Concordia Plus Schedule of Benefits

Transcription

1 Concordia Pls Schedle of Benefits Plan PA/NJ/OH IMPORTANT INFORMATION ABOUT YOUR PLAN Effective 1/1/218 12/31/218 This schedle of benefits provides a listing of procedres covered by yor plan. For procedres that reqire a copayment, the amont to be paid is shown in the colmn titled. Yo pay these copayments to the dental office at the time of service. Yo mst select a United Concordia Primary Dental Office (PDO) to receive covered services. Yor PDO will perform the below procedres or refer yo to a specialty care dentist for frther care. Treatment by an Ot-of-Network dentist is not covered, except as described in the Certificate of Coverage. Only procedres listed on this Schedle of Benefits are Covered Services. For services not listed (not covered), Yo are responsible for the fll fee charged by the dentist. Procedre codes and member Copayments may be pdated to meet American Dental Association () Crrent Dental Terminology (CDT) in accordance with national standards. For a complete description of yor plan, please refer to the Certificate of Coverage and the Schedle of Exclsions and Limitations in addition to this Schedle of Benefits. If yo have any qestions abot yor United Concordia dental plan, please call or Cstomer Service Department toll-free at or access or website at CLINICAL ORAL EVALUATIONS ORAL PATHOLOGY LABORATORY D12 Periodic Oral Evalation - Established Patient D1 Limited Oral Evalation - Problem Focsed D15 Oral Evalation For A Patient Under 3 Years Of Age And Conseling With Primary Caregiver D15 Comprehensive Oral Evalation - New Or Established Patient D16 Detailed And Extensive Oral Evalation - Problem Focsed, By Report D Re-Evalation-Limited, Problem Focsed (Established Patient; Not Post-Operative Visit) D1 Re Evalation Post-Operative Office Visit D18 Comprehensive Periodontal Evalation RADIOGRAPHS/DIAGNOSTIC IMAGING (inclding interpretation) D21 Intraoral - Complete Series Of Radiographic Images D22 Intraoral- Periapical First Radiographic Image D23 Intraoral- Periapical Each Additional Radiographic Image D2 Intraoral - Occlsal Radiographic Image D27 Bitewing - Single Radiographic Image D272 Bitewings - Two Radiographic Images D273 Bitewings - Three Radiographic Images D27 Bitewings - For Radiographic Images D277 Vertical Bitewings - 7 To 8 Radiographic Images D33 Panoramic Radiographic Image D3 2D Cephalometric Radiographic Image - Acqisition, Measrement And Analysis TESTS AND EXAMINATIONS D6 Plp Vitality Tests D7 Diagnostic Casts ORAL PATHOLOGY LABORATORY D61 Caries Risk Assessment And Docmentation, With A Finding Of Low Risk D62 Caries Risk Assessment And Docmentation, With A Finding Of Moderate Risk D63 Caries Risk Assessment And Docmentation, With A Finding Of High Risk DENTAL PROPHYLAXIS D1 Prophylaxis, Adlt D2 Prophylaxis, Child TOPICAL FLUORIDE TREATMENT (office procedre) D126 Topical Application Of Floride Varnish D128 Topical Application Of Floride Exclding Varnish OTHER PREVENTIVE SERVICES D133 Oral Hygiene Instrction D1351 Sealant - Per Tooth 8 D1353 Sealant Repair - Per Tooth 8 D135 Interim Caries Arresting Medicament Application - Per Tooth 15 SPACE MAINTENANCE (passive appliances) D151 Space Maintainer - Fixed, Unilateral (Tooth Nmbers Or Tooth Area Reqired) 2 D1515 Space Maintainer - Fixed, Bilateral 6 D152 Space Maintainer - Removable, Unilateral 55 D15 Space Maintainer - Removable, Bilateral 72 D1555 Removal Of Fixed Space Maintainer D1575 Distal shoe space maintainers - fixed - nilateral 2 AMALGAM RESTORATIONS (inclding polishing) D21 Amalgam - One Srface, Primary Or Permanent 13 D215 Amalgam - Two Srfaces, Primary Or Permanent D216 Amalgam - Three Srfaces, Primary Or Permanent Base 5 (1/) Crrent Dental Terminology 2 American Dental Association. All rights reserved. PA/NJ/OH

2 AMALGAM RESTORATIONS (inclding polishing) D2161 Amalgam - For Or More Srfaces, Primary Or 23 Permanent RESIN-BASED COMPOSITE RESTORATIONS - DIRECT D233 Resin-Based Composite - One Srface, Anterior 15 D2331 Resin-Based Composite - Two Srfaces, Anterior 2 D2332 Resin-Based Composite - Three Srfaces, Anterior 23 D2335 Resin-Based Composite - For Or More Srfaces Or Involving Incisal Angle (Anterior) INLAY/ONLAY RESTORATIONS D1 Inlay - Metallic - One Srface 236 D2 Inlay - Metallic - Two Srfaces D3 Inlay - Metallic - Three Or More Srfaces 279 D2 Onlay - Metallic-Two Srfaces 322 D3 Onlay - Metallic - Three Srfaces 32 D Onlay - Metallic - For Or More Srfaces 361 CROWNS - SINGLE RESTORATIONS ONLY D271 Crown-Resin-Based Composite (Indirect) 1 D2712 Crown - 3/ Resin-Based Composite (Indirect) 128 D27 Crown, Porcelain/Ceramic 31 D275 Crown, Porcelain Fsed To High Noble Metal 329 D2751 Crown-Porcelain Fsed To Predominantly 29 Base Metal D2752 Crown, Porcelain Fsed To Noble Metal 316 D278 Crown - 3/ Cast High Noble Metal 337 D2781 Crown - 3/ Cast Predominantly Base Metal 337 D2782 Crown - 3/ Cast Noble Metal 337 D2783 Crown - 3/ Porcelain/Ceramic 337 D279 Crown, Fll Cast High Noble Metal 321 D2791 Crown - Fll Cast Predominantly Base Metal 293 D2792 Crown, Fll Cast Noble Metal 3 D279 Crown-Titanim 29 D2799 Provisional Crown - Frther Treatment Or 26 Completion Of Diagnosis Necessary Prior To Final Impression OTHER RESTORATIVE SERVICES D291 Re-Cement Or Re Bond Inlay, Onlay, Veneer Or Partial Coverage Restoration D2915 Re Cement Or Rebond Indirectly Fabricated Or Prefabricated Post And Core D292 Re-Cement Or Re Bond Crown D293 Prefabricated Stainless Steel Crown - Primary Tooth 3 D2931 Prefabricated Stainless Steel Crown - Permanent Tooth 32 D29 Protective Restoration D299 Restorative Fondation For An Indirect Restoration D295 Core Bildp Inclding Any Pins When Reqired 36 D2951 Pin Retention - Per Tooth, In Addition To Restoration 12 D2952 Post And Core In Addition To Crown, Indirectly Fabricated 92 D2953 Each Additional Indirectly Fabricated Post - Same Tooth 5 OTHER RESTORATIVE SERVICES D295 Prefabricated Post And Core In Addition To Crown 2 D2957 Each Additional Prefabricated Post - Same Tooth D2971 Additional Procedres To Constrct New Crown Under Existing Partial Dentre Framework PULP CAPPING D3 Plp Cap - Direct (Exclding Final Restoration) D312 Plp Cap - Indirect (Exclding Final Restoration) PULPOTOMY D322 Therapetic Plpotomy (Exclding Final Restoration) D3221 Plpal Debridement, Primary And Permanent Teeth 16 D3222 Partial Plpotomy For Apexogenesis- Permanent Tooth With Incomplete Root Development ENDODONTIC THERAPY ON PRIMARY TEETH D323 Plpal Therapy (Resorbable Filling)-Anterior, Primary Tooth (Exclding Final Restoration) 26 D32 Plpal Therapy (Resorbable Filling)-Posterior, Primary Tooth (Exclding Final Restoration) 32 ENDODONTIC THERAPY (inclding treatment plan, clinical procedres and follow-p care) D331 Endodontic Therapy, Anterior Tooth (Exclding Final Restoration) 75 D332 Endodontic Therapy, Premolar Tooth (Exclding Final Restoration) 9 D333 Endodontic Therapy, Molar Tooth (Exclding Final Restoration) 8 ENDODONTIC RETREATMENT D336 Retreatment Of Previos Root Canal Therapy - Anterior 69 D337 Retreatment Or Previos Root Canal Therapy - Premolar 8 D338 Retreatment Of Previos Root Canal Therapy - Molar 28 APICOECTOMY/PERIRADICULAR SERVICES D31 Apicoectomy - Anterior D321 Apicoectomy - Premolar (First Root) 183 D3 Apicoectomy - Molar (First Root) 6 D326 Apicoectomy (Each Additional Root) 69 D327 Periradiclar Srgery Withot Apicoectomy 6 D35 Root Amptation - Per Root OTHER ENDODONTIC PROCEDURES D392 Hemisection (Inclding Any Root Removal) Not Inclding Root Canal Therapy 8 D395 Canal Preparation And Fitting Of Preformed Dowel Or Post SURGICAL SERVICES (inclding sal postoperative care) D21 Gingivectomy Or Gingivoplasty - For Or More Contigos Teeth Or Tooth Bonded Spaces Per Qadrant 82 D2 Gingivectomy Or Gingivoplasty - One To Three Contigos Teeth Or Tooth Bonded Spaces Per Qadrant 37 D212 Gingivectomy Or Gingivoplasty To Allow Access For Restorative Procedre, Per Tooth Base 5 (1/) Crrent Dental Terminology 2 American Dental Association. All rights reserved. PA/NJ/OH

3 Effective 1/1/218 12/31/218 SURGICAL SERVICES (inclding sal postoperative care) D2 Gingival Flap Procedre, Inclding Root Planing - For Or More Contigos Teeth Or Tooth Bonded Spaces Per Qadrant 15 D21 Gingival Flap Procedre, Inclding Root Planing - One To Three Contigos Teeth Or Tooth Bonded Spaces Per Qadrant 7 D25 Apically Positioned Flap 138 D29 Clinical Crown Lengthening-Hard Tisse 168 D26 Osseos Srgery (Inclding Elevation Of A Fll Thickness Flap And Closre) For Or More Contigos Teeth Or Tooth Bonded Spaces Per Qadrant D261 Osseos Srgery (Inclding Elevation Of A Fll Thickness Flap And Closre) One To Three Contigos Teeth Or Tooth Bonded Spaces Per Qadrant 87 D27 Mesial/Distal Wedge Procedre, Single Tooth (When Not Performed In Conjnction With Srgical Procedres In The Same Anatomical Area) 1 NON-SURGICAL PERIODONTAL SERVICES D31 Periodontal Scaling And Root Planing - For Or More Teeth Per Qadrant D32 Periodontal Scaling And Root Planing - One To Three Teeth Per Qadrant D36 Scaling In Presence Of Generalized Moderate Or Severe Gingival Inflammation - Fll Moth, After Oral Evalation 32 D355 Fll Moth Debridement To Enable a Comprehensive Oral Evalation And Diagnosis on a Sbseqent Visit 22 D381 Localized Delivery Of Antimicrobial Agents Via Controlled Release Vehicle Into Diseased Creviclar Tisse, Per Tooth 1 OTHER PERIODONTAL SERVICES D91 Periodontal Maintenance 32 D921 Gingival Irrigation - Per Qadrant COMPLETE DENTURES (inclding rotine post delivery care) D5 Complete Dentre - Maxillary 33 D512 Complete Dentre - Mandiblar 33 D513 Immediate Dentre - Maxillary 359 D51 Immediate Dentre - Mandiblar 359 PARTIAL DENTURES (inclding rotine post-delivery care) D52 Maxillary Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests 28 D5212 Mandiblar Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests 335 D5213 Maxillary Partial Dentre - Cast Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests D521 Mandiblar Partial Dentre - Cast Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rest And Teeth) D5221 Immediate Maxillary Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests and Teeth) 28 D5222 Immediate Mandiblar Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests and Teeth) 335 PARTIAL DENTURES (inclding rotine post-delivery care) D5223 Immediate Maxillary Partial Dentre - Case Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests D522 Immediate Mandiblar Partial Dentre - Case Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests D52 Maxillary Partial Dentre - Flexible Base (Inclding Any Clasps, Rests 33 D5226 Mandiblar Partial Dentre - Flexible Base (Inclding Any Clasps, Rests 33 D5281 Removable Unilateral Partial Dentre-One Piece Cast Metal (Inclding Clasps 232 ADJUSTMENTS TO DENTURES D51 Adjst Complete Dentre - Maxillary 1 D5 Adjst Complete Dentre - Mandiblar 1 D521 Adjst Partial Dentre - Maxillary D522 Adjst Partial Dentre - Mandiblar REPAIRS TO COMPLETE DENTURES D55 Repair Broken Complete Dentre Base, Mandiblar D5512 Repair Broken Complete Dentre Base, Maxillary D552 Replace Missing Or Broken Teeth-Complete Dentre (Each Tooth) REPAIRS TO PARTIAL DENTURES D56 Repair Resin Partial Dentre Base, Mandiblar D5612 Repair Resin Partial Dentre Base, Maxillary D5621 Repair Cast Partial Framework, Mandiblar 2 D5622 Repair Cast Partial Framework, Maxillary 2 D563 Repair Or Replace Broken Clasp - Per Tooth 23 D56 Replace Broken Teeth-Per Tooth D565 Add Tooth To Existing Partial Dentre 2 D566 Add Clasp To Existing Partial Dentre - Per Tooth 2 D567 Replace All Teeth And Acrylic On Cast Metal Framework (Maxillary) 22 D5671 Replace All Teeth And Acrylic On Cast Metal Framework (Mandiblar) 22 DENTURE REBASE PROCEDURES D571 Rebase Complete Maxillary Dentre 6 D57 Rebase Complete Mandiblar Dentre 6 D572 Rebase Maxillary Partial Dentre 58 D5721 Rebase Mandiblar Partial Dentre 58 DENTURE RELINE PROCEDURES D573 Reline Complete Maxillary Dentre (Chairside) 36 D5731 Reline Complete Mandiblar Dentre (Chairside) 36 D57 Reline Maxillary Partial Dentre (Chairside) 33 D571 Reline Mandiblar Partial Dentre (Chairside) 33 D575 Reline Complete Maxillary Dentre (Laboratory) 51 D5751 Reline Complete Mandiblar Dentre (Laboratory) 51 D576 Reline Maxillary Partial Dentre (Laboratory) 9 D5761 Reline Mandiblar Partial Dentre (Laboratory) 8 Base 5 (1/) Crrent Dental Terminology 2 American Dental Association. All rights reserved. PA/NJ/OH

4 Effective 1/1/218 12/31/218 OTHER REMOVABLE PROSTHETIC SERVICES D585 Tisse Conditioning, Maxillary 33 D5851 Tisse Conditioning, Mandiblar 33 D5863 Overdentre - Complete Maxillary 33 D586 Overdentre - Partial Maxillary D5865 Overdentre - Complete Mandiblar 33 D5866 Overdentre - Partial Mandiblar FIXED PARTIAL DENTURE PONTICS D6 Pontic - Indirect Resin Based Composite 29 D621 Pontic-Cast High Noble Metal 3 D62 Pontic-Cast Predominatly Base Metal 298 D6212 Pontic-Cast Noble Metal 312 D621 Pontic - Titanim 299 D62 Pontic-Porcelain Fsed To High Noble Metal 327 D621 Pontic-Porcelain Fsed To Predominantly 289 Base Metal D622 Pontic-Porcelain Fsed To Noble Metal 315 D625 Pontic - Procelain/Ceramic 29 FIXED PARTIAL DENTURE RETAINTERS - INLAYS/ONLAYS D661 Retainer Onlay - Cast High Noble Metal, Two Srfaces 322 D6612 Retainer Onlay - Cast Predominantly Base 322 Metal, Two Srfaces D661 Retainer Onlay - Cast Noble Metal, Two 322 Srfaces FIXED PARTIAL DENTURE RETAINERS - CROWNS D671 Retainer Crown - Indirect Resin Based Composite 295 D67 Retainer Crown - Porcelain/Ceramic 295 D675 Retainer Crown, Porcelain Fsed To High Noble Metal 329 D6751 Retainer Crown - Porcelain Fsed To 29 Predominantly Base Metal D6752 Retainer Crown, Porcelain Fsed To Noble 316 Metal D678 Retainer Crown, 3/ Cast High Noble Metal 321 D6781 Retainer Crown - 3/ Cast Predominantly Base 321 Metal D6782 Retainer Crown - 3/ Cast Noble Metal 321 D6783 Retainer Crown - 3/ Porcelain/Ceramic 321 D679 Retainer Crown, Fll Cast High Noble Metal 327 D6791 Retainer Crown, Fll Cast Predominantly Base 292 Metal D6792 Retainer Crown, Fll Cast Noble Metal 3 D679 Retainer Crown - Titanim 292 OTHER FIXED PARTIAL DENTURE SERVICES D693 Re Cement Or Re-Bond Fixed Partial Dentre 3 EXTRACTIONS (incldes local anesthesia, string, if needed, and rotine postoperative care) D71 Extraction, Coronal Remnants - Primary Tooth 1 D71 Extraction, Erpted Tooth Or Exposed Root (Elevation And/Or Forceps Removal) 16 SURGICAL EXTRACTIONS (incldes local anesthesia, string, if needed, and rotine postoperative care) D721 Extraction, Erpted Tooth Reqiring Removal Of Bone And/Or Sectioning Of Tooth, And Inclding Elevation Of Mcoperiosteal Flap If Indicated 51 D722 Removal Of Impacted Tooth - Soft Tisse 72 SURGICAL EXTRACTIONS (incldes local anesthesia, string, if needed, and rotine postoperative care) D723 Removal Of Impacted Tooth - Partially Bony 98 D72 Removal Of Impacted Tooth - Completely Bony 3 D721 Removal Of Impacted Tooth - Completely Bony, With Unsal Srgical Complications 12 D7 Removal Of Residal Tooth Roots (Ctting Procedre) 53 D71 Coronectomy-Intentional Partial Tooth Removal 3 OTHER SURGICAL PROCEDURES D728 Exposre Of An Unerpted Tooth 97 D7283 Placement Of Device To Facilitate Erption Of Impacted Tooth 26 D7288 Brsh Biopsy - Transepithelial Sample Collection 5 ALVEOLOPLASTY (srgical preparation of ridge for dentres) D731 Alveoloplasty In Conjnction With Extractions - For Or More Teeth Or Tooth Spaces, Per Qadrant 8 D732 Alveoloplasty Not In Conjnction With Extractions - For Or More Teeth Or Tooth Spaces, Per Qadrant 6 D7321 Alveoloplasty Not In Conjnction With Extractions - One To Three Teeth Or Tooth Spaces, Per Qadrant OTHER REPAIR PROCEDURES D796 Frenlectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedre Not Incidental To Another Procedre 89 D7963 Frenloplasty LIMITED ORTHODONTIC TREATMENT D81 Limited Orthodontic Treatment Of Primary 599 D82 Limited Orthodontic Treatment Of Transitional 759 D83 Limited Orthodontic Treatment Of Adolescent 1 D8 Limited Orthodontic Treatment Of The Adlt 927 INTERCEPTIVE ORTHODONTIC TREATMENT D85 Interceptive Orthodontic Treatment Of Primary 885 D86 Interceptive Orthodontic Treatment Of Transitional 139 COMPREHENSIVE ORTHODONTIC TREATMENT D87 Comprehensive Orthodontic Treatment Of Transitional 3 D88 Comprehensive Orthodontic Treatment Of Adolescent 35 D89 Comprehensive Orthodontic Treatment Of Adlt 35 MINOR TREATMENT TO CONTROL HARMFUL HABITS D821 Removable Appliance Therapy For Control Of Harmfl Habits 33 D822 Fixed Appliance Therapy For Control Of Harmfl Habits 537 OTHER ORTHODONTIC SERVICES D868 Orthodontic Retention (Removal Of 33 Appliances, Constrction And Placement Of Retainer(S) Base 5 (1/) Crrent Dental Terminology 2 American Dental Association. All rights reserved. PA/NJ/OH

5 UNCLASSIFIED TREATMENT Effective 1/1/218 12/31/218 D9 Palliative (Emergency) Treatment Of Dental Pain, Minor Procedres PROFESSIONAL CONSULTATION D931 Consltation - Diagnostic Service Provided By Dentist Or Physician Other Than Reqesting Dentist Or Physician D93 Consltation With A Medical Health Care Professional PROFESSIONAL VISITS D93 Office Visit For Observation (Dring Reglarly Schedled Hors) - No Other Services Performed MISCELLANEOUS SERVICES D9932 Cleaning And Inspection Of Removable Complete Dentre, Maxillary D9933 Cleaning And Inspection Of Removable Complete Dentre, Mandiblar D993 Cleaning And Inspection Of Removable Partial Dentre, Maxillary D9935 Cleaning And Inspection Of Removable Partial Dentre, Mandiblar D9986 Missed Appointment 15 D9987 Cancelled appointment 15 D9991 Dental Case Management - Addressing Appointment Compliance Barriers D9992 Dental Case Management - Care Coordination D9993 Dental Case Management - Motivational Interviewing D999 Dental Case Management - Patient Edcation To Improve Oral Health Literacy D9995 Teledentistry - Synchronos; Real-Time Enconter D9996 Teledentistry - Asynchronos; Information Stored and Forwarded to Dentist for Sbseqent Review FOOTNOTES Charges for the se of precios (high noble) or semi precios (noble) metal are not inclded in the copayment for crowns, bridges, pontics, inlays and onlays. The decision to se these materials is a cooperative effort between the provider and the patient, based on the professional advice of the provider. Providers are expected to charge no more than an additional $1 for these materials. Base 5 (1/) Crrent Dental Terminology 2 American Dental Association. All rights reserved. PA/NJ/OH

6 SCHEDULE OF EXCLUSIONS AND LIMITATIONS EXCLUSIONS Except as specifically provided in this Certificate, Schedles of Benefits, Riders to the Certificate, no coverage will be provided for services, spplies or charges: 1. Not specifically listed in the Schedle of Benefits as a Covered Service. 2. Provided to s by Ot-of-Network Dentists except when immediate dental treatment is reqired as a reslt of a Dental Emergency occrring more than 5 miles from the s home. 3. Which in the opinion of the treating dentist, or the Company, are not clinically necessary, or do not have a reasonable, favorable prognosis. This exclsion does not apply to Grop Contracts and Certificates issed and delivered in Maryland.. That are necessary de to lack of cooperation with Primary Dental Office, or failre to comply with a professionally prescribed Treatment Plan. 5. Started or incrred prior to the s Effective Date of Coverage with the Company or started after the Termination Date of Coverage with the Company. 6. For consltations by a Specialty Care Dentist for services not specifically listed on the Schedle of Benefits as a Covered Service. 7. Services or spplies that are not deemed generally accepted standards of dental treatment. 8. That are the responsibility of Workers Compensation or employer s liability insrance, or for treatment of any atomobile related injry in which the is entitled to payment nder an atomobile insrance policy. The Company s benefits wold be in excess to the third party benefits and therefore, the Company wold have right of recovery for any benefits paid in excess. For Grop Contracts and Certificates issed and delivered in Missori and New Jersey, only services that are the responsibility of Workers Compensation or employer s liability insrance shall be exclded from this Plan. For Grop Contracts and Certificates issed and delivered in Texas, only services that are the responsibility of the employer s liability insrance, or for treatment of any atomobile related injry shall be exclded from this Plan. For Grop Contracts and Certificates delivered in Maryland, only services related to Workers Compensation or employer s liability insrance shall be exclded from this Plan. For Grop Contracts and Certificates issed and delivered in Florida, only services that are paid by 981 (6/3) Workers Compensation or the employer s liability insrance, or for treatment of any atomobile related injry in which the is entitled to payment nder an atomobile insrance policy shall be exclded from this Plan. 9. Services and/or appliances that alter the vertical dimension, inclding, bt not limited to, fll moth rehabilitation, splinting, fillings to restore tooth strctre lost from attrition, erosion or abrasion, appliances or any other method. This exclsion does not apply to Grop Contracts and Certificates issed in Pennsylvania if the dental condition is as a reslt of an accidental injry. 1. That restore tooth strctre de to attrition, erosion or abrasion.. For periodontal splinting of teeth by any method. 12. For replacement of lost, missing, stolen or damaged prosthetic device or orthodontic appliance or for dplicate dentres, prosthetic devices or any dplicative device. 13. For replacement of existing dentres that are, or can be made serviceable. 1. For prosthetic reconstrction or other services which reqire a prosthodontist. 15. For assistant at srgery. 16. For elective procedres, inclding prophylactic extraction of third molars.. For congenital moth malformations or skeletal imbalances, inclding, bt not limited to, treatment related to cleft palate, disharmony of facial bone, or reqired as the reslt of orthognathic srgery, inclding orthodontic treatment, and oral and maxillofacial services, associated hospital and facility fees, anesthesia, and radiographic imaging even if the condition reqiring these services involves part of the body other than the moth or teeth. This exclsion shall not apply to newly born children of s as defined in the definition of Dependent. For Grop Contracts and Certificates issed and delivered in Kentcky and Pennsylvania, this exclsion shall not apply to newly born children of s as defined nder the definition of Dependent inclding newly adoptive children, regardless of age. For Grop Contracts and Certificates issed and delivered in Indiana and New Jersey, this exclsion

7 shall not apply to newly born children of s as defined nder the definition of Dependent. For Grop Contracts and Certificates issed and delivered in Florida, this exclsion shall not apply for diagnostic or srgical dental (not medical) procedres rendered to a of any age. For Grop Contracts and Certificates issed in Florida, this exclsion does not apply to diagnostic or srgical dental (not medical) procedres for treatment of TMD rendered to a of any age as a reslt of congenital or developmental moth malformation, disease, or injry and sch procedres are covered nder a Rider to the Certificate or the Schedle of Benefits. 18. For diagnostic services and treatment of jaw joint problems by any method. These jaw joint problems inclde bt are not limited to sch conditions as temporomandiblar joint disorder (TMD) and craniomandiblar disorders or other conditions of the joint linking the jaw bone and the complex of mscles, nerves and other tisses related to that joint.. For implants, srgical insertion and/or removal of, and any appliances and/or crowns attached to implants. 2. For the following, which are not inclded as orthodontic benefits: retreatment of orthodontic cases, changes in orthodontic treatment necessitated by patient noncooperation, repair of orthodontic appliances, replacement of lost or stolen appliances, special appliances (inclding, bt not limited to, headgear, orthopedic appliances, bite planes, fnctional appliances or palatal expanders), myofnctional therapy, cases involving orthognathic srgery, extractions for orthodontic prposes, and treatment in excess of 2 months. For Grop Contracts and Certificates issed in Florida, this exclsion does not apply to diagnostic and srgical dental (not medical) procedres for treatment of TMD rendered to a of any age as a reslt of congenital or developmental moth malformation, disease, or injry and sch procedres are covered nder a Rider to the Certificate or the Schedle of Benefits. 21. For active orthodontic treatment if started prior to a s effective date. 22. For prescription or nonprescription drgs, home care items, vitamins or dietary spplements. 23. For hospitalization and associated costs for rendering services in a hospital. 2. For hose or hospital calls for dental services.. For any dental or medical services performed by a physician and/or services which benefits are otherwise provided nder a health care plan of the employer. 26. Which are Cosmetic in natre as determined by the Company, inclding, bt not limited to bleaching, veneer facings, personalization or characterization of crowns, bridges and/or dentres. This exclsion does not apply to Grop Contracts and Certificates issed and delivered in Pennsylvania for Cosmetic services reqired as the reslt of an accidental injry. This exclsion does not apply to Grop Contracts and Certificates issed and delivered in New Jersey for Cosmetic services for newly-born children of s as defined in the definition of Dependent. For Grop Contracts and Certificates issed and delivered in Maryland services which are Cosmetic in natre, inclding, bleaching, veneer facings, personalization or characterization of crowns, bridges and/or dentres. 27. For broken appointments. 28. Arising from any intentionally self-inflicted injry or contsion when the injry is a conseqence of the s commission of or attempt to commit a felony or engagement in an illegal occpation or of the s being intoxicated or nder the inflence of illicit narcotics. This exclsion does not apply to Grop Contracts and Certificates issed and delivered in Maryland and Ohio. 29. For any condition cased by or reslting from declared or ndeclared war or act thereof, or reslting from service in the national gard or in the armed forces of any contry or international athority. 981 (6/3)

8 LIMITATIONS The following services, if listed on the Schedle of Benefits, will be sbject to limitations as set forth below: 1. Bitewing x-rays one set(s) per six consective months throgh age 13, and one set(s) of bitewing x- rays per 12 consective months for age 1 and older. 2. Panoramic or fll moth x-rays one per three-year period. 3. Prophylaxis one per six consective month period.. Rotine prophylaxis and periodontal maintenance procedres are limited to no more than any combination of one per six consective month period. 5. Sealants one per tooth per three year(s) throgh age 15 on permanent first and second molars. 6. Floride treatment one per six consective months throgh age Space maintainers only eligible for s throgh age 18 when sed to maintain space as a reslt of prematrely lost decidos first and second molars, or permanent first molars that have not, or will never develop. 8. Restorations, crowns, inlays and onlays covered only if necessary to treat diseased or fractred teeth. 9. Crowns, bridges, inlays, onlays, bildps, post and cores one per tooth in a five-year period. 1. Crown lengthening one per tooth per lifetime.. Referral for specialty care is limited to orthodontics, oral srgery, periodontics, endodontics, and pediatric dentists. This limitation does not apply to Grop Policies and Certificates issed in Maryland if the service was provided as a reslt of a standing or non-network referral as described in the Certificate of Coverage. 12. Coverage for referral to a pediatric Specialty Care Dentist ends on a s seventh birthday. 13. Ppal therapy throgh age five on primary anterior teeth and throgh age on primary posterior teeth. 1. Root canal treatment one per tooth per lifetime. 15. Root canal retreatment one per tooth per lifetime.. Dentre relining, rebasing or adjstments are inclded in the dentre charges if provided within six months of insertion by the same dentist. 2. Sbseqent dentre relining or rebasing limited to one every 36 consective months thereafter. 21. Oral srgery services are limited to srgical exposre of teeth, removal of teeth, preparation of the moth for dentres, removal of tooth generated cysts p to 1.cm, frenectomy and crown lengthening. 22. Wisdom teeth (third molars) extracted for s nder age 15 or over age 3 are not eligible for payment in the absence of specific pathology. 23. If for any reason orthodontic services are terminated or coverage nder the Company is terminated before completion of the approved orthodontic treatment, the responsibility of the Company will cease with payment throgh the month of termination. For Grop Contracts and Certificates issed and delivered in Maryland, services will contine for 6 days after termination if paid monthly, or ntil the later of 6 days after termination or the end of the qarter in progress if paid qarterly. This extension of orthodontic payment does not apply if coverage was terminated de to failre to pay reqired Premim, frad, or if scceeding coverage is provided by another health plan and the cost is less than or eqal to the cost of coverage dring the extension and there is no interrption of benefits. 2. Orthodontic treatment not eligible for s over age 18.. Comprehensive orthodontic treatment plan one per lifetime. 26. In the case of a Dental Emergency involving pain or a condition reqiring immediate treatment, the Plan covers necessary diagnostic and therapetic dental procedres administered by an Ot-of-Network Dentist p to the difference between the Ot-of-Network Dentist's charge and the Copayment p to a maximm of $5 for each emergency visit. This limitation does not apply to Grop Contracts and Certificates issed and delivered in California and Texas. 16. Periodontal scaling and root planing one per 2 consective month period per area of the moth.. Srgical periodontal procedres one per 2 consective month period per area of the moth. 18. Fll and partial dentres one per arch in a five-year period. 981 (6/3)

9 27. Administration of I.V. sedation or general anesthesia is limited to covered oral srgical procedres involving one or more impacted teeth (soft tisse, partial bony or complete bony impactions). 28. An Alternate Benefit Provision (ABP) may be applied by the Primary Dental Office if a dental condition can be treated by means of a professionally acceptable procedre, which is less costly than the treatment recommended by the dentist. The ABP does not commit the to the less costly treatment. However, if the and the dentist choose the more expensive treatment, the is responsible for the additional charges beyond those allowed for the ABP. 981 (6/3)