Primecare Dental Plan Individual Plan 400B

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Charles McCarthy
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1 Primecare Dental Plan Individual Whether you re a member of our dental plan, human resources or benefits professional we trust you will find our company a valuable resource for high quality and affordable dental benefits. We carefully evaluate every dental office prior to admission to the Primecare Dental network. If you have any questions, please call one of our member service Representatives at (909) or toll free (800) , or visit us at we ll be happy to assist you. DIAGNOSTIC 0110 Office visit per patient per visit Comprehensive oral evaluation Periodic oral evaluation Intraoral-complete series Intraoral-periapical-first film Intraoral-periapical-each additional Bitewings-four films Panoramic film 60 PREVENTIVE 1110 Prophylaxis-adult Prophylaxis-child Sealant per tooth 20 RESTORATIVE AMALAGAM RESTORATIONS (INCLUDING POLISHING) 2140 Amalgam-one surface, permanent, primary Amalgam-two surfaces, permanent, primary Amalgam-three surfaces, permanent, primary 60 RESIN RESTORATIONS 2330 Resin-one surface, anterior Resin-two surfaces, anterior Resin-three surfaces, anterior Resin-four or more surfaces involving incisal angle (anterior) 100 CROWNS-SINGLE RESTORATION ONLY 2740 Crown porcelain ceramic substrate Crown ¾ porcelain ceramic Crown-porcelain fused to high noble metal Crown-porcelain fused to predominantly base metal Crown-full cast predominantly base metal Crown-3/4 cast metallic Recement crown Prefabricated stainless steel crown - primary tooth Cast post and core in addition to crown Prefabricated post and core in addition to crown 110 Primecare Dental /2010

2 ENDODONTICS PULP CAPPING 3110 Pulp cap-direct (excluding final restoration) Pulp cap-indirect (excluding final restoration) Therapeutic Pulpotomy (excluding final restoration) Root Canal-Anterior (excluding final restoration) Root Canal-Bicuspid (excluding final restoration) Root Canal-Molar (excluding final restoration) Apicoectomy-anterior 370 PERIODONTICS 4210 Gingivectomy or gingivoplasty - per quadrant Gingivectomy or gingivoplasty - per tooth Gingival curettage, surgical, per quadrant, by report Osseous surgery (including flap entry and closure) per quadrant 525 PROSTHODONTICS 5110 Complete denture-maxillary Complete denture-mandibular Maxillary partial denture-resin base (including any conventional clasps, rests and teeth) Mandibular partial denture-resin base (including any conventional clasps, rests and teeth Maxillary partial denture-cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Mandibular partial denture-cast metal framework with resin denture bases (including any conventional clasps, rest and teeth) Adjust complete denture-maxillary Adjust complete denture-mandibular Adjust partial denture-maxillary Adjust partial denture-mandibular Repair broken complete denture base Repair or replace broken clasp Replace broken teeth-per tooth Add tooth to existing partial denture Add clasp to existing partial denture Reline complete maxillary denture (chairside) Reline complete mandibular denture (chairside) Reline complete maxillary denture (laboratory) Reline complete mandibular denture (laboratory) 165 ORAL SURGERY 7110 Single tooth Each additional tooth Surgical removal of erupted tooth Removal of impacted tooth - soft tissue Removal of impacted tooth - partially bony Removal of impacted tooth - completely bony 170 Primecare Dental /2010

3 GENERAL SERVICES 9999 Broken appointment (less than 24 hours notice given) Palliative (emergency) treatment of dental pain Emergency treatment after hours 45 EMERGENCY, OUT OF AREA EMERGENCY CARE(BY NON-PARTICIPATING PROVIDER) OUTPATIENT SERVICES/HOSPITALIZAION & DRUG COVERAGE AMBULANCE SERVICE/DURABLE MEDICAL EQUIPMENT MENTAL HEALTH/CHEMICAL DEPENDENCY SER./HOME HEALTH PROSTHODONCTIC SPECIALTY SERVICES REIMBURSABLE UP TO $50 NOT COVERED NOT COVERED NOT COVERED NOT COVERED Services When Performed By A Plan Specialist, By Referral Only ENDODONTICS (Services When Performed by Plan Specialist) 3310 Root canal therapy anterior traditional Root canal therapy bicuspid traditional Root canal therapy molar traditional Retreatment of root canal anterior Retreatment of root canal bicuspid Retreatment of root canal molar Apicoectomy/periadicular surgery-anterior Apicoectomy/periadicular surgery-bicuspid first root Apicoectomy/periadicular surgery molar first root Apicoectomy/periadicular surgery each additional root Retrograde filling per root in addition to apicoectomy Root amputation per root 298 PERIODONTICS 4210 Gingivectomy or gingivoplasty - per quadrant Gingivectomy or gingivoplasty - per tooth Anatomical crown exposure-four or more contiguous teeth per quad Anatomical crown exposure one to three per quad. 340 Gingival flap procedure-includes root planing 4 plus contiguous teeth Gingival flap procedure including root planing 1-3 contiguous 4241 teeth Crown lengthening hard tissue by report Osseous surgery four or more contiguous teeth per quad Osseous surgery (including flap entry and closure) 1-3 contiguous teeth Bone replacement graft-first site in quadrant Bone replacement graft-each additional site in quadrant Guided tissue regeneration-restorable barrier-per site Guided tissue regeneration-nonrestorable barrier per site Pedicle soft tissue graft procedure Free soft tissue graft procedures (including donor site surgery) Subepithelial connective tissue graft procedure per tooth Distal or proximal wedge procedure Soft tissue allograft Combined connective tissue graft procedures per tooth Provisional splinting-intracornal by report Provisional splinting-extracoronal by report Periodontal scaling & root planing four or more teeth per quad 120 Primecare Dental /2010

4 4342 Periodontal scaling & root planing-1-3 teeth per quad Full mouth debridement Localized delivery of antimicrobial agents-per tooth by report Periodontal maintenance procedures following active therapy 81 ORAL SURGERY 7210 Surgical removal of erupted tooth Removal of impacted tooth soft tissue Removal of impacted tooth partially bony Removal of impacted tooth completely bony Removal of impacted tooth completely bony with complications Surgical removal of residual tooth roots cutting procedures Oroantral fistula closure Primary closure of a sinus perforation Tooth reimplantation and/or stabilization of evulsed or displaced tooth Tooth transplantation (includes reimplantation from one site to another Surgical access of an erupted tooth Biopsy of oral tissue-hard (bone, tooth). Provide pathology report Biopsy of oral tissue-soft (all others). Provide pathology report Exfoliative cytological sample collection. Provide lab report Brush biopsy-transepithelia sample collection by report Transseptal fiberotomy/supra crestial fiberotomy by report Alveoloplasty in conjunction with extractions four or more teeth Alveoloplasty in conjunction with extractions-one to three teeth Alveoloplasty not in conjunction with extractions four or more teeth Alveoloplasty not in conjunction with extractions-one to three teeth Vestibuloplasty-ridge extension secondary epithelialization Vestibuloplasty ridge extension Excision of benign lesion up to 1.25cm Excision of benign lesion greater than 1.25cm Excision of benign lesion-complicated by report Excision of malignant lesion up to 1.25cm Excision of malignant lesion greater than 1.25cm Excision of malignant lesion-complicated by report Excision of malignant tumor-lesion diameter up to 1.25cm Excision of malignant tumor-lesion diameter greater than 1.25cm Removal of benign odontogenic cyst or tumor-lesion up to 1.25cm Removal of benign odontogenic cyst or tumor-lesion greater than 1.25cm Removal of benign nonodontogenic cyst or tumor-lesion up to 1.25cm Removal of benign nonodontogenic cyst or tumor-lesion greater than 1.25cm Removal of lateral exostosis (maxilla or mandible) Removal of torus palatinus Removal of torus mandibularis 366 Primecare Dental /2010

5 7485 Surgical reduction of osseous tuberosity Incision and drainage of abscess Intraoral soft tissue Removal of a foreign body from mucosa, skin or subcutaneous alveolar tissue Occlusal orthotic devise (TMJ treatment appliance) by report Suture of recent small wounds up to 5cm Complicated suture up to 5cm Complicated suture greater than 5cm Bone replacement graft for ridge preservation per site Frenulectomry (frenectomy or frenectomy) separate procedures Excision of hyperplasic tissue per arch Excision of periocornal gingiva Surgical reduction of fibrous tuberosity 269 IMPLANTS 5982 Surgical stent Surgical placement of implant body-endosteal implant Prefabricated abutment-includes placement Abutment supported crown-porcelain/ceramic Abutment supported crown porcelain fused to high noble metal Abutment supported crown porcelain fused to predominantly base metal Abutment supported crown porcelain fused to noble metal Abutment supported crown cast high noble metal Abutment supported crown cast predominantly base metal Abutment supported crown cast noble metal Implant supported crown porcelain/ceramic Implant supported crown high noble metal or titanium Abutment supported retainer for porcelain high noble metal or titanium Abutment supported retainer for porcelain/ceramic FPD Abutment supported retainer for porcelain fused to metal FPD (high noble metal) Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) Abutment supported retainer for porcelain fused to metal FPD (noble metal) Abutment supported retainer for cast metal FPD (high noble metal) Abutment supported retainer for cast metal FPD (predominantly base metal) Abutment supported retainer for cast metal FPD (noble metal) Implant supported retainer for ceramic FPD Implant supported retainer for porcelain fused to metal FPD (high noble metal or titanium) Implant supported retainer for cast metal FPD (high noble metal or titanium) Recement implant/abutment supported crown Recement implant/abutment supported fixed partial denture Abutment supported crown titanium Abutment supported retainer crown for FPD - titanium 579 Primecare Dental /2010

6 PROSTHODONTICS 2790 Crown full cast high noble metal Crown full cast predominantly base metal Crown full cast noble metal Crown titanium Labial veneer (resin laminate) chairside Labial veneer (resin laminate) laboratory Complete maxillary denture Complete mandibular denture Immediate maxillary denture Immediate mandibular denture Maxillary partial denture cast metal framework with resin denture base Mandibular partial denture-cast metal framework with resin denture base Overdenture-complete by report Overdenture partial by report Precision attachment by report 233 PEDODONTICS 1120 Prophylaxis child under age Topical application of fluoride child under age Topical fluoride varnish by report Sealant per tooth under age 16 on permanent molars only Space maintainer fixed unilateral Space maintainer fixed bilateral Space maintainer removable unilateral Space maintainer removable bilateral Amalgam four or more surfaces primary or permanent Amalgam two surfaces primary or permanent Amalgam three surfaces primary or permanent Amalgam four or more surfaces primary or permanent Resin based composite one surface anterior Resin based composite two surfaces anterior Resin based composite three surfaces anterior Resin based composite four or more surfaces anterior Resin based composite crown anterior Resin based composite one surface posterior Resin based composite two surfaces posterior Resin based composite three surfaces posterior Resin based composite four or more surfaces posterior Prefabricated stainless steel crown primary tooth Prefabricated stainless steel crown permanent tooth Sedative filling Pulp cap direct Pulp cap indirect Therapeutic Pulpotomy Pulpal debridement primary and permanent teeth 64 Primecare Dental /2010

7 ORTHODONTICS 8010 Limited orthodontic treatment of the primary dentition Limited orthodontic treatment of the transitional dentition Limited orthodontic treatment of the adult dentition Interceptive orthodontic treatment of the primary dentition Interceptive orthodontic treatment of the transitional dentition Comprehensive orthodontic treatment of the transitional dentition Comprehensive orthodontic treatment of the adult dentition Orthodontic retention removal of appliances/construction of retainer 192 MISCELLANEOUS SERVICES 9220 Deep sedation/general anesthesia first 30 minutes Deep sedation/general anesthesia each additional 15 minutes Analgesia anxiolysis, inhalation of nitrous oxide per visit Intravenous conscious sedation/analgesia first 30 minutes Intravenous conscious sedation/analgesia each additional 15 minutes Non-intravenous conscious sedation Office visit-for observation during office hours, no other services Office visit after regularly scheduled office hours Occlusal guard by report Limited occlusal adjustment per visit Complete occlusal adjustment by report External bleaching per arch External bleaching per tooth Internal bleaching per tooth 123 Primecare Dental Limitations & Exclusions 1. Full mouth X-rays: Limited to one (1) set every three (3) years unless diagnostically necessary. 2. Bitewing X-Rays: Two (2) sets in any twelve (12) month period unless diagnostically necessary. 3. Sealants: Limited to molars, up to the 16 th birthday. 4. Fluoride: Up to the 18 th birthday two(2) in any twelve (12) month period. 5. Delivery of removable prosthodontics includes adjustments within six months of delivery date of service. 6. Periodontal scaling and root planning: Limited to four (4) quadrants per twenty-four (24) consecutive months in combination with routine prophylaxis. 7. The copayments listed for endodontic procedures do not include the cost of the final restoration. 8. Panoramic x-rays: One (1) in any three (3) year period unless diagnostically necessary. 9. Prophylaxis: covered once every six consecutive months. 10. Reline of a complete or partial denture: One (1) per denture in any twelve (12) month period, unless dentally necessary. 11. Rebase of a complete or partial denture: One (1) per denture in any twelve (12) month period, unless diagnostically necessary. 12. Replacement of partial or full dentures are covered once per arch every five (5) years, except when they cannot be made functional through reline or repairs. 13. Complete or partial dentures are not to exceed one per arch in a five (5) year period unless necessary due to natural tooth loss where the addition to an existing partial or denture is not feasible. 14. Treatment of malignancies, cysts, or neoplasm. 15. Periodontal grafting or splinting. 16. Extractions of impacted teeth with no radiographic evidence of pathology (disease). The removal of asymptomatic third molars is not a covered benefit unless pathology (disease) exists. 17. General anesthesia, analgesia, intravenous /intramuscular sedation or the services of an anesthesiologist. Primecare Dental /2010

8 18. Elective or cosmetic dentistry that are cosmetic in nature including, but not limited to bonding, bleaching teeth, personalization or dentures, posterior composites, porcelain veneers unless covered as a benefit. 19. Orthodontic treatment in process, or extractions for orthodontic purposes. 20. Procedures, appliances or restorations whose primary purpose is to change the vertical deminsion of occlusion, correct congenital development or medically induced dental disorders including but not limited to treatment of myofunctional, myoskeletal, or tempormandibular joint disorders unless otherwise specifically listed as a covered benefit on the plans schedule of benefits. 21. Precision attachments, stress breakers, magnetic retention or overdenture attachments. 22. Cephalometric x-rays, except when performed as part of the orthodontic treatment plan and records for a covered course of comprehensive orthodontic treatment. 23. Inlays, onlays, crowns or fixed bridges started, but not completed, prior to the Member s eligibility to receive benefits under this Plan. 24. (Inlays, onlays, crowns or fixed bridges are considered to be started when the tooth or teeth are prepared, and completed when the final restoration is permanently cemented). 25. Dentures or orthodontic treatment started prior to the Member s eligibility to receive benefits under this Plan. 26. (Dentures are considered to be started when the impressions area taken. Orthodontic treatment is considered to be started when the teeth are banded). 27. Replacement of lost or stolen prosthetics or appliances including crowns, bridges, partial dentures, full dentures, and orthodontic appliance. 28. Any treatment requested, or appliances made, which are either not necessary for maintaining or improving dental health, or are for cosmetic purposes unless otherwise covered as a benefit. 29. Any procedure or treatment unable to be performed in the dental office due to the general health or physical limitation of the member. 30. Dental implants and services associated with the placement of implants, prosthodontic restoration of dental implants, and specialized implant maintenance services. 31. Oral surgery requiring the setting of bone fractures or dislocations, Hospitalization, Out- patient services, Ambulance services, Durable Medical Equipment, Mental Health services, Chemical dependency services, Home Health services. 32. Dispensing of drugs supplied in a dental office. 33. Any condition for which benefits of any nature are recovered or found to be recoverable, whether by adjudication or settlement, under any Worker s Compensation or Occupational Disease Law, even though the Member fails to claim his or her rights to such benefit. 34. Any service or procedure associated with the placement, prosthodontic restoration or maintenance of a dental implant and any incremental charges to other covered services as a result of the presence of a dental implant. 35. Root canal treatment started, but not completed, prior to the Member s legibility to receive benefits under this Plan. 36. (Root canal treatment is considered to be started when the pulp chamber is opened, and completed when the permanent root canal filling material is placed.) 37. Coverage is up to twenty-four (24) months of comprehensive orthodontic treatment. If treatment goes beyond twenty four (24) months is necessary, the Member will be responsible for additional charge for each additional month of treatment based up to the participating Orthodontic Specialist Dentist s contracted fee. 38. If a Member transfer to another Participating Orthodontist after comprehensive orthodontic treatment has been started the Member will be responsible for any additional costs associated with the change in orthodontist and subsequent treatment. Primecare Dental /2010

9 Orthodontic Limitations and Exclusions The Plan covers orthodontic services as listed under Covered Dental Services, limited to one course of treatment in lifetime. Orthodontic services are not covered if comprehensive treatment begins before the Member is eligible for benefits under the Plan. If a Member s coverage terminates after the fixed banding appliances are inserted, the Participating Orthodontist Specialist Dentist After the termination date, the Member will be responsible for any additional monthly amounts. Orthodontic treatment shall only be provided by a member of the Plan orthodontic panel. The following are exclusions of orthodontic coverage. 1. Re-treatment of orthodontic cases, or changes in orthodontic treatment necessitated by any kind of accident. 2. Replacement or repair of orthodontic appliances damaged due to the neglect of the Member. 3. Tracings, records, study models, x-rays and photographs. 4. Initial examination, consultation, diagnosis, treatment planning, retention appliances and related visits. 5. Cephalometric x-rays. 6. Lost or broken appliances. 7. Myofunctional therapy. 8. Surgical procedures such as extractions of teeth strictly for the purpose of orthodontia. 9. Any jaw surgical procedure related to orthodontia. 10. Dental services of any nature, performed in hospital or convalescent home or anywhere outside the office or Plan provider. 11. Dispensing of drugs not normally supplied in an orthodontic practice. 12. Treatment related to Temporomandibular Join Dysfunction or hormonal imbalances. Primecare Dental /2010

Primecare Dental Plan Individual Plan 106

Primecare Dental Plan Individual Whether you re a member of our dental plan, human resources or benefits professional we trust you will find our company a valuable resource for high quality and affordable