Dental Coverage. Hawai i. Coordinated Care Plans. H2491_H _WCM_BRO_ENG CMS Approved WellCare 2011 HI_07_11_WC

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1 Dental Coverage Coordinated Care Plans Hawai i Ohana 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. H2491_H _WCM_BRO_ENG CMS Approved WellCare 2011 HI_07_11_WC HIDENBRO39838E_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 s 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 Ohana 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 Ohana 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 Ohana at (TTY ), Monday Sunday, 8 a.m. to 8 p.m. HST. Between 2/15/12 and 10/14/12, representatives are available Monday Friday, 8 a.m. to 8 p.m. HST. Please refer to your Ohana 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 ADA Code Preventive Services 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 500 Ohana Value (HMO-POS) $500 $ every 6 mos. per 1 every 12 mos. per 1 every 6 mos. per 1 every 6 mos. per 1 every 6 mos. per 1 every 6 mos. per 1 every 6 mos. per 1 every 6 mos. per Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 1

5 D9310 D9410 Consultation Diagnostic Service Provided By Dentist Or Physician Other Than Requesting Dentist Or Physician House/Extended Care Facility Call D9420 Hospital Call D9430 D9440 D9450 X-Rays D0210 D0220 D0230 Office Visit For Observation (During Regularly Scheduled Hours) No Other Services Performed Office Visit After Regularly Scheduled Hours Case Presentation, Detailed And Extensive Treatment Planning Intraoral Complete Series Intraoral 1st Periapical Intraoral Each Additional Periapical D0240 Intraoral Occlusal D0250 Extraoral First Film D0260 Extraoral Each Additional Film 1 every 6 mos. per 1 every 6 mos. per 1 every 6 mos. per 1 every 6 mos. per 1 every 6 mos. per 1 every 6 mos. per 1 every 36 mos. per 1 per 4 per D0270 Single Bitewing 2 every 12 mos. per 1 every 12 mos. per 2 every 12 mos. per 4 every 12 mos. per 2012 Dental Coverage 2

6 ADA Code X-Rays Preventive Services Description of Service Co-pay D0272 Two Bitewings D0273 Three Bitewings D0274 Four Bitewings D0277 D0290 Vertical Bitewings 7 to 8 Films Posterior-Anterior Or Lateral Skull And Facial Bone Survey Film D0310 Sialography D0320 D0321 Temporomandibular Joint Arthrogram, Including Injection Other Temporomandibular Joint Films D0322 Tomographic Survey D0330 Panoramic Film D0340 Cephalometric Film Limitations 2 every 12 mos. per Dental 500 Ohana Value (HMO-POS) 1 every 12 mos. per 1 every 12 mos. per 1 every 36 mos. per 1 every 36 mos. per 1 every 36 mos. per 1 every 36 mos. per 1 every 36 mos. per 1 every 36 mos. per 1 every 36 mos. per 1 every 36 mos. per Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 3

7 D0350 D0360 D0362 D0363 Oral/Facial Photographic Images Cone Beam CT, Craniofacial Data Capture Cone Beam, Two- Dimensional Image Reconstruction Cone Beam, Three- Dimensional Image Reconstruction 1 every 36 mos. per 1 every 36 mos. per 1 every 36 mos. per 1 every 36 mos. per Additional Comprehensive Services Tests Preventive D0415 Collection Of Microorganisms For Culture 1 every 12 mos. per test D0416 Viral Culture 1 every 12 mos. per test D0421 Genetic Test For Susceptibility 1 every 12 mos. per test D0425 Caries Susceptibility Test 1 every 12 mos. per test D0431 Adjunctive Pre- Diagnostic Tests 1 every 12 mos. per test D0460 Pulp Vitality Tests 1 every 12 mos. per test D0470 Diagnostic Casts 1 every 12 mos. per test D0472 D0473 Accession Of Tissue, Gross Exam Accession Of Tissue, Gross And Microscopic Exam 1 every 12 mos. per test 1 every 12 mos. per test 2012 Dental Coverage 4

8 ADA Code Additional Comprehensive Services Description of Service Co-pay Limitations Dental 500 Ohana Value (HMO-POS) Tests Preventive Accession Of D0474 Tissue, Gross And Microscopic Exam, Including Surgical 1 every 12 mos. per test Margins D0475 Decalcification Procedure 1 every 12 mos. per test D0476 Special Stains For Microorganisms 1 every 12 mos. per test D0477 Special Stains Not For Microorganisms 1 every 12 mos. per test D0478 Immunohistochemical Stains 1 every 12 mos. per test D0479 Tissue In-Situ Hybridization 1 every 12 mos. per test D0480 Accession Of Exfoliative Cytological Smears 1 every 12 mos. per test D0481 Electron Microscopy 1 every 12 mos. per test D0482 Direct Immunofluorescence 1 every 12 mos. per test D0483 Indirect Immunofluorescence 1 every 12 mos. per test D0484 Consultation On Slides Prepared Elsewhere 1 every 12 mos. per test Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 5

9 D0485 Consultation Including Prep Of Slides From Biopsy 1 every 12 mos. per test D0486 Accession Of Brush Biopsy Sample 1 every 12 mos. per test D0502 Other Oral Pathology 1 every 12 mos. per test D0999 Unspecified Diagnostic 1 every 12 mos. per test Basic Restorative D2140 Amalgam One Surface, Primary Or Permanent 1 every 36 mos. per tooth D2150 Amalgam Two Surfaces, Primary Or Permanent 1 every 36 mos. per tooth D2160 Amalgam Three Surfaces, Primary Or Permanent 1 every 36 mos. per tooth D2161 Amalgam Four Surfaces, Primary Or Permanent 1 every 36 mos. per tooth Resin Restorative D2330 Resin-Based Composite 1 Surface, Anterior 1 every 36 mos. per tooth D2331 Resin-Based Composite 2 Surfaces, Anterior 1 every 36 mos. per tooth D2332 Resin-Based Composite 3 Surfaces, Anterior 1 every 36 mos. per tooth D2335 Resin-Based Composite 4+ Surfaces, Anterior 1 every 36 mos. per tooth Resin-Based Composite D2390 Crown, Anterior 1 every 36 mos. per tooth D2391 Resin-Based Composite 1 Surface, Posterior 1 every 36 mos. per tooth 2012 Dental Coverage 6

10 ADA Code Additional Comprehensive Services Description of Service Co-pay Resin Restorative Resin-Based Composite D Surfaces, Posterior D2393 Resin-Based Composite 3 Surfaces, Posterior D2394 Resin-Based Composite 4+ Surfaces, Posterior Endodontics Pulp Cap Direct D3110 (Excluding Final Restoration) Pulp Cap Indirect D3120 (Excluding Final Restoration) D3220 Therapeutic Pulpotomy Pulpal Debridement, D3221 Primary And Permanent Teeth Pulpal Therapy (Resorbable Filling) D3230 Anterior, Primary Tooth (Excluding Final Restoration) Limitations Dental 500 Ohana Value (HMO-POS) 1 every 36 mos. per tooth 1 every 36 mos. per tooth 1 every 36 mos. 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 Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 7

11 D3240 Pulpal Therapy (Resorbable Filling) Posterior, Primary Tooth (Excluding Final Restoration) 1 per lifetime per tooth D3310 Root Canal, Anterior 1 per lifetime per tooth D3320 Root Canal, Bicuspid 1 per lifetime per tooth D3330 Root Canal, Molar 1 per lifetime per tooth D3331 D3332 D3333 D3346 D3347 D3348 D3351 Treatment Of Root Canal Obstruction; Nonsurgical Access Incomplete Endodonic Therapy; Inoperable, Unrestorable Or Fractured Tooth Internal Root Repair Of Perforation Defects Retreatment Of Previous Root Canal Therapy Anterior Retreatment Of Previous Root Canal Therapy Bicuspid Retreatment Of Previous Root Canal Therapy Molar Apexification/ Recalcification Initial Visit (Apical Closure/ Calcific Repair Of Perforations, Root Resorption, Etc.) 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 2012 Dental Coverage 8

12 ADA Code Endodontics D3352 D3353 D3410 D3421 D3425 D3426 Additional Comprehensive Services Description of Service Co-pay Apexification/ Recalcification Interim Medication Replacement (Apical Closure/ Calcific Repair Of Perforations, Root Resorption, Etc.) Apexification/ Recalcification Final Visit (Apical Closure/ Calcific Repair Of Perforations, Root Resorption, Etc.) Apicoectomy/ Periradicular Surgery Anterior Apicoectomy/ Periradicular Surgery Bicuspid (First Root) Apicoectomy/ Periradicular Surgery Molar (First Root) Apicoectomy/ Periradicular Surgery (Each Additional Root) Limitations Dental 500 Ohana Value (HMO-POS) 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 Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 9

13 D3430 D3450 D3460 D3470 D3910 D3920 D3950 D3999 Periodontics D4210 D4211 Retrograde Filling Per Root Root Amputation Per Root Endodontic Endosseous Implant Intentional Reimplantation (Including Necessary Splinting) Surgical Procedure For Isolation Of Tooth With Rubber Dam Hemisection (Including Any Root Removal), Not Including Root Canal Therapy Canal Preparation And Fitting Of Preformed Dowel Or Post Unspecified Endodontic Procedure, By Report Gingivectomy Or Gingivoplasty Four Or More Contiguous Teeth Or Bounded Teeth Spaces Per Quadrant Gingivectomy Or Gingivoplasty One To Three Contiguous Teeth Or Bounded Teeth Spaces Per Quadrant 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 per lifetime per tooth quadrant quadrant 2012 Dental Coverage 10

14 ADA Code Periodontics D4230 D4231 D4240 D4241 D4245 D4249 Additional Comprehensive Services Description of Service Co-pay Limitations Anatomical Crown Exposure Four Or More Contiguous Teeth Per Quadrant Anatomical Crown Exposure One To Three Teeth Per Quadrant Gingival Flap Procedure, Including Root Planing Four Or More Contiguous Teeth Or Bounded Teeth Spaces Per Quadrant Gingival Flap Procedure, Including Root Planing One To Three Contiguous Teeth Or Bounded Teeth Spaces Per Quadrant Apically Positioned Flap Clinical Crown Lengthening Hard Tissue quadrant quadrant quadrant quadrant quadrant Dental 500 Ohana Value (HMO-POS) 1 per lifetime per tooth Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 11

15 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4268 D4270 Osseous Surgery (Including Flap Entry And Closure) Four Or More Contiguous Teeth Or Bounded Teeth Spaces Per Quadrant Osseous Surgery (Including Flap Entry And Closure) One To Three Contiguous Teeth Or Bounded Teeth Spaces Per Quadrant Bone Replacement Graft First Site In Quadrant Bone Replacement Graft Each Additional Site In Quadrant Biologic Materials To Aid In Soft And Osseous Tissue Regeneration Guided Tissue Regeneration Resorbable Barrier, Per Site Guided Tissue Regeneration Nonresorbable Barrier, Per Site (Includes Membrane Removal) Surgical Revision Procedure, Per Tooth Pedicle Soft Tissue Graft Procedure quadrant quadrant tooth tooth tooth tooth tooth tooth tooth 2012 Dental Coverage 12

16 ADA Code Additional Comprehensive Services Description of Service Co-pay Limitations Dental 500 Ohana Value (HMO-POS) Periodontics D4271 Free Soft Tissue Graft Procedure (Including Donor Site Surgery) tooth Subepithelial D4273 Connective Tissue Graft Procedures, Per tooth Tooth Distal Or Proximal Wedge Procedure D4274 (When Not Performed In Conjunction With Surgical Procedures In tooth The Same Anatomical Area) D4275 Soft Tissue Allograft tooth Combined Connective D4276 Tissue And Double Pedicle Graft, Per tooth Tooth D4320 Provisional Splinting Intracoronal arch D4321 Provisional Splinting Extracoronal arch D4341 Periodontal Scaling And Root Planing 4+ Teeth Per Quadrant quadrant Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 13

17 D4342 D4355 D4381 D4910 D4920 D4999 Extractions D7140 Crowns D2710 D2712 Periodontal Scaling And Root Planing 1 to 3 Teeth Per Quadrant Full Mouth Debridement To Enable Comprehensive Evaluation And Diagnosis Localized Delivery Of Antimicrobial Agents Via A Controlled Release Vehicle Into Diseased Crevicular Tissue, Per Tooth, By Report Periodontal Maintenance Unscheduled Dressing Change (By Someone Other Than Treating Dentist) Unspecified Periodontal Procedure, By Report Extraction, Erupted Tooth Or Exposed Root Crown Resin-Based Composite (Indirect) Crown 3/4 Resin- Based Composite (Indirect) quadrant 1 every 36 mos. per 1 every 12 mos. per tooth 1 every 6 mos. per 1 every 12 mos. per 1 every 12 mos. per 1 per lifetime per tooth tooth tooth 2012 Dental Coverage 14

18 ADA Code Crowns D2721 D2722 D2740 D2751 D2752 D2781 D2782 D2783 D2791 D2792 Additional Comprehensive Services Description of Service Co-pay Crown Resin With Predominantly Base Metal Crown Resin With Noble Metal Crown Porcelain/ Ceramic Substrate Crown Porcelain Fused To Predominantly Base Metal Crown Porcelain Fused To Noble Metal Crown 3/4 Cast Predominantly Base Metal Crown 3/4 Cast Noble Metal Crown 3/4 Porcelain/Ceramic Crown Full Cast Predominantly Base Metal Crown Full Cast Noble Metal Limitations Dental 500 Ohana Value (HMO-POS) tooth tooth tooth tooth tooth tooth tooth tooth tooth tooth Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 15

19 D2910 Recement Inlay, Onlay Or Partial Coverage Restoration 1 every 12 mos. per tooth D2915 Recement Cast Or Prefabricated Post And Core 1 every 12 mos. per tooth D2920 Recement Crown 1 every 12 mos. per tooth D2931 Prefabricated Stainless Steel Crown Permanent Tooth 1 every 36 mos. per tooth D2932 Prefabricated Resin Crown 1 every 36 mos. per tooth D2933 Prefabricated Stainless Steel Crown With Resin Window 1 every 36 mos. per tooth D2934 Prefabricated Esthetic Coated Stainless Steel Crown Primary 1 every 36 mos. per tooth Tooth D2940 Sedative Filling unlimited per tooth D2950 Core Buildup, Including Any Pins tooth D2951 Pin Retention Per Tooth, In Addition To Restoration tooth D2952 Post And Core In Addition To Crown, Indirectly Fabricated tooth D2953 Each Additional Indirectly Fabricated Post Same Tooth tooth D2954 Prefabricated Post And Core In Addition To Crown tooth 2012 Dental Coverage 16

20 ADA Code Additional Comprehensive Services Description of Service Co-pay Limitations Dental 500 Ohana Value (HMO-POS) Crowns D2955 Post Removal (Not In Conjunction With Endodontic Therapy) tooth Each Additional D2957 Prefabricated Post Same Tooth (Report In Addition To Code tooth D2954) D2970 Temporary Crown (Fractured Tooth) tooth Additional Procedures D2971 To Construct New Crown Under Existing Partial Denture tooth Framework D2975 Coping tooth Crown Repair, By Report (Pertinent Documentation To D2980 Evaluate Medical Appropriateness tooth Should Be Included When This Code Is Reported.) Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 17

21 D2999 Unspecified Restorative Procedure, By Report (Determine If An Alternative HCPCS Level II Or A CPT Code Better Describes The Service tooth Being Reported. This Code Should Be Used Only If A More Specific Code Is Unavailable.) D6205 Pontic Indirect Resin- Based Composite tooth D6210 Pontic Cast High Noble Metal tooth D6211 Pontic Cast Predominantly Base Metal tooth D6212 Pontic Cast Noble Metal tooth D6241 Pontic Porcelain Fused To Predominantly Base tooth Metal D6242 Pontic Porcelain Fused To Noble Metal tooth D6245 Pontic Porcelain/ Ceramic tooth D6251 Pontic Resin With Predominantly Base Metal tooth D6252 Pontic Resin With Noble Metal tooth D6253 Provisional Pontic tooth D6545 Retainer Cast Metal For Resin-Bonded Fixed Prosthesis tooth 2012 Dental Coverage 18

22 ADA Code Crowns D6548 D6600 D6601 D6602 D6603 D6604 D6605 D6606 Additional Comprehensive Services Description of Service Co-pay Retainer Porcelain/ Ceramic For Resin- Bonded Fixed Prosthesis Inlay Porcelain/ Ceramic, Two Surfaces Inlay Porcelain/ Ceramic, Three Or More Surfaces Inlay Cast High Noble Metal, Two Surfaces Inlay Cast High Noble Metal, Three Or More Surfaces Inlay Cast Predominantly Base Metal, Two Surfaces Inlay Cast Predominantly Base Metal, Three Or More Surfaces Inlay Cast Noble Metal, Two Surfaces Limitations Dental 500 Ohana Value (HMO-POS) tooth tooth tooth tooth tooth tooth tooth tooth Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 19

23 D6607 D6608 D6609 D6612 D6613 D6614 D6615 D6710 D6721 D6722 D6740 D6751 D6752 Inlay Cast Noble Metal, Three Or More Surfaces Onlay Porcelain/ Ceramic, Two Surfaces Onlay Porcelain/ Ceramic, Three Or More Surfaces Onlay Cast Predominantly Base Metal, Two Surfaces Onlay Cast Predominantly Base Metal, Three Or More Surfaces Onlay Cast Noble Metal, Two Surfaces Onlay Cast Noble Metal, Three Or More Surfaces Crown Indirect Resin- Based Composite Crown Resin With Predominantly Base Metal Crown Resin With Noble Metal Crown Porcelain/ Ceramic Crown Porcelain Fused To Predominantly Base Metal Crown Porcelain Fused To Noble Metal tooth tooth tooth tooth tooth tooth tooth tooth tooth tooth tooth tooth tooth 2012 Dental Coverage 20

24 ADA Code Additional Comprehensive Services Description of Service Co-pay Limitations Dental 500 Ohana Value (HMO-POS) Crowns D6781 Crown 3/4 Cast Predominantly Base Metal tooth D6782 Crown 3/4 Cast Noble Metal tooth D6783 Crown 3/4 Porcelain/Ceramic tooth D6791 Crown Full Cast Predominantly Base Metal tooth D6792 Crown Full Cast Noble Metal tooth D6793 Provisional Retainer Crown tooth D6920 Connector Bar tooth D6930 Recement Fixed Partial Denture tooth D6940 Stress Breaker tooth D6950 Precision Attachment tooth D6970 Post And Core In Addition To Fixed Partial Denture Retainer, Indirectly Fabricated tooth Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 21

25 D6972 Prefabricated Post And Core + Fixed Partial Denture tooth Retainer D6973 Core Build Up For Retainer, Including Any Pins tooth D6975 Coping Metal tooth D6976 Each Additional Indirectly Fabricated Post Same Tooth tooth D6977 Each Additional Prefabricated Post Same Tooth tooth D6980 Fixed Partial Denture Repair, By Report tooth D6999 Unspecified Fixed Prosthodontic Procedure, By Report arch Denture D5110 D5120 D5130 D5140 D5211 D5212 Complete Denture Maxillary Complete Denture Mandibular Immediate Denture Maxillary Immediate 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) 2012 Dental Coverage 22

26 ADA Code Additional Comprehensive Services Description of Service Co-pay Limitations Dental 500 Ohana Value (HMO-POS) Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) Denture D5213 Maxillary Partial Denture Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth) D5214 Mandibular Partial Denture Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth) D5225 Maxillary Partial Denture Flexible Base (Including Any Clasps, Rests And Teeth) D5226 Mandibular Partial Denture Flexible Base (Including Any Clasps, Rests And Teeth) 2012 Dental Coverage 23

27 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670 Removable Unilateral Partial Denture One Piece Cast Metal (Including Clasps And Teeth) Adjust Complete Denture Maxillary Adjust Complete Denture Mandibular Adjust Partial Denture Maxillary Adjust Partial Denture Mandibular Repair Broken Complete Denture Base Replace Missing Or Broken Teeth Complete Denture (Each Tooth) Repair Resin Denture Base Repair Cast Framework Repair Or Replace Broken Clasp Replace Broken Teeth Per Tooth Add Tooth To Existing Partial Denture Add Clasp To Existing Partial Denture Replace All Teeth And Acrylic On Cast Metal Framework (Maxillary) 1 every 12 mos. per 1 every 12 mos. per 1 every 12 mos. per 1 every 12 mos. per 1 every 12 mos. per arch 1 every 12 mos. per arch 1 every 12 mos. per arch 1 every 12 mos. per arch 1 every 12 mos. per arch 1 every 12 mos. per arch 1 every 12 mos. per arch 1 every 12 mos. per arch arch 2012 Dental Coverage 24

28 ADA Code Denture D5671 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 Additional Comprehensive Services Description of Service Co-pay Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular) Rebase Complete Maxillary Denture Rebase Complete Mandibular Denture Rebase Maxillary Partial Denture Rebase Mandibular Partial Denture Reline Complete Maxillary Denture (Chairside) Reline Complete Mandibular Denture (Chairside) Reline Maxillary Partial Denture (Chairside) Reline Mandibular Partial Denture (Chairside) Reline Complete Maxillary Denture (Laboratory) Limitations Dental 500 Ohana Value (HMO-POS) arch Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 25

29 D5751 D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5860 D5861 D5862 D5867 D5875 D5899 Reline Complete Mandibular Denture (Laboratory) Reline Maxillary Partial Denture (Laboratory) Reline Mandibular Partial Denture (Laboratory) Interim Complete Denture (Maxillary) Interim Complete Denture (Mandibular) Interim Partial Denture (Maxillary) Interim Partial Denture (Mandibular) Tissue Conditioning, Maxillary Tissue Conditioning, Mandibular Overdenture Complete, By Report Overdenture Partial, By Report Precision Attachment, By Report Replacement Of Replaceable Part Of Semi-Precision Or Precision Attachment Modification Of Removable Prosthesis Following Implant Surgery Unspecified Removable Prosthodontic Procedure, By Report 1 every 12 mos. per 1 every 12 mos. per arch arch 2012 Dental Coverage 26

30 ADA Code Inlays/Onlays D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 Additional Comprehensive Services Description of Service Co-pay Inlay Metallic One Surface Inlay Metallic Two Surfaces Inlay Metallic Three Or More Surfaces Onlay Metallic Two Surfaces Onlay Metallic Three Surfaces Onlay Metallic Four Or More Surfaces Inlay Porcelain/ Ceramic One Surface Inlay Porcelain/ Ceramic Two Surfaces Inlay Porcelain/ Ceramic Three Or More Surfaces Onlay Porcelain/ Ceramic Two Surfaces Limitations Dental 500 Ohana Value (HMO-POS) tooth tooth tooth tooth tooth tooth tooth tooth tooth tooth Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 27

31 Onlay Porcelain/ D2643 Ceramic Three Surfaces Onlay Porcelain/ D2644 Ceramic Four Or More Surfaces Inlay Resin-Based D2650 Composite One Surface Inlay Resin-Based D2651 Composite Two Surfaces Inlay Resin-Based D2652 Composite Three Or More Surfaces Onlay Resin-Based D2662 Composite Two Surfaces Onlay Resin-Based D2663 Composite Three Surfaces Onlay Resin-Based D2664 Composite Four Or More Surfaces 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 tooth tooth tooth tooth tooth tooth tooth 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 2012 Dental Coverage 28

32 ADA Code Additional Comprehensive Services Description of Service Co-pay Other Oral Maxillofacial Surgery D7250 Surgical Removal Of Residual Roots D7260 Oroantral Fistula Closure D7261 Primary Closure Of A Sinus Perforation Tooth Reimplantation And/Or Stabilization D7270 Of Accidentally Evulsed Or Displaced Tooth Tooth Transplantation (Includes D7272 Reimplantation From One Site To Another And Splinting And/Or Stabilization) D7280 Surgical Access Of An Unerupted Tooth Mobilization Of Erupted Or D7282 Malpositioned Tooth To Aid Eruption Placement Of Device D7283 To Facilitate Eruption Of Impacted Tooth Limitations Dental 500 Ohana Value (HMO-POS) 1 per lifetime per tooth Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 29

33 D7285 Biopsy Of Oral Tissue Hard (Bone, Tooth) D7286 Biopsy Of Oral Tissue Soft D7287 Exfoliative Cytological Sample Collection D7288 Brush Biopsy Transepithelial Sample Collection D7290 Surgical Repositioning Of Teeth D7291 Transseptal Fiberotomy/Supra Crestal Fiberotomy, By Report D7292 Surgical Placement: Temporary Anchorage Device (Screw- Retained Plate) Requiring Surgical Flap D7293 Surgical Placement: Temporary Anchorage Device Requiring Surgical Flap D7294 Surgical Placement: Temporary Anchorage Device Without Surgical Flap D7310 Alveoloplasty In Conjunction With Extractions Four Or More Teeth Or Tooth Spaces, Per Quadrant quadrant D7311 Alveoloplasty In Conjunction With Extractions One To Three Teeth Or Tooth Spaces, Per Quadrant quadrant 2012 Dental Coverage 30

34 ADA Code Additional Comprehensive Services Description of Service Co-pay Other Oral Maxillofacial Surgery Alveoloplasty Not In Conjunction With D7320 Extractions Four Or More Teeth Or Tooth Spaces, Per Quadrant Alveoloplasty Not In Conjunction With D7321 Extractions One To Three Teeth Or Tooth Spaces, Per Quadrant Vestibuloplasty D7340 Ridge Extension (Secondary Epithelialization) Vestibuloplasty Ridge Extension (Including Soft Tissue Grafts, Muscle D7350 Reattachment, Revision Of Soft Tissue Attachment And Management Of Hypertrophied And Hyperplastic Tissue) D7410 Excision Of Benign Lesion Up To 1.25 CM Limitations quadrant quadrant quadrant quadrant Dental 500 Ohana Value (HMO-POS) unlimited per Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 31

35 D7411 D7412 D7413 D7414 D7415 D7440 D7441 D7450 D7451 D7460 Excision Of Benign Lesion Greater Than 1.25 CM Excision Of Benign Lesion, Complicated Excision Of Malignant Lesion Up To 1.25 CM Excision Of Malignant Lesion Greater Than 1.25 CM Excision Of Malignant Lesion, Complicated Excision Of Malignant Tumor Lesion Diameter Up To 1.25 CM Excision Of Malignant Tumor Lesion Diameter Greater Than 1.25 CM Removal Of Benign Odontogenic Cyst Or Tumor Lesion Diameter Up To 1.25 CM Removal Of Benign Odontogenic Cyst Or Tumor Lesion Diameter Greater Than 1.25 CM Removal Of Benign Nonodontogenic Cyst Or Tumor Lesion Diameter Up To 1.25 CM unlimited per unlimited per unlimited per unlimited per unlimited per unlimited per unlimited per unlimited per unlimited per unlimited per 2012 Dental Coverage 32

36 Additional Comprehensive Services Dental 500 Ohana Value (HMO-POS) ADA Code Description of Service Co-pay Limitations Other Oral Maxillofacial Surgery Removal Of Benign D7461 Nonodontogenic Cyst Or Tumor Lesion Diameter Greater unlimited per Than 1.25 CM D7465 D7471 D7472 D7473 D7485 D7490 D7510 Destruction Of Lesion(s) By Physical Or Chemical Method, By Report Removal Of Lateral Exostosis (Maxilla Or Mandible) Removal Of Torus Palatinus Removal Of Torus Mandibularis Surgical Reduction Of Osseous Tuberosity Radical Resection Of Maxilla Or Mandible Incision And Drainage Of Abscess Intraoral Soft Tissue unlimited per 1 per lifetime per 1 per lifetime per 1 per lifetime per 1 per lifetime per 1 per lifetime per unlimited per Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 33

37 D7511 D7520 D7521 D7530 D7540 D7960 Incision And Drainage Of Abscess Intraoral Soft Tissue Complicated (Includes Drainage Of Multiple Fascial Spaces) Incision And Drainage Of Abscess Extraoral Soft Tissue Incision And Drainage Of Abscess Extraoral Soft Tissue Complicated (Includes Drainage Of Multiple Fascial Spaces) Removal Of Foreign Body From Mucosa, Skin, Or Subcutaneous Alveolar Tissue Removal Of Reaction-Producing Foreign Bodies, Musculoskeletal System Frenulectomy (Frenectomy Or Frenotomy) Separate Procedure unlimited per unlimited per unlimited per unlimited per unlimited per D7963 Frenuloplasty D7970 D7971 D7972 Excision Of Hyperplastic Tissue Per Arch Excision Of Pericoronal Gingiva Surgical Reduction Of Fibrous Tuberosity 1 per lifetime per 1 per lifetime per 2012 Dental Coverage 34

38 ADA Code Additional Comprehensive Services Description of Service Co-pay Limitations Dental 500 Ohana Value (HMO-POS) Other Oral Maxillofacial Surgery Appliance Removal D7997 (Not By Dentist Who Placed Appliance), Includes Removal Of Archbar D7999 Unspecified Oral Surgery Procedure, By Report Other Services Local Anesthesia Not D9210 In Conjunction With Operative Or Surgical unlimited per Procedure D9211 Regional Block Anesthesia unlimited per D9212 Trigeminal Division Block Anesthesia unlimited per D9215 Local Anesthesia unlimited per D9220 Deep Sedation/ General Anesthesia First 30 Minutes unlimited per Deep Sedation/ D9221 General Anesthesia Each Additional 15 unlimited per Minutes Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 35

39 D9230 D9241 D9242 D9248 D9120 D9610 D9612 D9630 D9910 D9911 D9920 Analgesia, Anxiolysis, Inhalation Of Nitrous Oxide Intravenous Conscious Sedation/Analgesia First 30 Minutes Intravenous Conscious Sedation/Analgesia Each Additional 15 Minutes Nonintravenous Conscious Sedation Fixed Partial Denture Sectioning Therapeutic Parenteral Drug, Single Administration Therapeutic Parenteral Drugs, Two Or More Administrations, Different Medications Other Drugs And/ Or Medicaments, By Report Application Of Desensitizing Medicament Application Of Desensitizing Resin For Cervical And/Or Root Surface, Per Tooth Behavior Management, By Report unlimited per unlimited per unlimited per unlimited per 1 every 12 mos. per 1 every 6 mos. per 1 every 6 mos. per 1 every 6 mos. per 2012 Dental Coverage 36

40 Additional Comprehensive Services ADA Code Description of Service Co-pay Limitations D9930 Treatment Of Complication (Postsurgical) Unusual Circumstances, By Report D9940 Occlusal Guard, By Report D9942 Repair And/Or Reline Of Occlusal Guard D9950 Occlusion Analysis Mounted Case D9951 Occlusal Adjustment Limited D9952 Occlusal Adjustment Complete Miscellaneous D9110 Palliative (Emergency) Treatment Dental 500 Ohana Value (HMO-POS) 1 visit per member per year Dental 1000 Ohana Reserve (HMO-POS) Ohana Liberty (HMO-POS SNP) 2012 Dental Coverage 37

41

42 Ohana Health Plan is a plan offered by WellCare Health Insurance of Arizona, Inc. 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 Ohana for details. You must use network dental providers. If you obtain care from out-of-network dental providers, neither Medicare nor Ohana will be responsible for the costs. Contact Ohana for more information

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