TWO GREAT DENTAL PROGRAMS

Transcription

1 A REGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION TWO GREAT DENTAL PROGRAMS FOR 2015 KAISER PERMANENTE FEDERAL MEMBERS You must be enrolled in one of Kaiser Permanente s medical plans to elect fee-for-service or DHMO dental coverage

2 Kaiser Permanente is pleased to offer Federal employees and eligible Federal retirees and dependents who are currently enrolled or planning to enroll in one of Kaiser Permanente s medical plans a choice of the dental plans described below. Option 1 is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc., and is administered by Delta Dental of California (Delta Dental). Option 2 is a DeltaCare USA dental HMO program provided by Delta Dental of California and administered by Delta Dental Insurance Company. (These companies are financially responsible for their own products.) These benefits are neither offered nor guaranteed under a contract with the Federal Employees Health Benefit (FEHB) Program, but are made available to all enrollees and family members who become members of Kaiser Permanente. During the annual open season period, you have the opportunity to enroll in one of the two plans. If you are already enrolled, you may change plans during this period. Your coverage under the enrolled plan will become effective on January 1, 2015 and will extend through December 31, 2015, subject to your continued premium payments and enrollment in Kaiser Permanente s traditional HMO Plan. If you are already enrolled under one of the two dental plans and are not planning on changing your coverage, you do not need to complete the enrollment form. If you are changing plans, you must provide 30-days advance written notice of termination. If you are covered under Option 1, the notice must be sent to Delta Dental (see page 7 for address). If you are covered under Option 2, the notice must be sent to DeltaCare USA (see page 18 for address). With DeltaCare USA... You select one of the more than 2,755 network dentists statewide. General dental care for the entire family is provided by a network dentist. Specialty care is coordinated through your general dentist. You pay a set or no copayment for covered services. Orthodontic services (braces) with a copayment of $1,600 for children under 19 and $1,800 for covered adults and dependent adult children. There are no claim forms to complete. There are no deductibles. There are no annual maximums except for accidental injury. See Green Section Beginning on Page 1 See Blue Section Beginning on Page 9 Monthly Premium* KPIC Dental Insurance Plan Self Only $ Self & One Party $ Self & Two or More $ *Good through December 31, 2015 You have two dental plans to choose from: 1KPIC s Group Dental Insurance Plan allows you the freedom to see any licensed dentist of your choice. It uses a Table of Allowances that lists the dollar amount KPIC will pay for each covered dental service. A copy of the Table of Allowances is included in this brochure. You must be enrolled in Kaiser Permanente s traditional HMO medical plan to elect this dental coverage. With KPIC s Group Dental Insurance Plan... You have the freedom to choose any licensed dentist. Each family member may visit a different dentist. Table of Allowances lists the specific dollar amount payable for each covered dental service. Your out-of-pocket costs will usually be lowest if you visit a Delta Dental PPO SM dentist. If you can t find a PPO dentist, a Delta Dental Premier dentist is your next best option. PPO and Premier dentists will not bill you above their Delta Dental contracted fees for covered services. You can find Delta Dental dentists at deltadentalins.com/directory. Orthodontic services (braces) are not covered. Claims paperwork is handled for you when you see one of Delta Dental s approximately 30,000 participating dentist locations in California. You may use your 10-digit Kaiser Permanente Medical Record Number (MRN) or your social security number as your ID number (to use your MRN, include the leading zeros). There is a deductible of $50 per person ($150 maximum per family); the maximum the program covers annually is $1,000 per person. There is no deductible for diagnostic and preventive services. Some procedures are subject to waiting period 2DeltaCare USA is a dental HMO program. With DeltaCare USA, you select a conveniently located network dentist to provide dental care for you and your family. A list of participating network dentists is enclosed for your review. Depending on the service you receive, you pay either a set dollar copayment or no copayment at all. With the DeltaCare USA program, there are no deductibles and no claim forms. You must be enrolled in Kaiser Permanente s traditional HMO medical plan to elect this dental coverage. DeltaCare USA Monthly* Quarterly* Self Only $ $ Self & One Party $ $ Self & Two or More $ $ *Good through December 31, 2015 Remember that you are enrolling in your selected dental plan for a period of one year. This does not apply if your employment is terminated. Payment for either the KPIC or DeltaCare USA plan may be automatically withdrawn from the checking, savings or credit union account you specify. To review a brochure of the program, visit kp.org/feds. If you are not already enrolled, for questions about KPIC s Dental Insurance Plan, contact Delta Dental at: Monday through Friday Your Kaiser Federal group number is # a.m. 4 p.m. Pacific time If you are already enrolled in the KPIC Dental Insurance Plan, for more information, please contact Delta Dental at: Monday through Friday Your Kaiser Federal group number is # a.m. 6 p.m. Pacific time For questions about DeltaCare USA, contact Delta Dental at: Monday through Friday Your Kaiser Federal group number is # a.m. 6 p.m. Pacific time

3 KPIC DENTAL INSURANCE PLAN One of your non-fehb Dental plan options is a dental insurance plan underwritten by KPIC, and administered by Delta Dental of California. KPIC s group dental insurance plan uses a Table of Allowances and allows you the freedom to see any licensed dentist of your choice. The Table of Allowances lists the dollar amount KPIC will pay for each covered dental service. A copy of the Table of Allowances is shown on pages 4 and 5 of this brochure. The monthly premiums for 2015 are listed below: Monthly Premiums* KPIC Dental Insurance Plan Self Only $ Self & One Party $ Self & Two or More $ *Good through December 31, 2015 These benefits are neither offered nor guaranteed under contract with the FEHB Program. NOTE: This is only a brief description of your coverage. A certificate of insurance and schedule of coverage setting forth the terms and conditions of your coverage will be sent to you after you enroll. The dental coverage described in this section of the brochure is underwritten by Kaiser Permanente Insurance Company, a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP). ABOUT KPIC S DENTAL INSURANCE PLAN If you re concerned about the cost of dental treatment for you and your family, you should know about KPIC s group dental insurance plan. With a low monthly premium, KPIC s group dental insurance plan allows you to budget for your annual dental costs. You can do this because KPIC s dental insurance plan contains a Table of Allowances listing the specific dollar amount KPIC will pay for each covered dental service. Since you receive in advance the complete Table of Allowances for the plan, you ll know exactly how much of your treatment will be covered. Because dental fees do vary by dentist, it may be to your advantage to compare your dentist s fees prior to making an appointment. WHO CAN JOIN As a Federal employee or a Federal retiree enrolled in one of Kaiser Permanente s Plans, you and your eligible dependents are eligible for coverage under KPIC s group dental insurance plan. Your eligible dependents include your lawful spouse and children under 26 years old, including stepchildren and children placed with you for adoption or foster care. A child 26 years of age or older may continue to be eligible as a dependent if incapable of self-support because of physical handicap or mental retardation that commenced prior to age 26, provided that the person is legally residing with and dependent upon the eligible member, and Delta Dental receives notice of the disability. FREE CHOICE OF DENTISTS Many dental plans restrict your choice of dentists to one from a limited network. But with KPIC s group dental insurance plan, you may go to any licensed dentist. You and your covered dependents may even choose to go to different dentists. You can find Delta Dental dentists at deltadentalins.com/directory. To use KPIC s group dental insurance plan, simply make an appointment with the dentist of your choice. Be sure to give the dental office your Kaiser Federal group number and social security number or Medical Record Number (MRN). SPECIAL ADVANTAGES FROM DELTA DENTAL DENTISTS KPIC s group dental insurance plan is administered by Delta Dental of California, and you get special advantages when you go to one of the more than 30,000 Delta Dental dentist locations in California. These participating dentists have agreed to handle all your claims paperwork and to charge you no more than their Delta Dental contracted fees. As KPIC s administrator, Delta Dental reimburses these dentists directly, so you are responsible only for the amount of the charge that exceeds the covered amount shown in the Table of Allowances and any deductible, non-covered services and/or amount over the annual maximum. Your out-of-pocket costs will usually be lowest if you visit a Delta Dental PPO SM dentist. If you can t find a PPO dentist, a Delta Dental Premier dentist is your next best option. PPO and Premier dentists will not bill you above their Delta Dental contracted fees for covered services (no balance billing ). You may use your 10-digit Kaiser Permanente Medical Record Number (MRN) or your social security number as your ID number (to use your MRN, include the leading zeros). Find Delta Dental dentists at deltadentalins.com/directory. If you go to a non-participating dentist (a dentist not contracted with Delta Dental), you are responsible for the entire charge and 1

4 2 must submit a claim to Delta Dental for reimbursement. Delta Dental will reimburse you directly for the amount shown in the Table of Allowances. Since a majority of California s dentists are Delta Dental dentists, your current dentist is probably already participating. Ask your dentist if he or she is a Delta Dental dentist. PREDICTABLE COSTS With KPIC s group dental insurance plan you know exactly how much KPIC will pay for a covered dental service. Just refer to the Table of Allowances on pages 4 and 5 of this brochure to see how much KPIC will pay for each covered dental service. NO DEDUCTIBLE ON DIAGNOSTIC AND PREVENTIVE SERVICES Your calendar year deductible is $50 per person, up to a maximum of $150 for the family. There is no deductible on diagnostic and preventive services. Your benefits cover a maximum of $1,000 of dental services for each covered enrollee per calendar year. When you enroll in KPIC s group dental insurance plan, you are enrolling for a period of one year. This does not apply if your employment is terminated. WAITING PERIODS Some of the covered dental services listed in the Table of Allowances are subject to a waiting period. This is the period of time that you and your covered dependents are required to have been continuously covered under KPIC s group dental insurance plan before a specific dental service will be a covered benefit. Consult the Table of Allowances on pages 4 and 5 of this brochure for the specific dental services that are subject to a waiting period. n BENEFITS KPIC s group dental insurance plan covers the following benefits when they are provided by a licensed dentist and when necessary and customary by the standards of generally accepted dental practice: I. DIAGNOSTIC AND PREVENTIVE BENEFITS Diagnostic: oral examinations x-rays diagnostic casts biopsy/tissue examinations specialist consultations Preventive: prophylaxis treatments (cleanings) fluoride treatments space maintainers Limitations on Diagnostic and Preventive Benefits Benefits for oral examinations are limited to two exams in any calendar year while the patient is covered under any KPIC dental insurance plan. Prophylaxis treatments are limited under General Limitations. II. Full mouth x-rays are covered only after five years have elapsed following any prior provision of full mouth x-rays under any KPIC dental insurance plan. Bitewing x-rays are covered on request by the dentist, but not more than twice in a calendar year for children through 18, and once in a calendar year for adults, while the patient is an eligible person under any KPIC dental insurance plan. BASIC BENEFITS Oral surgery: extractions and certain other surgical procedures, including pre- and postoperative care Restorative: Endodontic: Periodontic: Sealants: amalgam, synthetic porcelain and plastic restorations (fillings) for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay) treatment of the tooth pulp (root canal treatment) Emergency palliative treatment treatment of gums and bones supporting the teeth protective coating for posterior molar teeth Limitations on Basic Benefits Periodontal procedures which include prophylaxis are limited under General Limitations. Sealants are available for first molars for eligible persons through age 8 and for second molars for eligible persons through age 15. The benefit includes the application of sealants only to permanent first and second molars with no caries (decay), with no restorations and with the occlusal surface intact. The sealants benefit does not include the repair or replacement of a sealant on any tooth within two years of its application. III. CROWNS, INLAYS, ONLAYS AND CAST RESTORATION BENEFITS Crowns, inlays, onlays and cast restorations will be covered when teeth cannot be restored with amalgam, synthetic porcelain or plastic restorations. IV. Limitations on Crowns, Inlays, Onlays and Cast Restoration Benefits Crowns, inlays, onlays and cast restorations will be replaced only after five years have elapsed following any prior provision under any KPIC dental insurance plan. PROSTHODONTIC BENEFITS Procedures for construction or repair of fixed bridges, partial or complete dentures. Limitations on Prosthodontic Benefits Prosthodontic treatment is subject to a six-month waiting period. See Table of Allowances for further reference.

5 Prosthodontic appliances that were provided under any KPIC program will be replaced only after five (5) years have passed, except when KPIC determines that there is such extensive loss of remaining teeth or change in supporting tissue that the existing fixed bridge or denture cannot be made satisfactory. Fixed prosthodontic appliances are limited to Enrollees age 16 and older. Replacement of a prosthodontic appliance not provided under a KPIC program will be made if KPIC determines it is unsatisfactory and cannot be made satisfactory. KPIC group dental insurance plan will pay the listed allowance toward the dentist s fee for a standard cast chrome or acrylic partial denture or a standard complete denture. (A standard complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials.) KPIC will not pay for implants (artificial teeth implanted into or on bone or gums), their removal or other associated procedures, but KPIC will credit the cost of a crown, pontic or standard complete or partial denture toward the cost of the implant associated appliance i.e., the implant supported crown or denture. The implant appliance is not covered. V. GENERAL LIMITATIONS PROPHYLAXIS TREATMENTS AND OPTIONAL SERVICES Benefits under this insurance plan shall include only the first two prophylaxis treatments (cleanings) or single procedures which include prophylaxis, or combination thereof, provided to a patient in any calendar year while he or she is an eligible person under any KPIC dental insurance plan. If an eligible person selects a more expensive plan of treatment than is customarily provided, or specialized techniques rather than standard procedures, KPIC will pay the listed allowance for the lesser procedure, and the patient is responsible for the remainder of the dentist s fee (examples: a crown where a silver filling would restore the tooth or a precision denture where a standard denture would suffice). VI. GENERAL EXCLUSIONS Treatment of injuries covered by Workers Compensation or Employer s Liability Laws. Services which are provided to the Covered Person by any Federal or State Governmental Agency or are provided without cost to the Covered Person by any municipality, county or other political subdivision, unless this exclusion is prohibited by law. Services for congenital (hereditary) or developmental (following birth) malformations, including but not limited to cleft palate, upper and lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), except those services provided to newborn children for medically diagnosed congenital defects or birth abnormalities. Treatment to stabilize teeth, treatment to restore tooth structure lost from wear (abrasion, erosion), or treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion. Examples include but are not limited to: equilibration, periodontal splinting, occlusal adjustments or occlusal guards and abfraction. Any Single Procedure, provided prior to the date the Enrollee became eligible for services under this program. Prescribed drugs, medication, pain killers, antimicrobial agents, or experimental/investigational procedures. Experimental procedures. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the Provider for treatment in any such facility. Charges for anesthesia, except for general anesthesia administered by a licensed Provider in connection with covered oral surgery procedures. Extraoral grafts (grafting of tissues from outside the mouth to oral tissues). Services for implants (prosthetic appliances placed into or on the bone of the upper or lower jaw to retain or support dental prosthesis) their removal or other associated procedures. Services for any disturbance of the temporomandibular (jaw) joints or associated musculature, nerves and other tissues (TMJ). Replacement of existing restoration for any purpose other than active tooth decay. Intravenous sedation, occlusal guards and complete occlusal adjustment. Hypnosis. Dental practice administrative services including but not limited to, preparation of claims, any non-treatment phase of dentistry such as provision of an antiseptic environment, sterilization of equipment or infection control, or any ancillary materials used during the routine course of providing treatment such as cotton swabs, gauze, bibs, masks or relaxation techniques such as music. Charges for speech therapy. Charges for lost or stolen appliances. Services for which no charge is normally made in the absence of insurance. Charges incurred for oral hygiene instruction, a plaque control program, preventive control programs including home care times, dietary instruction, x-ray duplications, cancer screening, tobacco counseling or broker appointments. Orthodontic treatment. 3

6 Treatment plans that are more expensive than those customarily provided or specialized techniques used instead of standard procedures; for example, a precision denture where a standard denture would suffice. Maxillofacial prosthetics. Provisional and/or temporary restorations except an interim removable partial denture is covered only to replace extracted anterior permanent teeth during the healing period. Cosmetic surgery or procedures for purely cosmetic reasons. Laboratory processed crowns for Enrollees under age 12. Fixed bridges and removable partials for Enrollees under age 16. Interim implants. Indirectly fabricated resin-based inlays and onlays. Treatment by someone other than a Provider or a person who by law may work under a Provider s direct supervision. Services or supplies covered by any other health plan of the Contract holder. Procedures having a questionable prognosis based on a dental consultant s professional review of the submitted documentation. Any tax imposed (or incurred) by a government, state or other entity, in connection with any fees charged for Benefits provided under the Contract, will be the responsibility of the Enrollee and not a covered benefit. Deductibles, amounts over plan maximums and/or any service not covered under the dental plan. Services covered under the dental plan but exceed Benefit limitations or are not in accordance with processing policies in effect at the time the claim is processed. Procedures not shown on the Table of Allowances. To determine how much your out-of-pocket costs will be and what services will be covered, ask your dentist to obtain a pre-treatment estimate from Delta Dental. 3.1

7 Notes 3.2

8 4 KPIC Dental Insurance Plan 2015 Table of Allowances The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to your Certificate of Insurance for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered. Text that appears in italics below is specifically intended to clarify the delivery of benefits under the Delta Dental program and is not to be interpreted as CDT 2015 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. Code Description Allowance Code Description Allowance D0100-D0999 DIAGNOSTIC Clinical oral evaluations D0120 Periodic oral evaluation established patient D0140 Limited oral evaluation problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation limited, problem focused (established patient; not post-operative visit) D0180 Comprehensive periodontal evaluation new or established patient Pre-diagnostic services D0190 Screening of a patient D0191 Assessment of a patient Diagnostic imaging D0210 Intraoral complete series of radiographic images D0220 Intraoral periapical first radiographic image D0230 Intraoral periapical each additional radiographic image D0240 Intraoral occlusal radiographic image D0250 Extraoral first radiographic image D0260 Extraoral each additional radiographic image D0270 Bitewing single radiographic image D0272 Bitewings two radiographic images D0273 Bitewings three radiographic images D0274 Bitewings four radiographic images D0277 Vertical bitewings 7 to 8 radiographic images D0290 Posterior-anterior or lateral skull and facial bone survey radiographic image D0330 Panoramic radiographic image Oral pathology laboratory D0472 Accession of tissue, gross examination,preparation and transmission of written report D0473 Accession of tissue, gross and microscopic examination, preparation and transmission written report D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report D1000-D1999 PREVENTIVE Dental prophylaxis D1110 Prophylaxis adult D1120 Prophylaxis child Topical fluoride treatment (office procedure) D1206 Topical application of fluoride varnish D1208 Topical application of fluoride excluding varnish Other preventive services D1351 Sealant per tooth D1352 Preventive resin restoration in a moderate to high caries risk patient permanent tooth Space maintenance (passive appliances) D1510 Space maintainer fixed unilateral D1515 Space maintainer fixed bilateral D1520 Space maintainer removable unilateral D1525 Space maintainer removable bilateral D1555 Removal of fixed space maintainer D2000-D2999 RESTORATIVE Restorative procedures are subject to a 6 month waiting period Amalgam restorations (including polishing) D2140 Amalgam one surface, primary or permanent D2150 Amalgam two surfaces, primary or permanent D2160 Amalgam three surfaces, primary or permanent D2161 Amalgam four or more surfaces, primary or permanent Resin-based composite restorations-direct D2330 Resin-based composite one surface, anterior D2331 Resin-based composite two surfaces, anterior D2332 Resin-based composite three surfaces, anterior D2335 Resin-based composite four or more surfaces or involving incisal angle(anterior) D2390 Resin-based composite crown, anterior D2391 Resin-based composite one surface, posterior D2392 Resin-based composite two surfaces, posterior D2393 Resin-based composite three surfaces, posterior D2394 Resin-based composite four or more surfaces posterior Inlay/onlay restorations D2510 Inlay metallic one surface D2520 Inlay metallic two surfaces D2530 Inlay metallic three or more surfaces D2542 Onlay metallic two surfaces D2543 Onlay metallic three surfaces D2544 Onlay metallic four or more surfaces D2650 Inlay resin-based composite one surface D2651 Inlay resin-based composite two surfaces D2652 Inlay resin-based composite three or more surfaces D2662 Onlay resin-based composite two surfaces D2663 Onlay resin-based composite three surfaces D2664 Onlay resin-based composite four surfaces Crowns single restoration only D2710 Crown resin-based composite (indirect) D2712 Crown 3/4 resin-based composite (indirect) D2720 Crown resin with high noble metal D2721 Crown resin with predominantly base metal D2722 Crown resin with noble metal D2740 Crown porcelain/ceramic substrate D2750 Crown porcelain fused to high noble metal D2751 Crown porcelain fused to predominantly base metal D2752 Crown porcelain fused to noble metal D2780 Crown 3/4 cast high noble metal D2781 Crown 3/4 cast predominantly base metal D2782 Crown 3/4 cast noble metal D2790 Crown full cast high noble metal D2791 Crown full cast predominantly base metal D2792 Crown full cast noble metal D2794 Crown titanium Other restorative services D2910 Recement or re-bond inlay, onlay, veneer or partial coverage restoration D2915 Recement re-bond indirectly fabricated or prefabricated post and core D2920 Recement or re-bond crown D2921 Reattachment of tooth fragment, incisal edge or cusp D2929 Prefabricated porcelain/ceramic crown primary tooth D2930 Prefabricated stainless steel crown primary tooth D2931 Prefabricated stainless steel crown permanent tooth D2932 Prefabricated resin crown D2933 Prefabricated stainless steel crown with resin window D2934 Prefabricated esthetic coated stainless steel crown primary tooth D2950 Core buildup, including any pins when required D2951 Pin retention per tooth, in addition to restoration D2952 Post and core in addition to crown, indirectly fabricated D2954 Prefabricated post and core in addition to crown D2960 Labial veneer (resin laminate) chairside D2961 Labial veneer (resin laminate) laboratory D2962 Labial veneer (porcelain laminate) laboratory D2980 Crown repair necessitated by restorative material failure D3000-D3999 ENDODONTICS Endodontic procedures are subject to a 6 month waiting period Pulpotomy D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament D3221 Pulpal debridement, primary or permanent teeth D3222 Partial pulpotomy for apexogenesis permanent tooth with incomplete root development Endodontic therapy on primary teeth D3230 Pulpal therapy (resorbable filling) anterior, primary tooth (excluding final restoration) D3240 Pulpal therapy (resorbable filling) posterior, primary tooth (excluding final restoration) Endodontic therapy (including treatment plan, clinical procedures and follow-up care) D3310 Endodontic therapy, anterior tooth (excluding final restoration) D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) D3330 Endodontic therapy, molar tooth (excluding final restoration) Endodontic retreatment D3346 Retreatment of previous root canal therapy anterior D3347 Retreatment of previous root canal therapy bicuspid D3348 Retreatment of previous root canal therapy molar Apexification/recalcification procedures D3351 Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption etc.) D3352 Apexification/recalcification interim medication replacement D3353 Apexification/recalcification final visit (includes completed root canal therapy apical closure/calcific repair of perforations, root resorption, etc) Apicoectomy/periradicular services D3410 Apicoectomy anterior D3421 Apicoectomy bicuspid (first root) D3425 Apicoectomy molar (first root) D3426 Apicoectomy (each additional root) D3427 Periradicular surgery without apicoectomy D3430 Retrograde filling per root D3450 Root amputation per root Other endodontic procedures D3920 Hemisection (including any root removal), not including root canal therapy D4000-D4999 PERIODONTICS Periodontic procedures are subject to a 6 month waiting period Surgical services (including usual postoperative services) D4210 Gingivectomy or gingivoplasty four or more contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty one to three contiguous teeth or tooth bounded spaces per quadrant D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure,per tooth D4240 Gingival flap procedure, including rootplaning four or more contiguousteeth or tooth bounded spaces per quadrant D4241 Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant D4245 Apically positioned flap D4249 Clinical crown lengthening hard tissue D4260 Osseous surgery (including elevation of a full thickness flap and closure) four or more contiguous teeth or tooth bounded spaces per quadrant D4261 Osseous surgery (including elevation of a full thickness flap and closure) one to three contiguous teeth or tooth bounded spaces per quadrant D4263 Bone replacement graft first site in quadrant D4264 Bone replacement graft each additional site in quadrant D4266 Guided tissue regeneration resorbable barrier, per site D4267 Guided tissue regeneration nonresorbable barrier, per site (includes membrane removal) D4268 Surgical revision procedure, per tooth D4270 Pedicle soft tissue graft procedure D4273 Subepithelial connective tissue graft procedures, per tooth D4277 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft D4278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site Non-surgical periodontal services D4341 Periodontal scaling and root planing four or more teeth per quadrant D4342 Periodontal scaling and root planing one to three teeth per quadrant D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis Other periodontal services D4910 Periodontal maintenance D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) D5000 D5899 PROSTHODONTICS (REMOVABLE) Prosthodontic Removable procedures are subject to a 12 month waiting period Complete dentures (including routine post-delivery care) D5110 Complete denture maxillary D5120 Complete denture mandibular D5130 Immediate denture maxillary D5140 Immediate denture mandibular The above CDT 2015 codes and nomenclature are copyright of the American Dental Association. Note: This Appendix represents codes and nomenclature excerpted from the version of Current Dental Terminology (CDT) in effect on the date that this Contract or amendment was issued. CDT coding and nomenclature are the copyright of the American Dental Association, and have been accepted as the standard for data transmission purposes under federal Administrative Simplification regulations. For the purposes of this Appendix, Delta Dental s administration of Benefits, Limitations and Exclusions under this Contract will at all times be based on the current version of CDT whether or not a revised Appendix B is provided. Notes in italic type have been added by Delta Dental for clarification.

9 Code Description Allowance Code Description Allowance Partial dentures (including routine post-delivery care) D5211 Maxillary partial denture resin base (including any conventional clasps, rests and teeth) D5212 Mandibular partial denture resin base (including any conventional clasps, rests and teeth) D5213 Maxillary partial denture cast metal framework with resin denture bases (including any D5214 conventional clasps, rests and teeth) 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) D5281 Removable unilateral partial denture one piece cast metal (including clasps and teeth) Adjustments to dentures D5410 Adjust complete denture maxillary D5411 Adjust complete denture mandibular D5421 Adjust partial denture maxillary D5422 Adjust partial denture mandibular Repairs to complete dentures D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) Repairs to partial dentures D5610 Repair resin denture base D5620 Repair cast framework D5630 Repair or replace broken clasp D5640 Replace broken teeth per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture Denture rebase procedures D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture Denture reline procedures D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5740 Reline maxillary partial denture (chairside) D5741 Reline mandibular partial denture (chairside) D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5760 Reline maxillary partial denture (laboratory) D5761 Reline mandibular partial denture (laboratory) Interim prosthesis D5820 Interim partial denture (maxillary) D5821 Interim partial denture (mandibular) Other removable prosthetic services D5850 Tissue conditioning maxillary D5851 Tissue conditioning mandibular D5863 Overdenture complete maxillary D5864 Overdenture partial maxillary D5865 Overdenture complete mandibular D5866 Overdenture partial mandibular D6200 D6999 PROSTHODONTICS, FIXED Each retainer and each pontic constitutes a unit in a fixed partial denture Fixed prosthodontic procedures are subject to a 6 month waiting period Fixed partial denture pontics D6210 Pontic cast high noble metal D6211 Pontic cast predominantly base metal D6212 Pontic cast noble metal D6214 Pontic titanium D6240 Pontic porcelain fused to high noble metal D6241 Pontic porcelain fused to predominantly base metal D6242 Pontic porcelain fused to noble metal D6250 Pontic resin with high noble metal D6251 Pontic resin with predominantly base metal D6252 Pontic resin with noble metal Fixed partial denture retainers inlays/onlays D6545 Retainer cast metal for resin bonded fixed prosthesis D6549 Resin retainer for resin bonded fixed prosthesis D6602 Inlay cast high noble metal, two surfaces D6603 Inlay cast high noble metal, three or more surfaces D6604 Inlay cast predominantly base metal, two surfaces D6605 Inlay cast predominantly base metal, three or more surfaces D6606 Inlay cast noble metal, two surfaces D6607 Inlay cast noble metal, three or more surfaces D6610 Onlay cast high noble metal, two surfaces D6611 Onlay cast high noble metal, three or more surfaces D6612 Onlay cast predominantly base metal, two surfaces D6613 Onlay cast predominantly base metal, three or more surfaces D6614 Onlay cast noble metal, two surfaces D6615 Onlay cast noble metal, three or more surfaces D6624 Inlay titanium D6634 Onlay titanium Fixed partial denture retainers crowns D6720 Crown resin with high noble metal D6721 Crown resin with predominantly base metal D6722 Crown resin with noble metal D6750 Crown porcelain fused to high noble metal D6751 Crown porcelain fused to predominantly base metal D6752 Crown porcelain fused to noble metal D6780 Crown 3/4 cast high noble metal D6781 Crown 3/4 cast predominantly base metal D6782 Crown 3/4 cast noble metal D6790 Crown full cast high noble metal D6791 Crown full cast predominantly base metal D6792 Crown full cast noble metal D6794 Crown titanium Other fixed partial denture services D6930 Recement or re-bond fixed partial denture D6940 Stress breaker D6980 Fixed partial denture repair necessitated by restorative material failure D7000 D7999 ORAL AND MAXILLOFACIAL SURGERY The folllowing procedures are subject to a 6 month waiting period Extractions (includes local anesthesia, suturing, if needed, and routine postoperative care) D7111 Extraction, coronal remnantsdeciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical extractions (includes local anesthesia, suturing, if needed, and routine postoperative care) D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth soft tissue D7230 Removal of impacted tooth partially bony D7240 Removal of impacted tooth completely bony D7250 Surgical removal of residual tooth roots (cutting procedure) Other surgical procedures D7260 Oroantral fistual closure D7261 Primary closure of a sinus perforation D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) D7280 Surgical access of unerupted tooth D7285 Incisional biopsy of oral tissue hard (bone, tooth) D7286 Incisional biopsy of oral tissue soft Alveoloplasty surgical preparation of ridge for dentures D7310 Alveoloplasty in conjunction with extractions per quadrant D7311 Alveoloplasty in conjunction with extractions one to three teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions per quadrant D7321 Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant Vestibuloplasty D7340 Vestibuloplasty ridge extension (secondary epithelialization) D7350 Vestibuloplasty ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) Surgical excision of soft tissue lesions D7411 Excision of benign lesion greater than 125 cm D7465 Destruction of lesion(s) by physical or chemical method, by report Surgical excision of intra-osseous lesions D7440 Excision of malignant tumor lesion diameter up to 1.25 cm D7441 Excision of malignant tumor lesion diameter greater than 1.25 cm D7450 Removal of benign odontogenic cyst or tumor lesion diameter up to 125 cm D7451 Removal of benign odontogenic cyst or tumor lesion diameter greater than 125 cm D7460 Removal of benign nonodontogenic cyst or tumor lesion diameter up to 125 cm D7461 Removal of benign nonodontogenic cyst or tumor lesion diameter greater than 125 cm Excision of bone tissue D7471 Removal of lateral exostosis (maxilla or mandible) D7472 Removal of torus palatinus D7473 Removal of torus mandibularis D7485 Surgical reduction of osseous tuberosity D7490 Radical resection of maxilla or mandible....1, Surgical incision D7510 Incision and drainage of abscess intraoral soft tissue D7520 Incision and drainage of abscess extraoral soft tissue D7530 Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue D7540 Removal of reaction-producing foreign bodies, musculoskeletal system D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body Treatment of fractures simple D7610 Maxilla open reduction (teeth immobilized, if present) D7620 Maxilla closed reduction (teeth immobilized, if present) D7630 Mandible open reduction (teeth immobilized, if present) D7640 Mandible closed reduction (teeth immobilized, if present) D7650 Malar and/or zygomatic arch open reduction D7660 Malar and/or zygomatic arch closed reduction D7670 Alveolus closed reduction may include stabilization of teeth D7680 Facial bones complicated reduction with fixation and multiple surgical approaches , Treatment of fractures compound D7710 Maxilla open reduction D7720 Maxilla closed reduction D7730 Mandible open reduction...1, D7740 Mandible closed reduction D7750 Malar and/or zygomatic arch open reduction D7760 Malar and/or zygomatic arch closed reduction D7770 Alveolus open reduction stabilization of teeth D7780 Facial bones complicated reduction with fixation and multiple surgical approaches , Reduction of dislocation and management of other temporomandibular joint dysfunctions D7810 Open reduction of dislocation D7820 Closed reduction of dislocation D7830 Manipulation under anesthesia Repair of traumatic wounds D7910 Suture of recent small wounds up to 5 cm Complicated suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure) D7911 Complicated suture up to 5 cm D7912 Complicated suture greater than 5 cm Other repair procedures D7960 Frenulectomy also known as frenectomy or frenotomy separate procedure not incidental to another procedure D7970 Excision of hyperplastic tissue per arch D7971 Excision of pericoronal gingiva D7972 Surgical reduction of fibrous tuberosity D7980 Sialolithotomy D7981 Excision of salivary gland, by report...1, D7982 Sialodochoplasty D7983 Closure of salivary fistula D9000 D9999 ADJUNCTIVE GENERAL SERVICES Unclassified treatment D9110 Palliative (emergency) treatment of dental pain-minor procedure Anesthesia D9220 Deep sedation/general anesthesia first 30 minutes D9221 Deep sedation/general anesthesia each additional 15 minutes Professional visits D9310 Consultation diagnostic service provided by dentist or physician other than requesting dentist or physician D9430 Office visit for observation (during regularly scheduled hours) no other services performed D9440 Office visit after regularly scheduled hours Miscellaneous services D9930 Treatment of complications (post-surgical) unusual circumstances, by report D9951 Occlusal adjustment limited Drugs D9610 Therapeutic parenteral drug, single administration D9612 Therapeutic parenteral drugs, two or more administrations, different medications The above CDT 2015 codes and nomenclature are copyright of the American Dental Association. Note: This Appendix represents codes and nomenclature excerpted from the version of Current Dental Terminology (CDT) in effect on the date that this Contract or amendment was issued. CDT coding and nomenclature are the copyright of the American Dental Association, and have been accepted as the standard for data transmission purposes under federal Administrative Simplification regulations. For the purposes of this Appendix, Delta Dental s administration of Benefits, Limitations and Exclusions under this Contract will at all times be based on the current version of CDT whether or not a revised Appendix B is provided. Notes in italic type have been added by Delta Dental for clarification. 5

10 n How to enroll in KPIC s Dental Insurance Plan 1) Complete the enrollment form on page 7, or you also have the option to enroll online by visiting If you are already a Kaiser Permanente member, please include a copy of your Kaiser Permanente ID card. If you are not yet a Kaiser Permanente member, please include a copy of your Medical Enrollment Form (Form SF 2809). You must be a Federal member of Kaiser Permanente to enroll. 2) Sign the form to authorize automatic payment from your checking, savings or credit union account. Be sure to enclose a voided blank check or deposit form from this account. Call your bank to obtain the automatic deposit routing number and write the number on the payment authorization form. 3) Return the first month s payment and enrollment materials by December 21, 2014, to: KPIC Federal Employee Group Dental Insurance Plan Wolfpack Insurance Services, Inc. P.O. Box 720 Belmont, CA ) If your payment and enrollment materials are received by KPIC s Administrator by December 21, 2014, your effective date of coverage (including your eligible dependents) will be January 1, n Monthly Rates for Calendar Year 2015: One person... $ Two persons... $ Three or more persons... $ n Payment of Monthly Charges The dental coverage described in this brochure will not become effective until KPIC or its Administrator receives the initial premium from the eligible Federal Employee. The due date for subsequent premiums is the 10th day of each month. The Insured agrees to pay subsequent premiums no later than 31 days following the premium due date, unless the Insured has given notice requesting termination of dental coverage under the Certificate in accordance with the Termination section of the Certificate. The Insured will be responsible for the payment of the pro rata premium for the time dental coverage under the Certificate was in force during the 31-day grace period. n Billing To ensure timely processing of your benefits and claim payments, it is necessary that premiums be paid during the month prior to the coverage month. There are two payment options. You may choose to have your monthly premiums deducted from your checking, savings or credit union account on the 10th of each month prior to the coverage month (e.g., April dues will be deducted on March 10). Please complete the Automatic Payment Authorization form on page 8 of this brochure. If you do not have a checking, savings or credit union account, you may submit payments via a personal check, money order, etc. When completing the enrollment form, write DIRECT PAY across the top of page 8, Automatic Payment Authorization. You will be sent monthly invoices to submit with your premium payments. Premiums must be paid by the 10th of each month prior to the coverage month. 6

11 Instructions: Please complete this Group Dental Enrollment Form and return a signed copy with your first month s payment by December 21, 2014 to: KAISER PERMANENTE INSURANCE COMPANY Oakland, California Wolfpack Insurance Services Inc. P.O. Box 720 Belmont, CA GROUP DENTAL ENROLLMENT FORM ENROLLMENT FORM Enrollment Information Failure to accurately complete the questions on the enrollment form may delay the effective date of your coverage under the KPIC Dental Insurance Plan. Your full name Social Security Number or 10-digit Kaiser Permanente Medical Record Number Mailing address City State ZIP Male Female Date of birth / / Phone number ( ) Please list eligible dependents to be covered in addition to yourself: Spouse Male Female Date of birth / / Child Male Female Date of birth / / Child Male Female Date of birth / / Child Male Female Date of birth / / Child Male Female Date of birth / / Child Male Female Date of birth / / Enrollment Coverage not elected below will be assumed refused if not specifically refused. Yes, I would like to enroll in the Kaiser Permanente Insurance Company (KPIC) Group Dental Plan for Federal Employees. I understand that enrollment is voluntary. By electing to enroll, I agree to participate in the KPIC Trust (and/or any successor Trust), which holds the KPIC Group Dental Policy. I understand that to be eligible for the Plan, I must be enrolled along with any of my dependents to be covered, in Kaiser Permanente s Traditional HMO Plan for Federal Enrollees. I further understand that my continued eligibility, and that of my covered dependents, is contingent on our continued enrollment in Kaiser Permanente s Traditional HMO Plan for Federal Enrollees. I also understand that some covered dental services are subject to waiting periods. I certify that to the best of my knowledge and belief, any information disclosed on this enrollment form, is accurate and that my answers are correct, true and complete. No, I do not wish to participate. I understand that I will not be entitled to any benefits under the KPIC Group Dental Plan and will not be able to enroll until the next annual renewal period. (Coverage not elected will be assumed refused, even if not specifically refused.) Signature of enrollee Date KPIC Enroll 9793 (rev. 7/2012) 7

12 AUTOMATIC PAYMENT AUTHORIZATION Banking information: Checking account Savings account Credit union account The first two numbers of the RTN must be 01 through 12 or 21 Routing Transit Number (RTN): (Verify this number with your bank) Account number: Branch name Branch number Telephone number ( ) Automatic Payment Authorization Please enclose a voided check or preprinted deposit slip from the account checked. I (we-hereby authorize Delta/Wolfpack Insurance Services, Inc. to charge the applicable monthly dues for 12 months of dental coverage to my account designated above. I understand that coverage will become and remain effective only if there are sufficient funds at the time of the deduction. I agree to comply with the terms as outlined in the certificate of insurance. This authority is to remain in full force and effect until I notify Delta Dental in writing 30 days prior to termination. (My bank is authorized to make corrections if any should be necessary.) Signature of enrollee Signature of spouse Date Date James Smith Main St /0000 Anyplace, NY Attach check here PAY TO THE ORDER OF Wolfpack Insurance Services, Inc $ DOLLARS ANYPLACE BANK Anyplace, NY For 1: : RTN NOTE: Staple the check in this space. Use only a check from the account that corresponds to the banking information above. Payment instructions: Payments are due retroactively to the month you and/or dependents enrolled in the Kaiser Federal Employee Dental Plan plus one month in advance. After payment and application are received, the first automatic payment will occur on the 10th of the following month and each month thereafter. (Please enclose a voided check or preprinted deposit slip from the account checked.) CHECKS OR MONEY ORDERS MUST BE PAYABLE TO WOLFPACK INSURANCE SERVICES, INC. To enroll in the KPIC DENTAL insurance plan, please complete the enrollment form in this brochure (page 7-and enclose the first month s payment (payable to Wolfpack Insurance Services, Inc.). Return the enrollment form and the first month s payment by December 21, 2014 to: Wolfpack Insurance Services, Inc. P.O. Box 720 Belmont, CA Make checks payable to Wolfpack Insurance Services, Inc. Staple your check in the space provided on this form. Use only a check that corresponds to the banking information you have provided. Payment instructions: Payments are due retroactively to the month you and/or dependents enrolled in the Kaiser Federal Employee Dental Plan plus one month in advance. After payment and application are received, the first automatic payment will occur on the 10th of the following month and each month thereafter. 8

13 DeltaCare USA One of your non-fehb Dental benefit options, DeltaCare USA, is provided by Delta Dental of California, and administered by Delta Dental Insurance Company. With DeltaCare USA, you select a conveniently located network dentist to provide dental care for you and your family. You pay a set copayment or, for some services, no copayment. There are no deductibles and no claim forms to worry about. The dues for 2015 are listed below: Dues* Monthly* Quarterly* Self Only $ $ Self & One Party $ $ Self & Two or More $ $ *Good through December 31, These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are made available to all enrollees and family members of this Plan. NOTE: This is only a brief summary of the program. An Evidence of Coverage stating the terms of your program will be sent to you upon enrollment. Please read the following information so you will know how to get dental care under the DeltaCare USA program. n About DeltaCare USA The DeltaCare USA program is an HMO dental plan that focuses on preventing dental problems and assuring the delivery of quality dental care. Delta Dental of California has contracted with a network of dental offices. A listing of these offices is included for you in the back of this brochure, or you may go to deltadentalins.com to search for a conveniently located network dentist. The network of dental offices is composed of established dental practices. n WHO CAN JOIN As a Federal member of Kaiser Permanente, you are eligible to join the DeltaCare USA program. Your eligible dependents include your lawful spouse and dependent children under 26 years old, including stepchildren and children placed with you for adoption or foster care. A child 26 years of age or older may continue to be eligible as a dependent if incapable of self-support because of physical handicap or mental retardation that commenced prior to age 26, provided that the person is legally residing with and dependent upon the eligible member, and Delta Dental receives notice of the disability. n EMERGENCY SERVICES Dental emergencies are covered up to a maximum of $ per emergency, per Enrollee, less applicable copayment(s). n NO CLAIM FORMS The dental location you choose provides all primary dental services. There are no claim forms to complete or percentage of usual charges for you to pay. n NO DEDUCTIBLES With the DeltaCare USA program, there are no required deductibles to pay, so your benefits begin immediately. n NO DOLLAR LIMIT OF DENTAL BENEFITS No annual maximum, except for accidental injury. n PRE-EXISTING CONDITION RESTRICTIONS Pre-existing conditions are not excluded in the DeltaCare USA program. Exception: work in progress. n PREPAID PROGRAM SAVES ON DENTAL COSTS Your out-of-pocket savings could be substantial. You know the exact cost prior to treatment, allowing you to predict future dental expenses. When you enroll in this program, you are enrolling for a period of one year. This does not apply if your employment is terminated. n QUALITY REVIEW OF DENTAL PROVIDERS On-site audits of participating dental locations ensure that established standards of quality are maintained. n SPECIALTY SERVICES The DeltaCare USA program offers services in dental specialty areas. These include periodontics (treatment of diseased gums and bone), endodontics (root canal therapy) and oral surgery procedures. Specialty services must be referred by the assigned network dentist and some procedures may require preauthorization. If an enrollee is assigned to a dental school clinic for specialist services, those services may be provided by a dentist, a dental instructor, a clinician or a dental student under the supervision of a dentist. The DeltaCare USA program provides benefits for listed dental procedures (subject to the provisions, limitations and exclusions shown in the Combined Evidence of Coverage and Disclosure Form) if care is provided by your assigned network dentist. 9

14 10 When you enroll in DeltaCare USA, you select a participating dental office from the network directory to take care of dental needs for you and your family. After you have enrolled, you will receive an Evidence of Coverage booket that fully describes the benefits of your dental program, a welcome letter and a DeltaCare USA membership card. The welcome letter will have the address and telephone number of your participating network dentist. To receive all necessary dental care covered by the program, simply call your selected dental office to make an appointment. Remember to always contact your network dentist. Dental services which are not performed by this dentist or are not authorized in advance by Delta Dental will not be covered under the DeltaCare USA program. LIMITATIONS OF BENEFITS (PARTIAL LIST) Prophylaxis is limited to two treatments at no cost in any 12 consecutive months; additional treatments are available with a $27 patient copayment. Full upper and/or lower dentures are not to exceed one each in any five-year period. Replacement of partial dentures within any five-year period is not covered unless necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible. Denture relines are limited to one per denture during any 12 consecutive months. Periodontal treatments (root planing/subgingival curettage) are limited to five quadrants during any 12 consecutive months. Bitewing x-rays are limited to not more than one series of four films in any six-month period. Full mouth x-rays are limited to one set every 24 consecutive months. Sealants are limited to noncarious, nonrestored permanent first and second molars through age 15. EXCLUSIONS (PARTIAL LIST) The following services are not covered. General anesthesia and the services of a special anesthesiologist. Cosmetic dental care. Dental conditions arising out of and due to the enrollee s employment or for which Workers Compensation is payable. Services which are provided to the enrollee by state government or agency thereof, or are provided without cost to the enrollee by any municipality, county or other subdivisions. Dental services performed in a hospital and related hospital fees. Loss or theft of fixed and removable prosthetics (crowns, bridges, full or partial dentures). Dental expenses incurred in connection with any dental procedure started after termination of eligibility of coverage. Any service that is not specifically listed as a covered procedure. Dental expenses incurred in connection with any dental procedure started prior to the enrollee s eligibility. Example: teeth prepared for crowns, root canals in progress, orthodontics. Congenital malformations. Dispensing of drugs not normally supplied in a dental office. Cases in which, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained or where the prognosis is poor or guarded. Dental services received from any dental office other than the assigned dental office unless expressly authorized in writing by Delta Dental or as cited under Emergency Services. Prophylactic removal of impactions (asymptomatic nonpathological). Consultations for noncovered services. Implant placement or removal, appliances placed on, or services associated with, implants. ORTHODONTIC LIMITATIONS AND EXCLUSIONS (PARTIAL LIST) Orthodontic treatment must be provided by a member of the orthodontic network. Program benefits cover 24 months of usual and customary orthodontic treatment. If your coverage is terminated for any reason, and you are receiving any orthodontic treatment at the time, your copayment shall be $2,300 for dependent children to age 19 (and $2,500 for covered adults and dependent adult children) and be prorated over the number of months to completion of the treatment. Terms and conditions are arranged between you and the orthodontist. A consultation fee may be charged if treatment is not required, or if you elect not to start treatment after a diagnosis and consultation have been completed. Pre-, mid- and post-treatment records (cephalometric x-rays, tracings, photographs and study models) are excluded. Retreatment of orthodontic cases is excluded. Lost, stolen or broken appliances are excluded. Orthodontic treatment in progress is limited to new DeltaCare USA enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.

15 Schedule A Description of Benefits and Copayments The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to Schedule B for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered. Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT 2015 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. Code Description Enrollee Pays Code Description Enrollee Pays D0100-D0999 I. DIAGNOSTIC D0120 Periodic oral evaluation established patient... No Cost D0140 Limited oral evaluation problem focused... No Cost D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver... No Cost D0150 Comprehensive oral evaluation new or established patient No Cost D0160 Detailed and extensive oral evaluation problem focused, by report... No Cost D0170 Re-evaluation limited, problem focused (established patient; not post-operative visit) No Cost D0171 Re-evaluation post-operative office visit... No Cost D0180 Comprehensive periodontal evaluation new or established patient... No Cost D0190 Screening of a patient... No Cost D0191 Assessment of a patient... No Cost D0210 Intraoral complete series of radiographic images limited to 1 series every 24 months No Cost D0220 Intraoral periapical first radiographic image... No Cost D0230 Intraoral periapical each additional radiographic image... No Cost D0240 Intraoral occlusal radiographic image... No Cost D0270 Bitewing single radiographic image... No Cost D0272 Bitewings two radiographic images... No Cost D0273 Bitewings three radiographic images... No Cost D0274 Bitewings four radiographic images limited to 1 in 6 months... No Cost D0330 Panoramic radiographic image... No Cost D0460 Pulp vitality tests... No Cost D0470 Diagnostic casts... No Cost D0472 Accession of tissue, gross examination, preparation and transmission of written report No Cost D0473 Accession of tissue, gross and microscopic examination, preparation and transmission written report... No Cost D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report.. No Cost D0999 Unspecified diagnostic procedure, by report includes office visit, per visit (in addition to other services) D1000-D1999 II. PREVENTIVE D1110 Prophylaxis cleaning adult 2 per 12 month period... No Cost D1110 Additional cleaning adult (within the 6 month period) D1120 Prophylaxis cleaning child 2 per 12 month period... No Cost D1120 Additional cleaning (child within the 6 month period) D1206 Topical application of fluoride varnish child to age 19; 2 D1206 or D1208 per 12 month period... No Cost D1208 Topical application of fluoride excluding varnish child to age 19; 2 D1206 or D1208 per 12 month period No Cost D1330 Oral hygiene instructions... No Cost D1351 Sealant per tooth limited to permanent molars through age D1352 Preventive resin restoration in a moderate to high caries risk patient permanent tooth limited to permanent molars through age D1353 Sealant repair per tooth limited to permanent molars through age D1510 Space maintainer fixed unilateral D1515 Space maintainer fixed bilateral D1520 Space maintainer removable unilateral D1525 Space maintainer removable bilateral D1550 Re-cementation of space maintainer D1555 Removal of fixed space maintainer D2000 D2999 III. RESTORATIVE Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures. D2140 Amalgam one surface, primary or permanent D2150 Amalgam two surfaces, primary or permanent D2160 Amalgam three surfaces, primary or permanent D2161 Amalgam four or more surfaces, primary or permanent D2330 Resin-based composite one surface, anterior D2331 Resin-based composite two surfaces, anterior D2332 Resin-based composite three surfaces, anterior D2335 Resin-based composite four or more surfaces or involving incisal angle (anterior) D2390 Resin-based composite crown, anterior D2391 Resin-based composite one surface, posterior 1, 2... Optional D2392 Resin-based composite two surfaces, posterior 1, 2... Optional D2393 Resin-based composite three surfaces, posterior 1, 2... Optional D2394 Resin-based composite four or more surfaces posterior 1, 2... Optional D2510 Inlay metallic one surface 2, 3... Optional D2520 Inlay metallic two surfaces 2, 3... Optional D2530 Inlay metallic three or more surfaces 2, 3... Optional D2542 Onlay metallic two surfaces 2, 3... Optional D2543 Onlay metallic three surfaces 2, 3... Optional D2544 Onlay metallic four or more surfaces 2, 3... Optional D2610 Inlay porcelain/ceramic one surface 2, 3... Optional D2620 Inlay porcelain/ceramic two surfaces 2, 3... Optional D2630 Inlay porcelain/ceramic three or more surfaces 2, 3... Optional D2642 Onlay porcelain/ceramic two surfaces 2, 3... Optional D2643 Onlay porcelain/ceramic three surfaces 2, 3... Optional D2644 Onlay porcelain/ceramic four or more surfaces 2, 3... Optional D2650 Inlay resin-based composite one surface 2, 3... Optional D2651 Inlay resin-based composite two surfaces 2, 3... Optional D2652 Inlay resin-based composite three or more surfaces 2, 3... Optional D2662 Onlay resin-based composite two surfaces 2, 3... Optional D2663 Onlay resin-based composite three surfaces 2, 3... Optional D2664 Onlay resin-based composite four or more surfaces 2, 3... Optional D2710 Crown resin-based composite (indirect) 3, D2712 Crown ¾ resin-based composite (indirect) 3, D2720 Crown resin with high noble metal 3, 4, D2721 Crown resin with predominantly base metal 3, D2722 Crown resin with noble metal 3, D2740 Crown porcelain/ceramic substrate 3, D2750 Crown porcelain fused to high noble metal 3, 4, D2751 Crown porcelain fused to predominantly base metal 3, D2752 Crown porcelain fused to noble metal 3, D2780 Crown ¾ cast high noble metal 3, D2781 Crown ¾ cast predominantly base metal D2782 Crown ¾ cast noble metal D2790 Crown full cast high noble metal 3, D2791 Crown full cast predominantly base metal D2792 Crown full cast noble metal D2794 Crown titanium 3, D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restorations D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core D2920 Re-cement or re-bond crown D2921 Reattachment of tooth fragment, incisal edge or cusp (anterior) D2929 Prefabricated porcelain/ceramic crown primary tooth anterior primary tooth D2930 Prefabricated stainless steel crown primary tooth D2931 Prefabricated stainless steel crown permanent tooth D2932 Prefabricated resin crown anterior primary tooth D2933 Prefabricated stainless steel crown with resin window anterior primary tooth D2940 Protective restoration D2941 Interim therapeutic restoration primary dentition D2949 Restorative foundation for an indirect restoration D2950 Core buildup, including any pins when required D2951 Pin retention per tooth, in addition to restoration D2952 Post and core in addition to crown, indirectly fabricated includes canal preparation D2953 Each additional indirectly fabricated post same tooth includes canal preparation D2954 Prefabricated post and core in addition to crown base metal post; includes canal preparation D2957 Each additional prefabricated post same tooth base metal post; includes canal preparation D2970 Temporary crown (fractured tooth) palliative treatment only... No Cost D2980 Crown repair necessitated by restorative material failure D2981 Inlay repair necessitated by restorative material failure D2982 Onlay repair necessitated by restorative material failure D2983 Veneer repair necessitated by restorative material failure D2990 Resin infiltration of incipient smooth surface lesions limited to permanent molars through age D3000 D3999 IV. ENDODONTICS D3110 Pulp cap direct (excluding final restoration) D3120 Pulp cap indirect (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament D3221 Pulpal debridement, primary and permanent teeth D3222 Partial pulpotomy for apexogenesis permanent tooth with incomplete root development D3230 Pulpal therapy (resorbable filling) anterior, primary tooth (excluding final restoration) D3240 Pulpal therapy (resorbable filling) posterior, primary tooth (excluding final restoration) D3310 Root canal endodontic therapy, anterior tooth (excluding final restoration) D3320 Root canal endodontic therapy, bicuspid tooth (excluding final restoration) D3330 Root canal endodontic therapy, molar (excluding final restoration) D3346 Retreatment of previous root canal therapy anterior D3347 Retreatment of previous root canal therapy bicuspid D3348 Retreatment of previous root canal therapy molar D3351 Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption etc.) D3410 Apicoectomy anterior D3421 Apicoectomy bicuspid (first root) D3425 Apicoectomy molar (first root) D3426 Apicoectomy (each additional root) D3427 Periradicular surgery without apicoectomy D3430 Retrograde filling per root D3450 Root amputation per root not covered in conjunction with a hemisection D4000 D4999 V. PERIODONTICS Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D4210 Gingivectomy or gingivoplasty four or more contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty one to three contiguous teeth or tooth bounded spaces per quadrant D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth D4240 Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant D4241 Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant D4260 Osseous surgery (including elevation of a full thickness flap and closure) four or more contiguous teeth or tooth bounded spaces per quadrant D4261 Osseous surgery (including elevation of a full thickness flap and closure) one to three contiguous teeth or tooth bounded spaces per quadrant D4341 Periodontal scaling and root planing four or more teeth per quadrant limited to 5 quadrants during any 12 consecutive months D4342 Periodontal scaling and root planing one to three teeth per quadrant limited to 5 quadrants during any 12 consecutive months D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis limited to 1 treatment in any 12 consecutive months D4910 Periodontal maintenance limited to 2 treatments each 12 month period D4921 Gingival irrigation per quadrant... No Cost D5000 D5899 VI PROSTHODONTICS (REMOVABLE) D5110 Complete denture maxillary 7, D5120 Complete denture mandibular 7, D5130 Immediate denture maxillary 7, D5140 Immediate denture mandibular 7, D5211 Maxillary partial denture resin base (including any conventional clasps, rests and teeth) 7,

16 12 Code Description Enrollee Pays D5212 Mandibular partial denture resin base (including any conventional clasps, rests and teeth) 7, D5213 Maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 7, D5214 Mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 7, D5281 Removable unilateral partial denture one piece cast metal (including clasps and teeth) D5410 Adjust complete denture maxillary D5411 Adjust complete denture mandibular D5421 Adjust partial denture maxillary D5422 Adjust partial denture mandibular D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5620 Repair cast framework D5630 Repair or replace broken clasp D5640 Replace broken teeth per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5740 Reline maxillary partial denture (chairside) D5741 Reline mandibular partial denture (chairside) D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5760 Reline maxillary partial denture (laboratory) D5761 Reline mandibular partial denture (laboratory) D5820 Interim partial denture (maxillary) limited to initial placement of interim partial denture/ stayplate to replace extracted anterior teeth during healing D5821 Interim partial denture (mandibular) limited to initial placement of interim partial denture/stayplate to replace extracted anterior teeth during healing D5850 Tissue conditioning maxillary 7, D5851 Tissue conditioning mandibular 7, D5900 D5999 VII. MAXILLOFACIAL PROSTHETICS Not Covered D6000-D6199 VIII. IMPLANT SERVICES Not Covered D6200 D6999 IX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge]) D6210 Pontic cast high noble metal 5, D6211 Pontic cast predominantly base metal D6212 Pontic cast noble metal D6240 Pontic porcelain fused to high noble metal 4, 5, D6241 Pontic porcelain fused to predominantly base metal 4, D6242 Pontic porcelain fused to noble metal 4, D6245 Pontic porcelain/ceramic 2, Optional D6250 Pontic resin with high noble metal 4, 5, D6251 Pontic resin with predominantly base metal 4, D6252 Pontic resin with noble metal 4, D6545 Retainer cast metal for resin bonded fixed prosthesis 4, D6549 Resin retainer for resin bonded fixed prosthesis D6600 Inlay porcelain/ceramic, two surfaces 2, Optional D6601 Inlay porcelain/ceramic, three or more surfaces 2, Optional D6602 Inlay cast high noble metal, two surfaces 2, Optional D6603 Inlay cast high noble metal, three or more surfaces 2, Optional D6604 Inlay cast predominantly base metal, two surfaces 2, Optional D6605 Inlay cast predominantly base metal, three or more surfaces 2, Optional D6606 Inlay cast noble metal, two surfaces 2, Optional D6607 Inlay cast noble metal, three or more surfaces 2, Optional D6608 Onlay porcelain/ceramic, two surfaces 2, Optional D6609 Onlay porcelain/ceramic, three or more surfaces 2, Optional D6610 Onlay cast high noble metal, two surfaces 2, Optional D6611 Onlay cast high noble metal, three or more surfaces 2, Optional D6612 Onlay cast predominantly base metal, two surfaces 2, Optional D6613 Onlay cast predominantly base metal, three or more surfaces 2, Optional D6614 Onlay cast noble metal, two surfaces 2, Optional D6615 Onlay cast noble metal, three or more surfaces 2, Optional D6720 Crown resin with high noble metal 4, 5, D6721 Crown resin with predominantly base metal 4, D6722 Crown resin with noble metal 4, D6740 Crown porcelain/ceramic 2, Optional D6750 Crown porcelain fused to high noble metal 4, 5, D6751 Crown porcelain fused to predominantly base metal 4, D6752 Crown porcelain fused to noble metal 4, D6780 Crown ¾ cast high noble metal 5, D6781 Crown ¾ cast predominantly base metal D6782 Crown ¾ cast noble metal D6790 Crown full cast high noble metal 5, D6791 Crown full cast predominantly base metal D6792 Crown full cast noble metal D6930 Re-cement or re-bond fixed partial denture D6940 Stress breaker D6980 Fixed partial denture repair necessitated by restorative material failure D7000 D7999 X. ORAL AND MAXILLOFACIAL SURGERY Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D7111 Extraction, coronal remnants deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth soft tissue D7230 Removal of impacted tooth partially bony D7240 Removal of impacted tooth completely bony D7241 Removal of impacted tooth completely bony, with unusual surgical complications D7250 Surgical removal of residual tooth roots (cutting procedure) D7251 Coronectomy intentional partial tooth removal D7286 Incisional biopsy of oral tissue soft does not include histopathologic examination or other pathology laboratory procedures Code Description Enrollee Pays D7310 Alveoloplasty in conjunction with extractions per quadrant D7311 Alveoloplasty in conjunction with extractions one to three teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions per quadrant D7321 Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant D7471 Removal of lateral exostosis (maxilla or mandible) per site D7510 Incision and drainage of abscess intraoral soft tissue D7960 Frenulectomy also known as frenectomy or frenotomy separate procedure not incidental to another procedure D8000 D8999 XI. ORTHODONTICS D8070 Comprehensive orthodontic treatment of the transitional dentition child or adolescent to age , D8080 Comprehensive orthodontic treatment of the adolescent dentition adolescent toto age , D8090 Comprehensive orthodontic treatment of the adult dentition adults, including dependent adult children age 19 and older , D8660 Pre-orthodontic treatment examination to monitor growth and development not to be charged with any other consultation procedure(s) No Cost D8680 Orthodontic retention (removal of appliances, construction and placement of retainers) 13 No Cost D8999 Unspecified orthodontic procedure, by report includes the START-UP FEE, which includes initial examination, diagnosis, consultation and initial banding D9000 D9999 XII. ADJUNCTIVE GENERAL SERVICES D9110 Palliative (emergency) treatment of dental pain-minor procedure D9211 Regional block anesthesia... No Cost D9212 Trigeminal division block anesthesia... No Cost D9215 Local anesthesia in conjunction with operative or surgical procedures... No Cost D9219 Evaluation for deep sedation or general anesthesia... No Cost D9310 Consultation diagnostic service provided by dentist or physician other than requesting dentist or physician (specialist only)... No Cost D9430 Office visit for observation (during regularly scheduled hours) no other services performed No Cost D9440 Office visit after regularly scheduled hours D9931 Cleaning and inspection of a removable appliance... No Cost Procedures not listed above are not covered; however, may be available at the Contract Dentist s filed fees. Filed fees means the Contract Dentist s fees on file with Delta Dental. Questions regarding these fees should be directed to Delta Dental s Customer Service department at The above CDT 2015 codes and nomenclature are copyright of the American Dental Association. Note: This Schedule represents codes and nomenclature excerpted from the version of Current Dental Terminology (CDT) in effect on the date that this Contract or Amendment was issued. CDT coding and nomenclature are the copyright of the American Dental Association, and have been accepted as the standard for data transmission purposes under federal Administrative Simplification regulations. For the purposes of this Schedule, Delta Dental s administration of Benefits, Limitations and Exclusions under this Contract will at all times be based on the current version of CDT whether or not a revised Appendix B is provided. Notes in italic type have been added by Delta Dental for clarification. FOOTNOTES 1 An amalgam is the benefit. 2 Optional is defined as any alternative procedure presented by the Contract Dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee, and is subject to the Limitations and Exclusions of the program. The applicable charge to the Enrollee is the difference between the Contract Dentist s filed fee for the Optional procedure and the filed fee for the covered procedure, plus any applicable Copayment. Filed fees means the Contract Dentist s fees on file with Delta Dental. Questions regarding the DeltaCare USA program should be directed to Delta Dental s Customer Service department at Replacement is subject to a limitation requiring the existing restoration to be 5+ years old. 4 Porcelain and other tooth-colored materials on molars are considered a material upgrade with a maximum additional charge to the Enrollee of $ Base or noble metal is the benefit. High noble metal (precious), if used, will be charged to the Enrollee at the additional maximum cost to the Enrollee of $ per tooth. If an indirectly fabricated post and core is made of high noble metal, an additional fee up to $ per tooth will be charged for the upgrade. This charge also applies to a titanium crown.

17 6 A benefit for permanent teeth only. 7 Includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement, if the Enrollee continues to be eligible and the service is provided at the Contract Dentist s facility where the denture was originally delivered. 8 Replacement is subject to a limitation requiring the existing denture to be 5+ years old. 9 Limited to 1 per denture during any 12 consecutive months. 10 Replacement is subject to a limitation requiring the existing bridge to be 5+ years old. 11 Listed Copayment covers up to 24 months of active orthodontic treatment excluding the services listed for D8999 (Start-up fee). Beyond 24 months of active treatment, an additional monthly fee of $75.00 applies. 12 In the event comprehensive orthodontic treatment is not required or is declined by the Enrollee, a fee of $25.00 will apply. The Enrollee is also responsible for any incurred orthodontic diagnostic record fees. 13 Includes adjustments and/or office visits up to 24 months. After 24 months, a monthly fee of $75.00 applies. SCHEDULE B LIMITATIONS Of BENEFITS 1. Full mouth x-rays are limited to one set every 24 consecutive months and include any combination of periapicals, bitewings and/or panoramic film. 2. Bitewing x-rays are limited to not more than one series of four films in any six month period. 3. Diagnostic casts are limited to aid in diagnosis by the Contract Dentist for covered benefits. 4. If a biopsy is preauthorized by Delta Dental for an oral surgeon, then examination of the resulting biopsy specimen is covered under codes D0472, D0473 or D0474 and available at no additional cost. 5. Prophylaxis or periodontal maintenance is limited to two procedures each 12 month period. 6. Benefits for sealants include the application of sealants only to permanent first and second molars with no decay, with no restorations and with the occlusal surface intact, for first molars and second molars through age 15. Benefits for sealants do not include the repair or replacement of a sealant on any tooth within three years of its application. 7. A filling is a benefit for the removal of decay, for minor repairs of tooth structure or to replace a lost filling. 8. A crown is a benefit when there is insufficient tooth structure to support a filling or to replace an existing crown that is nonfunctional or non-restorable and meets the five year limitation (see Limitation #12). 9. A covered metallic inlay, onlay, crown or fixed partial denture (bridge) using base or noble metal is available for listed Copayment(s). If the Enrollee elects to have high noble metal used instead, the maximum additional cost of this material upgrade is $ per tooth or pontic. For an indirectly fabricated post and core, the benefit is for base or noble metal. If the Enrollee elects to have a high noble metal indirectly fabricated post and core instead, the maximum additional cost of this material upgrade is $ per tooth. 10. For molars, a covered crown or unit of a fixed partial denture (bridge) is a full cast metal restoration without porcelain or other tooth-colored material. If the Enrollee elects to have porcelain, porcelain- fused-to-metal, resin or resin-with-metal used instead, the maximum additional cost for this toothcolored material upgrade is $ per molar. 11. If a porcelain margin is also chosen by the Enrollee for a covered porcelain-fused-to-metal crown, the maximum additional cost for this laboratory upgrade is $ The replacement of an existing inlay, onlay, crown, fixed partial denture (bridge) or a removable full or partial denture is covered when: a. The existing restoration/bridge/denture is no longer functional and cannot be made functional by repair or adjustment, and (continued) 13

18 b. Either of the following: b. The existing non-functional restoration/bridge/denture was placed five or more years prior to its replacement, or b. If an existing partial denture is less than five years old, but must be replaced by a new partial denture due to the loss of a natural tooth, which cannot be replaced by adding another tooth to the existing partial denture. 13. A direct or indirect pulp cap is a benefit only on a vital permanent tooth with an open apex or a vital primary tooth. 14. With the exception of pulp caps and pulpotomies, endodontic procedures (e.g. root canal therapy, apicoectomy, retrofill, etc.) are only a benefit on a permanent tooth. 15. A therapeutic pulpotomy on a permanent tooth is limited to palliative treatment when the Contract Dentist is not performing root canal therapy. 16. Periodontal scaling and root planing are limited to five quadrants during any 12 month period. 17. Full mouth debridement (gross scale) is limited to one treatment in any 12 month period. 18. The benefit for the replacement of a missing posterior tooth (or teeth) is a removable partial denture. Coverage for the placement of a fixed partial denture (bridge) is optional except in the following cases: The sole tooth to be replaced in the arch is a permanent anterior tooth, provided it is not in connection with a partial denture on the same arch; or The new bridge would replace an existing, non-functional bridge utilizing the same abutment teeth, with no additional abutments or pontics with the exception of posterior cantilever bridges (see Limitation #12); or The abutment teeth are not being crowned solely for the purpose of supporting a pontic (each abutment tooth to be crowned must meet Limitation #8). 19. Relines, tissue conditioning and rebases are limited to one per denture during any 12 consecutive months. 20. Interim partial dentures (stayplates), in conjunction with fixed or removable appliances, are limited to: The replacement of extracted anterior teeth for adults during a healing period when the teeth cannot be added to an existing partial denture or The replacement of permanent tooth/teeth for children under 16 years of age. 21. Retained primary teeth shall be covered as primary teeth. 22. Excision of the frenum is a benefit only when it results in limited mobility of the tongue, it causes a large diastema between teeth or it interferes with a prosthetic appliance. 23. Benefits provided by a pediatric Dentist are limited to children through age seven following an attempt by the assigned Contract Dentist to treat the child and upon prior authorization by Delta Dental, less applicable Copayments. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis. 24. In cases of accidental injury, benefits available are described in Schedule B, Accident Injury Benefit. Damages to the hard and soft tissues of the oral cavity from normal masticatory (chewing) function, exclusive attrition and normal wear, will be covered as described in Schedules A, Description of Benefits and Copayments; and B, Limitations and Exclusions of Benefits. 25. Benefits for a soft tissue management program are limited to those parts, which are listed covered services listed on Schedule A. If an Enrollee declines non-covered services within a soft tissue management program, it does not eliminate or alter other covered benefits.es not eliminate or alter the benefit for covered services. 26. A new removable partial, complete or immediate denture includes after delivery adjustments and tissue conditioning at no additional cost for the first six months after placement if the Enrollee continues to be eligible and the service is provided at the Contract Dentist s facility where the denture was originally delivered. 27. An Optional procedure is defined as any alternative procedure presented by the Contract Dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee, and is subject to the limitations and exclusions of the program. The applicable charge to the Enrollee is the difference between the Contract Dentist s filed fees for the Optional procedure and the filed fees for the covered procedure, plus any applicable Copayment for the covered procedure. Optional treatment does not apply when alternative choices are benefits. Optional procedures include: The use of a tooth-colored material when restoring a posterior tooth with a filling, inlay or onlay; and Units in a fixed partial denture (bridge) made of porcelain/ ceramic, which is not fused to and supported by underlying cast metal. 28. Porcelain crowns, porcelain fused to metal or resin with metal type crowns are not a benefit for children under 16 years of age. An allowance will be made for a resin crown. (See Limitation #27). Filed fees means the Contract Dentist s fees on file with Delta Dental. Questions regarding these fees should be directed to Delta Dental s Customer Service department at

19 EXCLUSIONS Of BENEFITS 1. Any procedure that is not specifically listed under Schedule A, Descriptionefits and Copayments. 2. Dental conditions arising out of and due to Enrollee s employment for which Workers Compensation is paid. Services which are provided to the Enrollee by state government or agency thereof, or are provided without cost to the Enrollee by any municipality, county or other subdivision, except as provided in Section 1373(a) of the California Health and Safety Code. 3. All related fees for admission, use, or stays in a hospital, outpatient surgery center, extended care facility, or other similar care facility. 4. Loss or theft of full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges). 5. Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage. 6. Dental expenses incurred in connection with any dental procedure started before the Enrollee s eligibility with the DeltaCare USA program. Examples include: teeth prepared for crowns, root canals in progress, orthodontics. 7. Congenital malformations (e.g. congenitally missing teeth, supernumerary teeth, enamel and dentinal dysplasias, etc.), except for the treatment of newborn children with congenital defects or birth abnormalities. 8. Dispensing of drugs not normally utilized in the delivery of dental services. 9. Any procedure that in the professional opinion of the Contract Dentist: a. Has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/ or surrounding structures, or b. Is inconsistent with generally accepted standards for dentistry. 10. Dental services received from any dental facility other than the assigned Contract Dentist including the services of a dental specialist, unless expressly authorized in writing by Delta Dental or as cited under Emergency Services. To obtain written authorization, the Enrollee should call Delta Dental s Customer Service department at Consultations for non-covered benefits. 12. Implant placement or removal, appliances placed on or services associated with implants, including but not limited to prophylaxis and periodontal treatment. 13. Fixed partial dentures (bridges) for children under 16 years of age. 14. Restorations placed solely due to cosmetics, abrasions, attrition, erosion, restoring or altering vertical dimension, congenital or developmental malformation of teeth. 15. Appliances or restorations necessary to increase vertical dimension, replace or stabilize tooth structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings, equilibration or treatment of disturbances of the temporomandibular joint (TMJ). 16. An initial treatment plan which involves the removal and reestablishment of the occlusal contacts of 10 or more teeth with crowns, onlays, fixed partial dentures (bridges), or any combination of these is considered to be full mouth reconstruction under the DeltaCare USA program. Crowns, onlays and fixed partial dentures associated with such a treatment plan are not covered Benefits. This exclusion does not eliminate the benefit for other covered services. 17. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures. 18. Extraction of teeth, when teeth are asymptomatic/nonpathologic (no signs or symptoms of pathology or infection), including but not limited to the removal of third molars and orthodontic extractions. 19. Treatment or extraction of primary teeth when exfoliation (normal shedding and loss) is imminent. 15

20 ORTHODONTIC LIMITATIONS The DeltaCare USA program provides coverage for orthodontic treatment plans provided through Contract Orthodontists. The start-up fees and the cost to the Enrollee for the treatment plan are listed in Schedule A, Description of Benefits and Copayments and subject to the following: 1. Orthodontic treatment must be provided by a Contract Orthodontist. 2. Benefits cover 24 months of active comprehensive orthodontic treatment. Included is the initial examination, diagnosis, consultation, initial banding, 24 months of active treatment, de-banding and the retention phase of treatment. The retention phase includes the initial construction, placement and adjustment to retainers and office visits for a maximum of two years. 3. Treatment plans extending beyond 24 months of active treatment, or 24 months of the retention phase of treatment will be subject to a monthly office visit fee to the Enrollee not to exceed $75.00 per month. 4. Should an Enrollee s coverage be cancelled or terminated for any reason, and at the time of cancellation or termination be receiving any orthodontic treatment, the Enrollee and not Delta Dental will be responsible for payment of any balance due for treatment provided after cancellation or termination. In such a case the Enrollee s payment shall be based on a maximum of $2, for covered dependent children to age 19 and $2, for covered adults and dependent adult children age 19 and older. The amount will be prorated over the number of months to completion of the treatment and, will be payable by the Enrollee on such terms and conditions as are arranged between the Enrollee and the Contract Orthodontist. 5. If treatment is not required or the Enrollee chooses not to start treatment after the diagnosis and consultation has been completed by the Contract Orthodontist, the Enrollee will be charged a consultation fee of $25.00 in addition to diagnostic record fees. 6. Three recementations or replacements of a bracket/band on the same tooth or a total of five rebracketings/rebandings on different teeth during the covered course of treatment are benefits. If any additional recementations or replacements of brackets/bands are performed, the Enrollee is responsible for the cost at the Contract Orthodontist s filed fees. 7. Comprehensive orthodontic treatment (Phase II) consists of repositioning all or nearly all of the permanent teeth in an effort to make the Enrollee s occlusion as ideal as possible. This treatment usually requires complete fixed appliances; however, when the Contract Orthodontist deems it suitable, a European or removable appliance therapy may be substituted at the same Copayment amounts as for fixed appliances. 8. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases. Filed fees means the Contract Orthodontist s fees on file with Delta Dental. Questions regarding these fees should be directed to Delta Dental s Customer Service department at