and root planing (deep cleaning) is limited to 4 quadrants every 6 months, and 2 quadrants per visit. I. 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 initial delivery. Lost or stolen removable appliances are not covered. J. Relines are limited to once per twelve months, per appliance. K. Single unit inlays and crowns are a benefit as provided above only when the teeth cannot be adequately restored with other restorative materials. Enrollees should refer to the Group Service Agreement for further information on benefit exclusions and limitations. 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 lifetime maximums. Professional services - exam & preventive services: No charge for most services. Periodontal maintenance (D491) has a shared frequency with prophylaxis (D111 or D112) cleanings of 1 in 6 months; additional cleanings beyond the 6 months are available at a higher copayment. Full mouth x-rays (D21) are limited to one set every three years if needed and have a shared frequency limitation with a panoramic film (D33).. 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 of prosthetics are limited to every five years. Relines are limited to one per arch every 12 months. Professional services - specialty services: Services provided by a Specialist are not covered. Outpatient office visits: No additional charge 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 Atlantic Avenue, Long Beach, CA Dental Health Services