Dental Coverage. New Jersey. Coordinated Care Plans. H0913_NJ015515_WCM_BRO_ENG CMS Approved WellCare 2011 NJ_07_11_WC

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1 Dental Coverage Coordinated Care Plans New Jersey WellCare is pleased to offer you dental coverage that focuses on the importance of preventive care. Taking care of your teeth and gums begins with regular checkups and services. H0913_NJ015515_WCM_BRO_ENG CMS Approved WellCare 2011 NJ_07_11_WC NJDENBRO39845E_06_11

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3 TAKE A BITE OUT OF YOUR DENTAL COSTS Our coverage features fixed co-payments for many basic preventive procedures and may include additional services. Knowing what you have to pay ahead of time makes it easier for you to budget your dental dollars. DENTAL COVERAGE YOU CAN SINK YOUR TEETH INTO WellCare offers you dental coverage with: Preventive services such as exams, X-rays and cleanings Low or no co-payments for many services Virtually no paperwork No deductible In addition, some of our plans cover restorative care, such as fillings. BRIDGE THE GAP: SEE YOUR DENTIST REGULARLY A key to good dental health is regular visits to the dentist. Our coverage of routine preventive services will keep your smile healthy. And our low or no co-payments keep your wallet feeling healthy, too. It s a combination that makes it easy to see your dentist often. BRUSH UP ON HOW TO GET YOUR DENTAL BENEFITS WellCare offers you a network of participating dentists to choose from. To start getting dental care, simply call one of our network dentists. For full information on the dental benefits offered or for a listing of participating dental providers, call WellCare at (TTY ), Monday Sunday, 8 a.m. to 9 p.m. Eastern. Between 2/15/12 and 10/14/12, representatives are available Monday Friday, 8 a.m. to 9 p.m. Eastern. Please refer to your WellCare Evidence of Coverage booklet to find out which dental plan you have. Then refer to the corresponding column on the benefit chart (starting on the next page) to learn the specific items covered on your plan. On the chart, the first column is labeled ADA Code. ADA stands for American Dental Association. These are the billing codes that dentists use when they bill for services. Ask your dentist for the ADA Codes that he/she will use for the services you need. You can then look up the codes to see if they are covered on your plan. Before obtaining services, you should discuss your treatment options with your dental provider. You may be responsible for the cost of dental services not covered by the plan. Authorization rules may apply.

4 Preventive Services ADA Code Description of Service Co-pay Limitations Maximum plan benefit coverage amount* per calendar year: *For all covered supplemental dental services. Any unused portion may not be carried over to the next calendar year. Cleanings Fluoride Exams D1110 Prophylaxis Adult D1204 Topical Fluoride Adult D0120 D0140 D0150 Periodic Oral Evaluation Limited Oral Evaluation Comprehensive Oral Exam D0160 Extensive Oral Exam D0170 Re-Evaluation D0180 Comprehensive Periodontal Evaluation Dental Preventive WellCare Value (HMO) NA $500 1 every 12 mos. per procedure Dental 500 WellCare Access (HMO SNP) 2012 Dental Coverage 1

5 X-Rays D0210 D0220 D0230 Intraoral Complete Series Intraoral 1st Periapical Intraoral Each Additional Periapical D0240 Intraoral Occlusal D0270 Single Bitewing D0272 Two Bitewings D0273 Three Bitewings D0274 Four Bitewings D0277 Vertical Bitewings 7 to 8 Films 1 every 36 mos. per 1 per 4 per D0330 Panoramic Film Basic Restorative Amalgam One D2140 Surface, Primary Or Permanent Amalgam Two D2150 Surfaces, Primary Or Permanent Amalgam Three D2160 Surfaces, Primary Or Permanent Amalgam Four D2161 Surfaces, Primary Or Permanent 2 every 12 mos. per procedure 4 every 12 mos. per 2 every 12 mos. per 1 every 12 mos. per 1 every 12 mos. per 1 every 36 mos. per 1 every 36 mos. per 2012 Dental Coverage 2

6 ADA Code Preventive Services Description of Service Co-pay Resin Restorative D Surface, Anterior D Surfaces, Anterior D Surfaces, Anterior D Surfaces, Anterior D2390 Crown, Anterior D Surface, Posterior D Surfaces, Posterior D Surfaces, Posterior D Surfaces, Posterior Periodontics Full Mouth Debridement To D4355 Enable Comprehensive Evaluation And Diagnosis Limitations Dental Preventive WellCare Value (HMO) 1 every 36 mos. per procedure Dental 500 WellCare Access (HMO SNP) 2012 Dental Coverage 3

7 Extractions Extraction, Erupted D7140 Tooth Or Exposed Root Other Oral Maxillofacial Surgery D7210 Surgical Removal Of Erupted Tooth D7220 Removal Of Impacted Tooth Soft Tissue D7230 Removal Of Impacted Tooth Partially Bony Removal Of Impacted D7240 Tooth Completely Bony Removal Of Impacted D7241 Tooth Completely Bony, With Unusual Surgical Complications D7250 Surgical Removal Of Residual Roots D7260 Oroantral Fistula Closure Miscellaneous D9110 Palliative (Emergency) Treatment 1 per lifetime per tooth 1 per lifetime per tooth 1 per lifetime per tooth 1 per lifetime per tooth 1 per lifetime per tooth 1 per lifetime per tooth 1 per lifetime per tooth 1 every 60 mos. per procedure 1 visit per member per year 2012 Dental Coverage 4

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10 WellCare is a Coordinated Care Plan with a Medicare Advantage contract. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information, contact the plan. Benefits, limitations, co-payments and restrictions may vary by plan and by county. Benefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may change on January 1, You must continue to pay your Medicare Part B premium. If you meet certain eligibility requirements for both Medicare and Medicaid, your Part B premiums may be covered in full. Members also enrolled in Medicaid may be eligible for secondary coverage of their routine dental services by the state. Before obtaining these dental services, ask the provider if they are able to bill Medicaid as the secondary payer. Be sure to show your Medicaid identification card. Please contact WellCare for details. You must use network dental providers. If you obtain care from out-of-network dental providers, neither Medicare nor WellCare will be responsible for the costs. Contact WellCare for more information