LifeWise Health Plan of Washington LifeWise Adult Health Plan ($75 Deductible) For Individuals and Families Residing in Washington

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1 LifeWise Health Plan of Washington LifeWise Adult Health Plan ($75 Deductible) For Individuals and Families Residing in Washington PLEASE READ THIS CONTRACT CAREFULLY This is a contract between the subscriber and LifeWise Health Plan of Washington (LifeWise) and shall be construed in accordance with the laws of the State of Washington. Please read this contract carefully to understand all of your rights and duties and those of LifeWise. In consideration of timely payment of the full subscription charge, LifeWise agrees to provide the benefits of this contract subject to the terms and conditions appearing on this and the following pages, including any endorsements, amendments, and addenda to this contract which are signed and issued by LifeWise. LifeWise has issued this contract at Mountlake Terrace, Washington Jim Havens President and Chief Executive Officer LifeWise Health Plan of Washington YOUR RIGHT TO RETURN THIS CONTRACT WITHIN TEN DAYS If you are not satisfied with this contract after you read it, for any reason, you may return it. You have 10 days after the delivery date for a full refund. Delivery date means 5 days after the postmark date. We will refund your payment no more than 30 days after we receive the returned contract. If your refund takes longer than 30 days, we will add 10 percent to the refund amount. If you return this contract within the 10-day period, we will treat it as if it was never in effect. However, we have the right to recover any benefits we paid before you returned the contract. We may deduct that amount from your refund.

2 TABLE OF CONTENTS INTRODUCTION... 1 SUMMARY OF YOUR COSTS... 3 COVERED SERVICES... 3 WHAT I NEED TO KNOW BEFORE I GET DENTAL CARE IMPORTANT PLAN INFORMATION HOW PROVIDERS AFFECT YOUR COST EXCLUSIONS OTHER COVERAGE SENDING US A CLAIM COMPLAINTS AND APPEALS ELIGIBILITY, ENROLLMENT, AND TERMINATION OTHER PLAN INFORMATION DEFINITIONS... 41]

3 WELCOME This contract tells you about your plan benefits and how to make the most of them. Please read this contract to find out how your health care plan works. Some words have special meanings under your health care plan. Please see Definitions at the end of this contract. In this contract, the words we, us, and our mean LifeWise Health Plan of Washington. The words you and your mean any member enrolled in the plan. The word plan means your health care plan with us. Please call us if you have any questions about this contract or your health care plan. We are happy to answer your questions and hear any comments. See the back cover for phone numbers and addresses. On our website at lifewisewa.com you can also: Learn more about your plan Find a health care provider near you Look for information about many health topics We look forward to serving you and your family. Once again, thank you again for choosing LifeWise for your health care coverage. Your Individual Dental and Vision Care Plan Contract This is your contract. The term "contract" means this document. LifeWise Health Plan of Washington uses its expertise and judgment to reasonably construe the terms of this contract as they apply to specific eligibility and claims determinations. This does not prevent you from exercising rights you may have under applicable law to appeal, have independent review or bring civil challenge to any eligibility or claims determinations. Medical and payment policies we use in administration of this plan are available on lifewisewa.com. 1

4 INTRODUCTION This contract booklet is for members of LifeWise Health Plan of Washington (LifeWise). This contract describes the benefits, exclusions and other provisions of your plan and replaces any other contract you may have received. Translation Service If you need an interpreter to help with oral translations services, please call us. Customer Service will be able to guide you through the services. How to Use This Booklet We realize that using a health care plan can seem complicated, so we ve prepared this contract to help you understand how to get the most out of your benefits. Please contact Customer Service if you have any questions about this plan. We are happy to answer your questions and hear any of your comments. On our website at lifewisewa.com you can also: Learn more about your plan Find a healthcare provider near you Look for information about many health topics Every section in this booklet contains important information, but the following sections may be particularly useful to you: How to Contact Us Our website, phone numbers, mailing addresses and other contact information are on the back cover Summary of Your Costs Lists your costs for covered services Covered Services A detailed description of what is covered Important Plan Information Describes deductibles, copayments, coinsurance, out-of-pocket maximums and allowed amounts How Providers Affect Your Costs How using a network provider affects your benefits and lowers your out-of-pocket costs Exclusions Describes services that are not covered Other Coverage Describes how benefits are paid when you have other coverage or what you must do when a third party is responsible for an injury or illness Sending Us a Claim Instructions on how to send in a claim Complaints and Appeals What to do if You want to share ideas, ask questions, file a complaint or submit an appeal Eligibility, Enrollment and Termination Describes who can be covered and when coverage ends Other Plan Information Lists general information about how this plan is administered and required state and federal notices Definitions Meanings of words and terms used 2

5 LIFEWISE ADULT HEALTH PLAN - $75 DEDUCTIBLE Provider Network This plan uses the following networks: LifeWise Connect medical network (for vision services) LifeWise Individual Dental Copay dental network (for dental services) SUMMARY OF YOUR COSTS This plan provides dental and vision benefits to enrolled adult members. An adult member is 19 years of age or older and is eligible for services as stated on the Summary of Your Costs. This plan may exclude or limit benefits for some services. See the Covered Services section for specific covered services and supplies and the Exclusions section for services that are not covered. Your costs are subject to all of the following: The allowable amount. This is the most this plan allows for a covered service The copays. These are set dollar amounts you pay at the time you get services. The deductible. A calendar year deductible applies to basic and major dental services only. The costs shown below are after the deductible is met. This is shown below. The conditions, time limits and maximum limits are described in this contract. Some services have special rules. See Covered Services for those details. year shown below means calendar year. VISION SERVICES Routine Vision Exam limit of 1 per year Vision Hardware limit of $150 per year YOUR COSTS OF THE ALLOWED AMOUNT NETWORK PROVIDERS $25 Copay Covered in Full NON-NETWORK PROVIDERS $25 Copay Covered in Full DENTAL SERVICES Individual Deductible: $75 per year Family Deductible: $225 per year Dental Benefit Maximum: $1,000 per year Diagnostic & Preventive Services (Class I) Basic Services (Class II) Major Services (Class III)* *There is a 12 month waiting period for Major Services Dental Services are classified as Diagnostic, Preventive, Basic and Major. Deductible applies to all Basic and Major services. Refer to the Schedule of Dental Benefits for specific covered dental services and applicable costs for Network and Non-Network Providers 3

6 COVERED SERVICES This section describes the services this plan covers. Covered services are medically necessary services (see Definitions) you get when you are covered for that benefit. This plan does not cover service that are covered under your LifeWise medical plan. This plan provides benefits for covered services only if all of the following are true when you get the services: The reason for the service is to prevent, diagnose or treat a covered illness, disease or injury The service takes place in a medically necessary setting. The service is not excluded. The service is not covered by your LifeWise medical plan. The service is received from a provider working within the scope of their license or certification. This plan may exclude or limit benefits for some services. See the specific benefits in this section and the Exclusions section for details. Benefits for covered services are subject to the following: Copays Deductibles (applies to Basic and Major dental services only) Coinsurance Benefit limits Waiting Period (applies to Major dental services only) Medical and payment policies. The plan has policies are used to administer the terms of the plan. Medical policies are generally used to further define medical necessity or investigational status for a specific procedure, drugs, biologic agents, devices, level of care or services. Payment policies define provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), American Dental Association (ADA), other professional societies and the Center for Medicare and Medicaid Services (CMS). Our policies are available to you and your provider at lifewisewa.com or by calling Customer Service. If you have any questions regarding your benefits and how to use them, call Customer Service at the number listed on the back cover. 4

7 COVERED SERVICES FOR ROUTINE VISION CARE Benefits for routine vision care are provided as shown on the Summary of Your Costs. Covered services include the following: Vision Exam Covered services for adult vision exams include: Examination of the outer and inner parts of the eye Evaluation of vision sharpness (refraction) Binocular balance testing Routine tests of color vision, peripheral vision and intraocular pressure Case history and recommendations This benefit does not cover: For vision exams and testing related to medical conditions of the eye, please see your LifeWise medical booklet for this benefit. Corrective Vision Hardware Covered services for adult vision hardware include: Prescription eyeglass lenses (single vision, bifocal, trifocal, quadrafocal or lenticular) Frames for eyeglasses Prescription contact lenses (soft, hard or disposable) Prescription safety glasses Prescription sunglasses Special features, such as tinting or coating Fitting of eyeglass lenses to frames Fitting of contact lenses to the eyes The vision hardware benefit doesn t cover: Services or supplies that aren t named above as covered, or that are covered under other provisions of your LifeWise medical plan. Please see the Medical Equipment and Supplies benefit in your LifeWise medical plan for hardware coverage for certain conditions of the eye. Non-prescription eyeglasses or contact lenses, or other special purpose vision aids (such as magnifying attachments) or light-sensitive lenses, even if prescribed Vision therapy, eye exercise, or any sort of training to correct muscular imbalance of the eye (orthoptics), or pleoptics Supplies used for the maintenance of contact lenses Services and supplies (including hardware) received after your coverage under this benefit has ended, except when all of the following requirements are met: You ordered covered contact lenses, eyeglass lenses and/or frames before the date your coverage under this benefit or plan ended You received the contact lenses, eyeglass lenses and/or frames within 30 days of the date your coverage under this benefit or plan ended This plan does not cover services in excess of the vision benefit as shown on the Summary of Your Costs. 5

8 COVERED SERVICES FOR DENTAL CARE Covered dental services fall into 3 categories: Diagnostic and Preventive, Basic, and Major services. After satisfying any applicable calendar year deductible, you pay the following copays or coinsurance for each covered service, up to the dental benefit maximum. The dental deductible applies to all Basic and Major services. There are special conditions and limitations concerning the benefits included in this plan. Please see the Diagnostic and Preventive, Basic and Major Limits provisions of each category and the Exclusions section for more information. Dental services and procedures must be medically necessary as defined by this contract. See the Schedule of Dental Benefits list for your costs. Dental services and procedures that are not listed in the Schedule of Dental Benefits list are not covered under this plan. Diagnostic and Preventive Services (Class I) Procedure Code Description SCHEDULE OF DENTAL BENEFITS Your Costs (Deductible Waived) Network Provider (Your Copay) Non-Network Provider (Your Coinsurance) D0120 Periodic Oral Evaluation Established Patient $0 You Pay 30% Of D0140 Limited Oral Evaluation Problem Focused $0 Allowable Charges And Any Amounts In D0150 Comprehensive Oral Evaluation New or $0 Excess Of The Established Patient Allowable Charges D0160 Detailed And Extensive Oral Evaluation $0 Problem Focused, By Report D0170 Re-evaluation Limited, Problem Focused $0 D0180 Comprehensive Periodontal Evaluation New or $0 Established Patient D0270 Bitewing Single Radiographic Image $0 D0272 Bitewing Two Radiographic Images $0 D0273 Bitewing Three Radiographic Images $0 D0274 Bitewing Four Radiographic Images $0 D0277 Vertical Bitewings 7 to 8 Radiographic Images $0 D1110 Prophylaxis (Routine Cleaning) Adult $20 D1206 Topical Application Fluoride Varnish $0 D1208 Topical Application of Fluoride $0 D9310 Consultation - Diagnostic Service Provided By Dentist or Physician Other Than Requesting Dentist or Physician Diagnostic and Preventive Services (Class I) Limits Routine comprehensive oral and periodic oral evaluations are limited to 2 per calendar year. Professional consultations, periodontal evaluations and other professional office visits apply to this limit. Problem focused evaluations and emergency oral exams are not subject to this limit. See the Definitions section for the definition of a Dental Emergency. Prophylaxis (cleaning) is limited to 2 per calendar year Topical application of fluoride is covered for members under the age of 20, and is limited to 2 treatments per calendar year $0 6

9 SCHEDULE OF DENTAL BENEFITS Basic Services (Class II) Your Costs (after deductible is met) Procedure Code Description Network Provider (Your Copay) Non-Network Provider (Your Coinsurance) D0210 D0220 Intraoral Complete Series Radiographic Images Intraoral Periapical First Radiographic $30 $5 You Pay 50% Of Allowable Charges And Any Amounts In Excess D0230 Image Intraoral Periapical Each Additional $5 Of The Allowable Charges Radiographic Image D0240 Intraoral Occlusal Radiographic Image $5 D0330 Panoramic Radiographic Image $25 D0460 Pulp Vitality Tests $10 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2391 D2392 D2393 D2394 Amalgam One Surface, 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 or Involving Incisal Angle, 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 $30 $35 $50 $55 $35 $50 $55 $65 $40 $55 $65 $65 7

10 SCHEDULE OF DENTAL BENEFITS Basic Services (Class II) - continued Your Costs (after deductible is met) Procedure Code Description Network Provider (Your Copay) Non-Network Provider (Your Coinsurance) D2910 D2915 Recement Inlay, Onlay or Partial Coverage Restoration Recement Cast or Prefabricated Post and $20 $25 You Pay 50% Of Allowable Charges And Any Amounts In Excess D2920 Core Recement Crown $20 Of The Allowable Charges D2940 Protective Restoration (Sedative Filling) $20 D2980 Crown Repair, Necessitated by Restorative $25 Material Failure D2982 Onlay Repair Necessitated by Restorative $40 Material Failure D4910 Periodontal Maintenance $40 D5510 Repair Broken Complete Denture Base $35 D5520 Replace Missing or Broken Teeth, Complete $30 Denture (Each Tooth) D5610 Repair Resin Denture Base $35 D5620 Repair Cast Framework $40 D5630 Repair or Replace Broken Clasp $50 D5640 Replace Broken Teeth Per Tooth $25 D5650 Add Tooth to Existing Partial Denture $40 D5660 Add Clasp to Existing Partial Denture $50 D6930 Recement Fixed Partial Denture $30 D6980 D7140 D9110 Basic Services Limits Fixed Partial Denture Repair Necessitated by Restorative Material Failure Extraction, Erupted Tooth or Exposed Root (Elevation and/or Forceps Removal) Palliative (Emergency) Treatment of Dental Pain Minor Procedure A complete series or panoramic x-ray once in any 36 consecutive months, but not both. Fillings, consisting of amalgam and composite resins on any given tooth surface are covered once in any 24 consecutive months. For non-network providers resin based composite fillings performed on second and third molars are considered cosmetic and will be reduced to the amalgam allowance. Periodontal maintenance, as a follow-up to active periodontal treatment is limited to 4 visits per calendar year Emergency palliative treatment. We require a written description and/or office records of services provided. $85 $30 $5 8

11 SCHEDULE OF DENTAL BENEFITS Major Services (Class III) Your Costs (after deductible is met) Procedure Code Description Network Provider (Your Copay) Non-Network Provider (Your Coinsurance) D2542 Onlay Metallic, Two Surfaces $435 You Pay 70% Of Allowable D2543 Onlay Metallic, Three Surfaces $450 Charges And Any Amounts In Excess Of The D2544 Onlay Metallic, Four or More $475 Allowable Charges Surfaces D2642 Onlay Porcelain/Ceramic, Two $450 Surfaces D2643 Onlay Porcelain/Ceramic, Three $475 Surfaces D2644 Onlay Porcelain/Ceramic, Four or $490 More Surfaces D2662 Onlay Resin-Based Composite, Two $310 Surfaces D2663 Onlay Resin-Based Composite, $350 Three Surfaces D2664 Onlay Resin-Based Composite, Four $350 or More Surfaces D2740 Crown Porcelain/Ceramic Substrate $515 D2750 Crown Porcelain Fused to High $490 Noble Metal D2751 Crown Porcelain Fused to $450 Predominantly Base Metal D2752 Crown Porcelain Fused to Noble $475 Metal D2780 Crown 3/4 Cast High Noble Metal $475 D2781 Crown 3/4 Cast Predominantly Base $435 Metal D2782 Crown 3/4 Cast Noble Metal $450 D2783 Crown 3/4 Porcelain/Ceramic $490 D2790 Crown Full Cast High Noble Metal $475 D2791 Crown Full Cast Predominantly Base $435 Metal D2792 Crown Full Cast Noble Metal $450 D2950 D2952 D2954 D3110 D3220 Core Buildup, Including Any Pins When Required Post and Core in Addition to Crown, Indirectly Fabricated Prefabricated Post and Core in Addition to Crown Pulp Cap Direct (Excluding Final Restoration) Therapeutic Pulpotomy (Excluding Final Restoration) 9 $115 $165 $165 $30 $60

12 SCHEDULE OF DENTAL BENEFITS Major Services (Class III) - continued Your Costs (after deductible is met) Procedure Code Description Network Provider (Your Copay) Non-Network Provider (Your Coinsurance) D3221 D3310 Pulpal Debridement, Primary and Permanent Teeth Endodontic Therapy, Anterior Tooth $60 $385 You Pay 70% Of Allowable Charges And Any Amounts In Excess Of The (Excluding Final Restoration) Allowable Charges D3320 Endodontic Therapy, Bicuspid Tooth $435 (Excluding Final Restoration) D3330 Endodontic Therapy, Molar Tooth $515 (Excluding Final Restoration) D3331 Treatment of Root Canal Obstruction, $75 Non-Surgical Access D3332 Incomplete Endodontic Therapy, $115 Inoperable, Unrestorable or Fractured Tooth D3346 Retreatment of Previous Root Canal $435 Therapy Anterior D3347 Retreatment of Previous Root Canal $490 Therapy Bicuspid D3348 Retreatment of Previous Root Canal $515 Therapy Molar D3351 Apexification/Recalcification, Initial $165 Visit D3352 Apexification/Recalcification, Interim $75 Medication Replacement D3353 Apexification/Recalcification, Final Visit $145 D3355 Pulpal Regeneration Initial Visit $180 D3356 Pulpal Regeneration Interim $55 Medication Replacement D3357 Pulpal Regeneration Completion of $235 Treatment D3410 Apicoectomy Anterior $310 D3421 Apicoectomy Bicuspid, First Root $385 D3425 Apicoectomy Molar, First Root $385 D3426 Apicoectomy, Each Additional Root $130 D3427 Periradicular Surgery Without Apicoectomy $310 10

13 SCHEDULE OF DENTAL BENEFITS Major Services (Class III) - continued Your Costs (after deductible is met) Procedure Code Description Network Provider (Your Copay) Non-Network Provider (Your Coinsurance) D3430 Retrograde Filling, Per Root $60 You Pay 70% Of D3450 Root Amputation, Per Root $205 D4210 Gingivectomy or Gingivoplasty, Four or $235 More Contiguous Teeth or Tooth Bounded Spaces Per Quadrant D4211 Gingivectomy or Gingivoplasty, One to $100 Three Contiguous Teeth or Tooth Bounded Spaces Per Quadrant D4212 Gingivectomy or Gingivoplasty to Allow $30 Access for Restorative Procedure, Per Tooth D4240 Gingival Flap Procedure, Including Root $310 Planing, Four or More Contiguous Teeth or Tooth Bounded Spaces Per Quadrant D4241 Gingival Flap Procedure, Including Root $165 Planing, One to Three Contiguous Teeth or Tooth Bounded Spaces Per Quadrant D4260 Osseous Surgery (Including Flap Entry and $595 Closure) Four or More Contiguous Teeth or Tooth Bounded Spaces Per Quadrant D4261 Osseous Surgery (Including Flap Entry and $350 Closure) One to Three Contiguous Teeth or Tooth Bounded Spaces Per Quadrant D4341 Periodontal Scaling and Root Planing $100 Four or More Teeth Per Quadrant D4342 Periodontal Scaling and Root Planing $60 One to Three Teeth, Per Quadrant D5110 Complete Denture Maxillary $595 D5120 Complete Denture Mandibular $595 D5130 Immediate Denture Maxillary $645 D5140 Immediate Denture Mandibular $645 D5211 Maxillary Partial Denture Resin Base $350 D5212 Mandibular Partial Denture Resin Base $350 D5213 Maxillary Partial Denture Cast Metal Framework With Resin Denture Bases $645 Allowable Charges And Any Amounts In Excess Of The Allowable Charges 11

14 SCHEDULE OF DENTAL BENEFITS Major Services (Class III) - continued Your Costs (after deductible is met) Procedure Code Description Network Provider (Your Copay) Non-Network Provider (Your Coinsurance) D5214 D5225 Mandibular Partial Denture Cast Metal Framework With Resin Denture Bases Maxillary Partial Denture Flexible Base $645 $350 You Pay 70% Of Allowable Charges And Any Amounts In Excess Of The Allowable D5226 Mandibular Partial Denture Flexible $350 Charges Base D5281 Removable Unilateral Partial Denture $350 One Piece Cast Metal D5410 Adjust Complete Denture Maxillary $30 D5411 Adjust Complete Denture Mandibular $30 D5421 Adjust Partial Denture Maxillary $30 D5422 Adjust Partial Denture Mandibular $30 D5710 Rebase Complete Maxillary Denture $235 D5711 Rebase Complete Mandibular Denture $235 D5720 Rebase Maxillary Partial Denture $235 D5721 Rebase Mandibular Partial Denture $235 D5730 Reline Complete Maxillary Denture $130 (Chairside) D5731 Reline Complete Mandibular Denture $130 (Chairside) D5740 Reline Maxillary Partial Denture $130 (Chairside) D5741 Reline Mandibular Partial Denture $130 (Chairside) D5750 Reline Complete Maxillary Denture $180 (Laboratory) D5751 Reline Complete Mandibular Denture $180 (Laboratory) D5760 Reline Maxillary Partial Denture $180 (Laboratory) D5761 Reline Mandibular Partial Denture $180 (Laboratory) D5850 Tissue Conditioning, Maxillary $55 D5851 Tissue Conditioning, Mandibular $60 D5863 Overdenture Complete Maxillary $645 D5864 Overdenture Partial Maxillary $515 D5865 Overdenture Complete Mandibular $645 D5866 Overdenture -- Partial Mandibular $515 D6210 Pontic Cast High Noble Metal $490 D6211 Pontic Cast Predominantly Base Metal $435 D6212 Pontic Cast Noble Metal $435 12

15 SCHEDULE OF DENTAL BENEFITS Major Services (Class III) - continued Your Costs (after deductible is met) Procedure Code Description Network Provider (Your Copay) Non-Network Provider (Your Coinsurance) D6240 D6241 Pontic Porcelain Fused to High Noble Metal Pontic Porcelain Fused to Predominantly $515 $435 You Pay 70% Of Allowable Charges And Any Amounts In Excess D6242 Base Metal Pontic Porcelain Fused to Noble Metal $435 Of The Allowable Charges D6245 Pontic Porcelain/Ceramic $490 D6250 Pontic Resin With High Noble Metal $450 D6251 Pontic Resin With Perdominantly Base $235 Metal D6252 Pontic Resin With Noble Metal $385 D6545 Retainer Cast Metal For Resin Bonded $180 Fixed Prosthesis D6548 Retainer Porcelain/Ceramic For Resin $205 Bonded Fixed Prosthesis D6608 Onlay Porcelain/Ceramic, Two Surfaces $385 D6609 Onlay Porcelain/Ceramic, Three or More $435 Surfaces D6610 Onlay Cast High Noble Metal, Two $385 Surfaces D6611 Onlay Cast High Noble Metal, Three or $435 More Surfaces D6612 Onlay Cast Predominantly Base Metal, $385 Two Surfaces D6613 Onlay Cast Predominantly Base Metal, $385 Three or More Surfaces D6614 Onlay Cast Noble Metal, Two Surfaces $385 D6615 Onlay Cast Noble Metal, Three or More $435 Surfaces D6740 Crown Porcelain/Ceramic $515 D6750 Crown Porcelain Fused to High Noble $490 Metal D6751 Crown Porcelain Fused to Predominantly $435 Base Metal D6752 Crown Porcelain Fused to Noble Metal $475 D6780 Crown 3/4 Cast High Noble Metal $475 D6781 Crown 3/4 Cast Predominately Based $435 Metal D6782 Crown 3/4 Cast Noble Metal $450 D6783 Crown 3/4 Porcelain/Ceramic $490 D6790 Crown Full Cast High Noble Metal $475 13

16 SCHEDULE OF DENTAL BENEFITS Major Services (Class III) - continued Your Costs (after deductible is met) Procedure Code Description Network Provider (Your Copay) Non-Network Provider (Your Coinsurance) D6791 Crown Full Cast Predominately Based $435 You Pay 70% Of Metal D6792 Crown Full Cast Noble Metal $450 D7210 Surgical Removal of Erupted Tooth $115 Requiring Removal of Bone and/or Elevation of Mucoperiosteal Flap if Indicated D7220 Removal of Impacted Tooth Soft Tissue $130 D7230 Removal of Impacted Tooth Partially Bony $165 D7240 Removal of Impacted Tooth Completely $205 Bony D7241 Removal of Impacted Tooth, Completely $235 Bony With Unusual Surgical Complications D7250 Surgical Removal of Residual Tooth Roots $115 (Cutting Procedure) D7280 Surgical Access of an Unerupted Tooth $235 D7310 Alveoloplasty in Conjunction With Extractions, Four or More Teeth or Tooth Spaces, Per Quadrant D7311 Alveoloplasty in Conjunction With Extraction, One to Three Teeth or Tooth Spaces, Per Quadrant D7320 Alveoloplasty Not in Conjunction With Extractions, Four or More Teeth or Tooth Spaces Per Quadrant D7321 Alveoloplasty Not in Conjunction With Extraction, One to Three Teeth or Tooth Spaces, Per Quadrant D7510 Incision and Drainage of Abscess Intraoral Soft Tissue D7511 Incision and Drainage of Abscess Intraoral Soft Tissue, Complicated D9220 Deep Sedation/General Anesthesia, First 30 Minutes D9221 Deep Sedation/General Anesthesia, Each Additional 15 Minutes D9241 Intravenous Conscious Sedation/Analgesia, First 30 Minutes D9242 Intravenous Conscious Sedation/Analgesia, Each Additional 15 Minutes $100 $75 $145 $130 $75 $145 $165 $55 $130 $55 Allowable Charges And Any Amounts In Excess Of The Allowable Charges 14

17 Major Services Limits Crowns and onlays including crown buildups are allowed only when the tooth cannot be restored with amalgam or composite resin filling material because of decayed or fractured tooth structure. For nonnetwork providers initial crowns and onlays consisting of porcelain, ceramic, or resin, performed on second or third molars will be limited to the corresponding metal allowance. Replacement onlays and crowns, but only when: The existing restoration was seated at least 5 calendar years before replacement Replacement dentures and fixed bridgework, but only when: The existing denture or bridgework was installed at least 5 years before replacement and only if it s unserviceable and can t be made serviceable; The replacement or addition of teeth is required to replace 1 or more additional teeth extracted after initial placement Relining and rebasing of dentures when performed 6 or more months after denture installation. General anesthesia or intravenous conscious sedation in a dental care provider s office, when medically necessary. Periodontal scaling and root planing is limited to once per quadrant every 2 calendar years Osseous surgery (surgical periodontal treatment) is covered in the same quadrant once every 3 calendar years Endodontic (root canal) treatment is limited to once per tooth every 2 calendar years Benefits for root canals performed in conjunction with overdentures are limited to 2 per arch Open and drain (open and broach) (open and medicate) procedures may be limited to a combined allowance based on our review of the services rendered WHAT I NEED TO KNOW BEFORE I GET DENTAL CARE The covered services under this dental plan are classified as Diagnostic and Preventive, Basic, and Major. The lists of services that relate to each type are outlined in the Schedule of Dental Benefits section. These services are covered once all of the following requirements are met. It is important to understand all of these requirements so you can make the most of your dental benefits. Benefits are available for the services described in this plan that are furnished for a covered dental condition. Such services must meet all of the following requirements: They must be medically necessary (see Definitions to learn how the plan defines medically necessary) They must be named in this plan as covered They must be furnished by a licensed dentist (D.M.D. or D.D.S.) or denturist. Services may also be provided by a dental hygienist under the supervision of a licensed dentist, or other individual, performing within the scope of his or her license or certification, as allowed by law. (These providers are referred to as Dental Care Providers. ) They must not be excluded from coverage under this benefit At times we may need to review diagnostic materials such as dental x-rays to determine your available benefits. These materials will be requested directly from your dental care provider. If we are unable to obtain necessary materials, we will provide benefits only for those dental services we can verify as covered. Coverage is based on allowable charges (allowed amounts) for medically necessary covered services. The percentage of an allowed amount you are responsible for is called coinsurance. Please see the Definitions section in this booklet for a detailed explanation of allowable charges. 15

18 Alternative Benefits For Dental Services To determine benefits available under this plan, we consider alternative procedures or services with different fees that are consistent with acceptable standards of dental practice. In all cases where there s an alternative course of treatment that s less costly, we ll only provide benefits for the treatment with the lesser fee. If you and your dental care provider choose a more costly treatment, you re responsible for additional charges beyond those for the less costly alternative treatment Requesting An Estimate Of Dental Benefits An estimate of benefits verifies, for the dental care provider and yourself, your eligibility and benefits. Because we consider alternative treatment at the time we review the estimate, our review may result in a lower cost of treatment and additional services under this benefit. It may also clarify, before services are rendered, treatment that isn t covered in whole or in part. This can protect you from unexpected out-of-pocket expenses. An estimate of benefits isn t required in order for you to receive your dental benefits. However, we suggest that your dental care provider submit an estimate to us for any proposed dental services in which you are concerned about your out-of-pocket expenses. Our estimate of benefits shouldn t be considered a guarantee of payment. Payment of any service will be based on your eligibility and benefits available at the time services are rendered. IMPORTANT PLAN INFORMATION This plan is a Preferred Provider Plan (PPO). You have the flexibility to receive covered services from providers without referrals. Also, this plan allows you to use a LifeWise contracted provider or the provider of your choice. See How Providers Affect Your Cost for more information. Individual Calendar Year Deductible Individual deductible means the amount you must pay for covered services in a calendar year before we begin to provide certain benefits to you. See Summary of Your Costs for your individual deductible. Basic and Major dental services are subject to an individual calendar year deductible. Preventive dental services and vision services are not subject to an individual calendar year deductible. Family Calendar Year Deductible Family deductible means the aggregate amount a family must pay for covered services in a calendar year before we begin to provide certain benefits to all enrolled family members. Once the family deductible is met, any remaining deductibles for dental services will be waived for that calendar year. See Summary of Your Costs for your family Deductible. Basic and Major dental services are subject to a family calendar year deductible. Preventive dental services and vision services are not subject to the family calendar year deductible. Calendar Year Maximum This is the total amount of benefit the plan pays for certain covered services. See Summary of Your Costs for benefit limits. Coinsurance Coinsurance is a defined percentage that you pay of the allowable charge for covered services and supplies you receive. The percentage you are responsible for, not including any applicable calendar year deductible, is called coinsurance. See Summary of Your Costs for coinsurance amounts. Copayments A copayment is a set dollar amount you are responsible for paying to a health care provider for a covered service. A copayment is also called a copay See Summary of Your Costs and the list of Schedule of Dental Benefits for copay amounts. 16

19 Dental Benefit Maximum The maximum amount of dental benefits available to any one member in a calendar year is $1,000. Benefits for covered services with multiple treatment dates are subject to the dental benefit maximum of the calendar year in which the services are started. See Summary of Your Costs for your dental benefit maximum. Out-Of-Pocket Maximum This plan does not have an out-of-pocket limit. Waiting Period This plan has a 12 month waiting period for Major dental services. You will receive benefits for Major dental services after you have been continuously covered under this plan for 12 months. Waiting periods apply from the effective date of your policy with no lapse of coverage. If you have a lapse of coverage, a new waiting period will be applied on the effective date of your new policy. Your waiting period may be waived or credited for members with prior group coverage from LifeWise or a LifeWise affiliate, if your dental coverage is still in effect or was terminated within 63 days of the date you enrolled in this Plan. Allowable Charge (Allowed Amount) This plan provides benefits based on the allowed amount for covered services. We reserve the right to determine the amount allowed for any given service or supply. The allowed amount is described below. Network Dental Care Providers The amount for medically necessary services and supplies these providers have agreed to accept as payment in full pursuant to the applicable agreement between us and the provider. These providers agree to seek payment from us when they furnish covered services to you. You ll be responsible only for any applicable calendar year deductibles, copays, coinsurance, charges in excess of the stated benefit maximums, and charges for services and supplies not covered under this plan. Your liability for any applicable calendar year deductibles, copays, coinsurance and amounts applied toward benefit maximums will be calculated on the basis of the allowable charge. Non-Network Dental Care Providers The allowable charge will be the maximum allowable charge as determined by LifeWise Health Plan of Washington in the area where the services were provided, but in no case higher than the 90 th percentile of provider fees in that geographic area. When you receive services from dental care providers that don t have agreements with us, your liability is for any amount above the allowable charge, and for any calendar year deductibles, coinsurance, amounts that are in excess of stated benefit maximums and charges for non-covered services and supplies. We reserve the right to determine the amount allowed for any given service or supply In-Network Vision Providers The allowed amount is the fee that we have negotiated with providers who have signed contracts with us and are in your provider network. See the Summary of Your Costs for the name of your provider network. When you receive covered services from an in-network provider, your medical bills will be reimbursed at a higher percentage (the in-network provider benefit level). In-network providers will not charge more than the allowed amount. This means that your portion of the charges for covered services will be lower. If a covered service is not available from an in-network provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. See Prior Authorization for details. 17

20 Out-of-Network Vision Providers Out-of-network providers are providers that are not part of your network. Your bills will be reimbursed at the lower percentage (the out-of-network benefit level) and the provider may bill you for charges above the allowed amount. You may also be required to submit the claim yourself. See Sending Us a Claim for details. Contracted providers. In some cases, an out-of-network provider may have a contract with us, but is not part of your network. Even though your bills will be reimbursed at the lower percentage (the out-of-network benefit level), contracted providers will not bill you for the amount above the allowed amount for a covered service. Non-contracted providers. Out-of-network non-contracted providers do not have a contract with us or with any of the other networks used by this plan. These providers will bill you the amount above the allowed amount for a covered service. HOW PROVIDERS AFFECT YOUR COST This plan is designed to provide the highest level of benefits when you receive covered services from a network provider. As a LifeWise member, you have access to a nationwide network of contracted medical and dental providers. Our provider directory is available any time on our website at lifewisewa.com. You may also request a copy of this directory by calling Customer Service at the number located on the back cover or on your LifeWise ID card. See the Summary of Your Costs for the name of your medical and dental provider network. Network Providers Network providers provide medical and dental services for a negotiated fee. This fee is the allowed amount for in-network providers. When you receive covered services from an in-network provider, your medical bills will be reimbursed at a higher percentage (the network provider benefit level). Network providers will not charge more than the allowed amount. This means that your portion of the charges for covered services will be lower. This plan uses the following networks: LifeWise Connect medical network (for vision services) LifeWise Individual Dental Copay dental network (for dental services) Non-Network Providers Non-network providers are providers that are not part of your network. Your bills will be reimbursed at the lower percentage (the non-network benefit level) and the provider may bill you for charges above the allowed amount. You may also be required to submit the claim yourself. See Sending Us a Claim for details. Contracted providers. In some cases, a non-network provider may have a contract with us, but is not part of your network. Even though your bills will be reimbursed at the lower percentage (the out-of-network benefit level), contracted providers will not bill you for the amount above the allowed amount for a covered service. Non-contracted providers. Out-of-network non-contracted providers do not have a contract with us or with any of the other networks used by this plan. These providers will bill you the amount above the allowed amount for a covered service. 18

21 EXCLUSIONS This section of your booklet explains circumstances in which benefits of this plan are limited or not available. Benefits can also be affected by your eligibility. Some benefits may also have their own specific limitations. LIMITED AND NON-COVERED SERVICES In addition to the specific limitations stated elsewhere in this plan, this plan doesn t cover: Amounts That Exceed The Allowed Amount This plan does not cover amounts over the allowed amount, as defined in the plan. You will have to pay charges over the allowed amount. Benefits From Other Sources Benefits aren t available under this plan when coverage is available through: Motor vehicle medical/dental or motor vehicle no-fault Personal injury protection (PIP) coverage Commercial liability coverage Homeowner policy Other types of liability insurance Worker's Compensation or similar coverage Benefits That Have Been Exhausted Amounts that exceed the allowed amount or maximum benefit for a covered service. Broken Appointment Charges Amounts that are billed for broken or late appointments. Charges For Records Or Reports Separate charges from providers for supplying records or reports, except those we request for utilization review. Conditions From Professional Sports Any condition related to semiprofessional or professional athletics, including practice. Semiprofessional athletics are athletics requiring a high level of skill, for which you are paid, even if the activity is not your fulltime occupation. Cosmetic Services Treatment of congenital malformations, except when the patient is an eligible dependent child. Services and supplies rendered for cosmetic or aesthetic purposes, including any direct or indirect complications and aftereffects thereof. Cosmetic orthodontia Dental Services Received From A: Dental or medical department maintained for employees by or on behalf of an employer; or Mutual benefit association, labor union, trustee, or similar person or group. Dietary Services Dietary planning for the control of dental caries, oral hygiene instruction and training in preventive dental care. 19

22 Experimental Or Investigational Services This plan does not cover any service that is experimental or investigative, see Definitions. This plan also does not cover any complications or effects of such services. This exclusion does not apply to certain services provided as part of a covered clinical trial. Extra Or Replacement Items Extra dentures or other appliances, including replacements due to loss or theft. Facility Charges Hospital and ambulatory surgical center care for dental procedures. Family Members Or Volunteers Services or supplies that you furnish to yourself or that are furnished to you by a provider who lives in your home or is related to you by blood, marriage, or adoption. Examples of such providers are your spouse, parent, or child. Services or supplies furnished by volunteers. Home-Use Products Services and supplies that are normally intended for home use such as take home fluoride, toothbrushes, floss and toothpaste. Illegal Acts and Terrorism This plan does not cover illness or injuries resulting from a member s commission of: A felony (except for a victim of domestic violence) An act of terrorism An act of riot or revolt Implants Dental implants and implant related services. Increase Of Vertical Dimension Any service to increase or alter the vertical dimension. Military-Related Disabilities This plan does not cover services to which you are legally entitled for a military service-connected disability and for which facilities are reasonably available. Military Service and War This plan does not cover illness or injury that is caused by or arises from: Acts of war, such as armed invasion, no matter if war has been declared or not Services in the armed forces of any country. This includes the air force, army, coast guard, marines, national guard or navy. It also includes any related civilian forces or units. Multiple Providers Services provided by more than one dental care provider for the same dental procedure. No Charge Or You Don t Legally Have To Pay Services for which no charge is made, or for which none would have been made if this plan weren t in effect Services for which you don t legally have to pay, unless benefits must be provided by law Non-Standard Techniques Other than standard techniques used in the making of restorations or prosthetic appliances, such as personalized restorations. 20

23 Not Covered Under This Plan Services that are covered benefits under your LifeWise medical plan. Services that aren t listed in this booklet as covered or that are directly related to any condition, service or supply that isn t covered under this plan. See the list of Schedule of Dental Benefits for covered dental services. Services received or ordered when this plan isn t in effect, or when you aren t covered under this plan (including services and supplies started before your effective date or after the date coverage ends), except for Major services and root canals that: Were started after your effective date and before the date your coverage ended under this plan; and Were completed within 30 days after the date your coverage ended under this plan. The following are deemed service start dates: For root canals, it s the date the canal is opened. For onlays, crowns, and bridges, it s the preparation date. For partial and complete dentures, it s the impression date. The following are deemed service completion dates: For root canals, it s the date the canal is filled. For onlays, crowns, and bridges, it s the seat date. For partial and complete dentures, it s the seat or delivery date. Not Medically Necessary Services that aren t medically necessary (see definition of Medically Necessary ) Orthodontia Services Orthodontia, including casts, models, x-rays, photographs, examinations, appliances, braces and retainers. This exclusion doesn t apply to extractions incidental to orthodontic services. Orthognathic Surgery (Jaw Augmentation or Reduction) Jaw augmentation or reduction (orthognathic and/or maxillofacial), regardless of origin of the condition that makes the procedure necessary, including any direct or indirect complications and aftereffects thereof. Outside The Scope Of A Provider s License or Certification Services or supplies that are outside the scope of the provider s license or certification, or that are furnished by a provider that isn t licensed or certified by the state in which the services or supplies were received. Prescription Drugs Any prescription drugs or medicines. This includes vitamins, food supplements, and patient management drugs, such as premedication, sedation and nitrous oxide. Sealants Mechanically and/or chemically prepared enamel surface sealed to prevent decay. Services Provided to Members Who Do Not Meet Age Requirements This plan has specific age requirements to be eligible for dental services; members must be 19 years or older and dependent children must be between age 19 and 26. Any dental services provided to members who do not meet age requirements are excluded under this plan. Temporomandibular Joint (TMJ) Disorders Any dental services or supplies connected with the diagnosis or treatment of temporomandibular joint (TMJ) disorders, including any direct or indirect complications and aftereffects thereof. 21

24 Testing And Treatment Services Testing and treatment for mercury sensitivity or that are allergy-related. Work-Related Conditions Any illness, condition or injury arising out of or in the course of employment, for which the member is entitled to receive benefits, whether or not a proper and timely claim for such benefits has been made under: Occupational coverage required or voluntarily obtained by the employer; State or federal workers compensation acts; or Any legislative act providing compensation for work-related illness or injury. OTHER COVERAGE COORDINATING BENEFITS WITH OTHER PLANS When you have more than one health plan, "coordination of benefits (COB)" makes sure that the combined payments of all your plans don't exceed your covered health costs. You or your provider should file your claims with your primary plan first. If you have Medicare, Medicare may submit your claims to your secondary plan. Please see "COB's Effect on Benefits" below in this section for details on primary and secondary plans. If you do not know which is your primary plan, you or your provider should contact any of the health plans to verify which plan is primary. The health plan you contact is responsible for working with the other plan(s) to determine which is primary and will let you know within 30 calendar days. Caution: All health plans have timely filing requirements. If you or your provider fails to submit your claim to your secondary plan within that plan s claim filing time limit, the plan can deny the claim. If you experience delays in the processing of your claim by the primary plan, you or your provider will need to submit your claim to the secondary plan within its claim filing time limit to prevent a denial of the claim. To avoid delays in claims processing, if you are covered by more than one plan you should promptly report to your providers any changes in your coverage DEFINITIONS For the purposes of COB: A plan is any of the following that provides benefits or services for medical or dental care. If separate contracts are used to provide coordinated coverage for group members, all the contracts are considered parts of the same plan and there is no COB among them. However, if COB rules don't apply to all contracts, or to all benefits in the same contract, the contact or benefit to which COB doesn't apply is treated as a separate plan. "Plan" means: Group, individual or blanket disability insurance contracts, and group or individual contracts issued by health care service contractors or HMOs, closed panel plans or other forms of group coverage; medical care provided by long-term care plans; and Medicare or any other federal governmental plan, as permitted by law. "Plan" doesn't mean: Hospital or other fixed indemnity or fixed payment coverage; accident-only coverage; specified disease or accident coverage; limited benefit health coverage, as defined by state law; school accident type coverage; non-medical parts of long-term care plans; automobile coverage required by law to provide medical benefits; Medicare supplement policies; Medicaid or other federal governmental plans, unless permitted by law. This plan means your plan's health care benefits to which COB applies. A contract may apply one COB process to coordinating certain benefits only with similar benefits and may apply another COB process to coordinate other benefits. All the benefits of your LifeWise plan are subject to COB, but your plan coordinates dental benefits separately from medical benefits. Dental benefits are coordinated only with other plans' dental benefits, while medical benefits are coordinated only with other plans' medical benefits. Primary plan is a plan that provides benefits as if you had no other coverage. 22