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Schedule of Covered Services and Copayments First Smile - EarlyCare Plan Code Description Services when performed by a Dental Health Services participating dentist or specialist Code Description Copayment D0350 Oral/facial photographic images obtained intraorally or extraorally............................................................20 D0460 Pulp vitality tests - one test per visit.......................................20 D0470 Diagnostic casts.........................................................................20 D1110 Prophylaxis - adult - once every 6 months............................20 D1120 Prophylaxis - child - once every 6 months............................20 D1206 Topical application of fluoride varnish..................................20 D1208 Topical application of fluoride - frequency is based on age of enrollee, see limitations..........................................20 D1330 Oral hygiene instructions - Available for enrollees 8 and younger. Available once every 6 months, up to 2 times in a 12-month period..................................................20 D1351 Sealant - per tooth - See limitations for details about frequency.........................................................................20 D9543 Office Visit.................................................................................20 D9630 Other drugs and/or medicaments, by report........................20 D9930 Treatment of complications (post-surgical) - unusual circumstances, by report...........................................................20 Copayment Annual maximum.................................................................................None Deductible.....................................................................................................0 *Out-of-pocket maximum - Individual................................................350 *Out-of-pocket maximum - Family......................................................700 According to D9986 Missed appointment................................................ office policy According to D9987 Cancelled appointment........................................... office policy Specialty services covered.......................................................................Yes *For pediatric enrollees (18 years of age and under), all copayments for essential health benefits listed under Covered Services and Copayments apply to the member out-of-pocket maximum. Copayments for non-essential health benefits services, listed as Other Covered Services do not apply to the member out-of-pocket maximum. Basic Dental Care - Child Specialty services must be pre-authorized and are only available for children 18 and under. D1510 D1515 D1550 D1555 D2140 D2150 D2160 D2161 Dental Check-up For Children D0120 Periodic oral evaluation - established patient - once every 6 months...........................................................................20 D0140 Limited oral evaluation - problem focused............................20 D0150 Comprehensive oral evaluation - new or established patient.....................................................................20 D0190 Screening of a patient - limit of 2 per calendar year...........20 D0191 Assessment of a patient - limit of 2 per calendar year........20 D0210 Intraoral - complete series of radiographic images once in a 3-year period..............................................................20 D0220 Intraoral - periapical first radiographic image - once in a two-year period...................................................................20 D0230 Intraoral - periapical each additional radiographic image - once in a two-year period...........................................20 D0240 Intraoral - occlusal radiographic image..................................20 D0270 Bitewing - single radiographic image......................................20 D0272 Bitewings - two radiographic images......................................20 D0273 Bitewings - three radiographic images...................................20 D0274 Bitewings - four radiographic images - once every 12 months...................................................................................20 D0330 Panoramic radiographic image - once in a 3 year period..................................................................................20 D0340 Cephalometric radiographic image - once in a 2 year period..................................................................................20 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2710 D2910 D2915 D2920 D2929 D2930 Space maintainer - fixed - unilateral........................................30 Space maintainer - fixed - bilateral..........................................30 Re-cementation of space maintainer......................................30 Removal of fixed space maintainer.........................................30 Amalgam - one surface, primary or permanent....................30 Amalgam - two surfaces, primary or permanent..................30 Amalgam - three surfaces, primary or permanent................30 Amalgam - four or more surfaces, primary or permanent..............................................................................30 Resin-based composite - one surface, anterior.....................30 Resin-based composite - two surfaces, anterior....................30 Resin-based composite - three surfaces, anterior.................30 Resin-based composite - four or more surfaces or involving incisal angle (anterior).........................................30 Resin-based composite crown, anterior.................................30 Resin-based composite - one surface, posterior...................30 Resin-based composite - two surfaces, posterior..................30 Resin-based composite - three surfaces, posterior...............30 Resin-based composite - four or more surfaces, posterior......................................................................30 Crown - resin-based composite (indirect)..............................30 Recement inlay, onlay, or partial coverage restoration.........30 Recement cast or prefabricated post and core......................30 Recement crown........................................................................30 Prefabricated porcelain/ceramic crown – primary tooth.............................................................................30 Prefabricated stainless steel crown - primary tooth.............30 01.14WAFSECLX | Current Dental Terminology © 2015 American Dental Association. All rights reserved. 1 Code Description D2931 D2932 D2933 D2934 D2950 D2952 D2954 D3120 D3220 D3221 D3230 D3240 D3351 D3352 D3430 D4211 D4341 D4342 D4355 D4910 D5410 D5411 D5421 D5422 D5510 D5520 D5620 D5650 D5660 D5850 D5851 Copayment Code Description Prefabricated stainless steel crown - permanent tooth........30 Prefabricated resin crown.........................................................30 Prefabricated stainless steel crown with resin window........30 Prefabricated esthetic coated stainless steel crown - primary tooth...............................................................30 Core buildup, including any pins when required..................30 Post and core in addition to crown, indirectly fabricated...................................................................30 Prefabricated post and core in addition to crown................30 Pulp cap - indirect (excluding final restoration)....................30 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament - Not offered on permanent teeth...................................................................30 Pulpal debridement, primary and permanent teeth Not offered on primary teeth and excludes teeth 1, 16, 17, and 32.............................................................................30 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) - Only for permanent anterior teeth..........................................................30 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)............................30 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) - Only for permanent anterior teeth..............................................................................30 Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)........................................................................30 Retrograde filling - per root.....................................................30 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant...............................................................................30 Periodontal scaling and root planing - four or more teeth per quadrant - Available for patients 13 and older. Once per quadrant per two year period......................30 Periodontal scaling and root planing - one to three teeth per quadrant - Available for patients 13 and older. Once per quadrant per two year period......................30 Full mouth debridement to enable comprehensive evaluation and diagnosis...........................................................30 Periodontal maintenance (limited to 1 per 3 months).........30 Adjust complete denture - maxillary.......................................30 Adjust complete denture - mandibular...................................30 Adjust partial denture - maxillary............................................30 Adjust partial denture - mandibular........................................30 Repair broken complete denture base....................................30 Replace missing or broken teeth - complete denture (each tooth)..................................................................30 Repair cast framework..............................................................30 Add tooth to existing partial denture.....................................30 Add clasp to existing partial denture......................................30 Tissue conditioning, maxillary.................................................30 Tissue conditioning, mandibular.............................................30 Copayment D5899 Unspecified removable prosthodontic procedure, by report......................................................................................30 D6930 Recement fixed partial denture................................................30 D7111 Extraction, coronal remnants - deciduous tooth..................30 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)........................................30 D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated.......................30 D7250 Surgical removal of residual tooth roots (cutting procedure)....................................................................30 D7283 Placement of device to facilitate eruption of impacted tooth...........................................................................30 D7286 Biopsy of oral tissue - soft.......................................................30 D7288 Brush biopsy - transepithelial sample collection..................30 D7510 Incision and drainage of abscess - intraoral soft tissue.......30 D7971 Excision of pericoronal gingiva..............................................30 D9110 Palliative (emergency) treatment of dental pain - minor procedure......................................................................30 D9221 Deep sedation/general anesthesia - each additional 15 minutes................................................................30 D9230 Inhalation of nitrous oxide / anxiolysis, analgesia...............30 D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes....................................................30 D9248 Non-intravenous conscious sedation.....................................30 D9440 Office visit - after regularly scheduled hours........................30 D9610 Therapeutic parenteral drug, single administration..............30 D9612 Therapeutic parenteral drugs, two or more administrations, different medications...................................30 D9920 Behavior management, by report............................................30 99201 Office/outpatient visit, new - When performed by your participating general dentist or contracted specialist..................................................................30 99211 Office/outpatient visit, established - When performed by your participating general dentist or contracted specialist..................................................................30 99231 Subsequent hospital care - When performed by your participating general dentist or contracted specialist..................................................................30 99241 Office consultation - When performed by your participating general dentist or contracted specialist...........30 99251 Inpatient consultation - When performed by your participating general dentist or contracted specialist...........30 Major Dental Care - Child D2720 D2721 D2722 D2740 D2750 D2751 D2752 D3310 2 Crown - resin with high noble metal....................................325 Crown - resin with predominantly base metal....................325 Crown - resin with noble metal.............................................325 Crown - porcelain/ceramic substrate...................................325 Crown - porcelain fused to high noble metal......................325 Crown - porcelain fused to predominantly base metal......325 Crown - porcelain fused to noble metal...............................325 Endodontic therapy, anterior tooth (excluding final restoration)...................................................325 Code Description Copayment Code Description D3320 Endodontic therapy, bicuspid tooth (excluding final restoration)...................................................325 D3330 Endodontic therapy, molar (excluding final restoration).......................................................................325 D3346 Retreatment of previous root canal therapy - anterior......325 D3347 Retreatment of previous root canal therapy - bicuspid.....325 D3348 Retreatment of previous root canal therapy - molar.........325 D3410 Apicoectomy - anterior - Only for anterior teeth...............325 D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant.............................................................................325 D5110 Complete denture - maxillary................................................325 D5120 Complete denture - mandibular............................................325 D5130 Immediate denture - maxillary...............................................325 D5140 Immediate denture - mandibular...........................................325 D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth).............................325 D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth).............................325 D5710 Rebase complete maxillary denture......................................325 D5711 Rebase complete mandibular denture..................................325 D5720 Rebase maxillary partial denture............................................325 D5721 Rebase mandibular partial denture........................................325 D5750 Reline complete maxillary denture (laboratory)..................325 D5751 Reline complete mandibular denture (laboratory)..............325 D5760 Reline maxillary partial denture (laboratory).......................325 D5761 Reline mandibular partial denture (laboratory)...................325 D5863 Overdenture – complete maxillary.......................................325 D5865 Overdenture – complete mandibular...................................325 D7220 Removal of impacted tooth - soft tissue.............................325 D7230 Removal of impacted tooth - partially bony.......................325 D7240 Removal of impacted tooth - completely bony..................325 D7241 Removal of impacted tooth - completely bony, with unusual surgical complications.....................................325 D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth................................325 D7280 Surgical access of an unerupted tooth.................................325 D7285 Biopsy of oral tissue - hard (bone, tooth)...........................325 D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant............325 D7321 Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant................325 D7410 Excision of benign lesion up to 1.25 cm.............................325 D7471 Removal of lateral exostosis (maxilla or mandible)............325 D7472 Removal of torus palatinus....................................................325 D7473 Removal of torus mandibularis.............................................325 D7485 Surgical reduction of osseous tuberosity.............................325 D7520 Incision and drainage of abscess - extraoral soft tissue..................................................................................325 D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue..................................................325 D7880 Occlusal orthotic device, by report.......................................325 D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure - Pre-authorization is not needed for members 6 and under.......................................................325 Copayment D7963 Frenuloplasty - Pre-authorization is not needed for members 6 and under.............................................................325 D7970 Excision of hyperplastic tissue - per arch............................325 D7972 Surgical reduction of fibrous tuberosity..............................325 D9220 Deep sedation/general anesthesia - first 30 minutes.........325 D9241 Intravenous conscious sedation/analgesia - first 30 minutes.................................................................................325 D9410 House/extended care facility call - Up to 2 calls per facility per provider..........................................................325 D9420 Hospital or ambulatory surgical center call - Up to 1 call per provider, per day.....................................................325 D9940 Occlusal guard, by report.......................................................325 Medically Necessary Orthodontia Copayments for medically necessary orthodontia apply to the member Out-of-Pocket Maximum. Medically necessary orthodontia - member pays $350/year prorated monthly starting with the first month of treatment, with a maximum lifetime copayment of $700. Orthodontic Services will only be approved for enrollees with a malocclusion associated with: a. Cleft lip and palate, cleft palate, or cleft lip with alveolar process involvement; b. Craniofacial anomalies for: • Hemifacial microsomia; • Craniosynostosis syndromes; • Arthrogryposis; or • Marfan syndrome. Must be prior approved. Orthodontia (Non-Medically Necessary) Copayments for non-essential health benefits services listed under Orthodontia (Non-Medically Necessary) do not apply to the member out-of-pocket maximum. D8210 Removable appliance therapy................................................250 D8220 Fixed appliance therapy..........................................................230 D8660 Pre-orthodontic treatment examination to monitor growth and development..........................................40 D8670 Periodic orthodontic treatment visit.......................................10 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)).........................315 D8690 Orthodontic treatment (alternative billing to a contract fee)..................................................................................0 D8691 Repair of orthodontic appliance.............................................50 D8693 Re-cement or re-bond fixed retainer......................................45 3 Code Description Copayment Code Description Other Covered Services Copayment D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.).......................300 D3355 Pulpal regeneration - initial visit............................................100 D3356 Pulpal regeneration - interim medication replacement......100 D3357 Pulpal regeneration - completion of treatment..................550 D4921 Gingival irrigation – per quadrant...........................................25 D5986 Fluoride gel carrier....................................................................30 D9210 Local anesthesia not in conjunction with operative or surgical procedures....................................................................10 D9211 Regional block anesthesia.........................................................40 D9212 Trigeminal division block anesthesia......................................75 D9215 Local anesthesia in conjunction with operative or surgical procedures......................................................................0 D9219 Evaluation for deep sedation or general anesthesia.............40 D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician......20 D9430 Office visit for observation (during regularly scheduled hours) - no other services performed....................................25 D9450 Case presentation, detailed and extensive treatment planning.......................................................................0 D9910 Application of desensitizing medicament.............................15 D9911 Application of desensitizing resin for cervical and/or root surface, per tooth..............................................................15 D9941 Fabrication of athletic mouthguard......................................125 D9942 Repair and/or reline of occlusal guard..................................75 D9951 Occlusal adjustment - limited..................................................35 D9952 Occlusal adjustment - complete............................................150 Copayments for non-essential health benefits services listed under, Other Covered Services do not apply to the member out-of-pocket maximum. D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver............................20 D0160 Detailed and extensive oral evaluation - problem focused, by report......................................................................40 D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit)........................15 D0171 Re-evaluation – post-operative office visit............................10 D0180 Comprehensive periodontal evaluation - new or established patient.....................................................................20 D0250 Extraoral - first radiographic image........................................10 D0260 Extraoral - each additional radiographic image......................6 D0277 Vertical bitewings - 7 to 8 radiographic images....................20 D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report..........................................................................25 D0415 Collection of microorganisms for culture and sensitivity.............................................................................35 D0425 Caries susceptibility tests..........................................................10 D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures......................................................................15 D0601 Caries risk assessment and documentation, with a finding of low risk.....................................................................15 D0602 Caries risk assessment and documentation, with a finding of moderate risk...........................................................15 D0603 Caries risk assessment and documentation, with a finding of high risk....................................................................15 D1310 Nutritional counseling for control of dental disease.............0 D1320 Tobacco counseling for the control and prevention of oral disease....................................................................................0 D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent tooth.....................................50 D1353 Sealant repair – per tooth...........................................................5 D1520 Space maintainer - removable - unilateral............................150 D1525 Space maintainer - removable - bilateral..............................250 D2940 Protective restoration................................................................35 D2941 Interim therapeutic restoration – primary dentition..............5 D2949 Restorative foundation for an indirect restoration...............30 D2951 Pin retention - per tooth, in addition to restoration............35 D2953 Each additional indirectly fabricated post - same tooth......90 D2955 Post removal.............................................................................140 D2957 Each additional prefabricated post - same tooth..................80 D3331 Treatment of root canal obstruction; non-surgical access..................................................................175 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth.............................................200 D3333 Internal root repair of perforation defects..........................150 Congenital Anomalies Coverage for the treatment of congenital anomalies is available utilizing the services and copayments listed above. For more detailed information on the terms of your coverage, please consult your Exclusions and Limitations document. Please note: The listed procedures and copayments apply when service is received at your participating general dentist. Not every dentist will perform all services. If your dentist refers you to a specialist, please contact your Member Service Specialist before proceeding. All procedures are available from Dental Health Services participating specialists. All specialty services must be preauthorized with Dental Health Services through a referral from your participating dentist. If you ever have questions about your dental coverage, call your Member Service Specialist at 855-495-0906. We are happy to help you. 4 Exclusions and Limitations b. A maximum of five surfaces per tooth for permanent posterior teeth, except for upper molars and a maximum of six surfaces per tooth for teeth 1, 2, 3, 14, 15 and 16; c. A maximum of six surfaces per tooth for resin-based composite restorations for permanent anterior teeth; d. An indirect crown once every 5 years, per tooth, for permanent anterior teeth for enrollees from 12 through 18 years of age. Must be pre-authorized; e. All recementations of permanent indirect crowns for enrollees from 12 through 18 years of age; f. Prefabricated stainless steel crowns for primary posterior teeth once every 3 years; g. Prefabricated stainless steel crowns for permanent posterior teeth excluding 1, 16, 17, and 32 once every 3 years; h. Core buildup, including pins, only on permanent teeth, when performed in conjunction with a crown; i. Cast post and core or prefabricated post and core, on permanent teeth when performed in conjunction with a crown. Limitations: Diagnostic Services are covered with the following limitations: a. Intraoral complete series (D0210) is covered once in a threeyear period unless a panoramic radiograph (D0330) for the same enrollee has been performed in the same three-year period. Additional D0210 and D0330 are only covered if deemed by an orthodontist or Oral Surgeon to be medically necessary (see e.); b. Medically necessary periapical x-rays that are not included in a complete series for diagnosis in conjunction with definitive treatment; c. An occlusal intraoral x-ray once in a two-year period; d. A maximum of four bitewing x-rays (once per quadrant) once every twelve months; e. Panoramic radiograph (D0330) in conjunction with four bitewings (D0274), once in a three-year period, only when an intraoral complete series (D0210) for the same enrollee has not been paid in the same three- year period. f. Radiographs with no specific limitation are on a case-by-case basis when medically necessary. g. Oral and facial photographic images (D0350) on a case-by-case basis. Periodontal Services are covered with the following limitations: a. Surgical periodontal services and post-operative care for ginigivectomy/gingivoplasty. b. Non-surgical periodontal scaling and root planing for teeth scaled that are periodontically involved, once per quadrant for enrollees aged 13 and older, per enrollee per two year period when preauthorized and evidenced by x-ray. c. Periodontal maintenance for enrollees aged 13 and older, once per enrollee, per 3 month period with pre-authorization. Preventive Services are covered with the following limitations: a. Dental Prophylaxis (D1110 & D1120) limited to once every 6 months for enrollees 18 and under; b. Topical Fluoride Treatment (D1208) including fluoride rinse, foam or gel, including disposable trays for enrollees: i. 6 years of age and younger up to 3 times per 12-month period per enrollee; ii. 7 to 18 years of age, up to 2 times per 12 month period per enrollee; iii. Up to 3 times in a 12-month period per enrollee during orthodontic treatment; iv. Additional applications on a case-by-case basis. c. Oral hygiene instruction for enrollees 8 and younger. The benefit must inc lude individualized oral hygiene instructions, tooth brushing techniques, flossing, and use of oral hygiene aids no more than once every 6 months, up to 2 times in a 12 month period. d. Sealants (D1351) are for enrollees 18 years or younger when used on mechanically and/or chemically prepared enamel surface once per tooth in a 3-year period. For developmentally disabled performed in a two-year period. e. Space Maintainers (D1510, D1515, D1550, D1555) for enrollees 12 years of age and younger for fixed unilateral or bilateral space maintenance subject to one space maintainer per quadrant, for primary molars A, B, I, J, K, L, S and T. i. Replacement space maintainers are covered on a case-by-case basis. ii. Removal of fixed space maintainers for enrollees 18 years of age or younger. Endodontic Services are covered with the following limitations: a. Therapeutic pulpotomy on primary teeth and pulpal debridement on permanent teeth only [excluding teeth 1, 16, 17, and 32]; b. Treatment with resorbable material for primary maxillary incisor teeth D, E, F, and G, if the entire root is present at treatment; c. Treatment for permanent anterior, bicuspid, and molar teeth [excluding teeth 1, 16, 17, and 32]. d. Retreatment for the removal of post, pin, old root canal filing material, and all procedures necessary to prepare the canal with placement of new filing material. Prosthodontic Services - Removable are covered with the following limitations: a. One resin based partial denture; replacement covered if provided at least three years after the seat date; b. One complete denture upper and lower and one replacement denture per lifetime after at least 5 years from the seat date; c. Rebasing and relining of complete or partial dentures once in a 3 year period, if performed at least 6 months from the seating date; d. Partial, complete and immediate dentures must be pre-approved. Other Limitations: a. Authorized treatment is rendered only by your selected participating dentist or participating specialist. Services provided by a dentist other than the enrollee’s designated participating dentist or participating specialist, except for emergency dental conditions, are not covered. b. All services performed must be medically necessary and consistent with a diagnosis of dental disease or condition. Restorative Services are covered with the following limitations: a. Two occlusal restorations for the upper molars on teeth 1, 2, 3, 14, 15, and 16 if, the restorations are anatomically separated by sound tooth structure; 5 licensed dentist for the relief of pain, swelling or bleeding. This does not include routine, extensive or postponable treatment. Emergency dental care is limited to palliative treatment. Enrollee must attempt to contact their plan dentist. When an enrollee’s plan dentist is not able to be reached, emergency treatment can be sought at any participating dentist. In cases where a participating dentist cannot be reached, the treatment for the emergency dental condition can be completed at any licensed dentist. Plan will reimburse for procedures submitted on a Post Service Emergency Dental Care Claim Form up to $150 per occurrence beyond all applicable copayments. m. Temporomandibular joint (TMJ) disorders and related disease treatment are limited to coverage for occlusal orthotic device for 12-20 months on a case by case basis. n. Medical necessity is defined under this plan as dental services and supplies provided by a participating dentist appropriate to the evaluation and treatment of disease, condition, illness or injury and consistent with the applicable standard of care. This does not include any service that is cosmetic in nature. c. Specialty services require a referral from your participating dentist and must be pre-authorized by Dental Health Services, including a referral to a pediatric dentist. d. Optional services (all cases in which the enrollee selects a plan of treatment that is considered unnecessary by the dentist). The enrollee is responsible for fee-for-service rates. This does not apply to standard covered restorative procedures which offer a choice of material. e. Upgraded services (cases in which the enrollee selects a plan of treatment that is considered an upgraded procedure) Dental Health Services’ upgrade charges would apply. f. Cosmetic dentistry – services for appearance only. This includes such services as the replacement of clinically acceptable amalgam fillings, veneers and bonding. g. Unsatisfactory patient-doctor relationship: Dental Health Services participating dentists reserve the right to limit or deny services to an enrollee who fails to follow the prescribed course of treatment, repeatedly fails to keep appointments, fails to pay applicable copayments, is abusive to the participating dentist or their staff, or obtains services by fraud or deception. h. Denturists - Enrollees may elect to travel to the nearest participating denturist for services. Enrollees may be able to receive services from a participating denturist as long as the service performed was within the lawful scope of the denturist’s license. i. Dental procedure that cannot be performed in the dental office due to the general health and/or physical limitations of the enrollee are limited to covered services listed in this Schedule of Covered Services and Copayments. j. Not all participating dentists can perform all dental procedures, please verify what services your selected dentist can perform for you. Some complicated extractions, periodontal treatment, osseous surgery and root canal treatment may be referred to a participating specialist at the discretion of the participating general dentist. k. Coverage for services are only available during period of enrollment. l. Emergency dental condition – is the emergent and acute onset of a symptom or symptoms, including severe pain that would lead a prudent layperson acting reasonably to believe that dental condition exists that requires immediate, palliative care by a Exclusions: The following are not covered by your dental plan. a. Services not specifically listed in the “Schedule of Covered Services and Copayments.” b. Work in progress: Dental work in progress (non-emergency/ temporary procedures started but not finished prior to the date of eligibility) is not covered. This includes crown preps prepared and temporized but not cemented, root canals in mid-treatment, prosthetic cases post final impression stage (sent to the lab), etc. This does not include teeth slated for root canal treatment and/or canals filled during an emergency visit. c. Benefits are only available if work is completed at the enrollee’s participating dentist’s or participating specialist’s office. d. This Plan does not provide benefits for services or supplies to the extent that benefits are payable for them under any motor vehicle medical, motor vehicle no-fault, uninsured motorist, underinsured motorist, personal injury protection (PIP), commercial liability, homeowner’s policy, or other similar type of coverage. If you ever have questions about your dental coverage, call your Member Service Specialist. We are happy to help you. Dental Health Services A Great Reason to Smile sm 100 W. Harrison St., Suite S-440, South Tower, Seattle, WA 98119 855-495-0906 www.dentalhealthservices.com/WA 0415WM079 © 2015 Dental Health Services 6