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Schedule of Covered Services and Copayments First Smile-EarlyCare Plus Plan Code Description Pediatric Covered Services and Copayments (18 years old and under) Code Description Copayment Plan Information Annual maximum ........................................................................None D9543 Office visit .......................................................................................12 D9986 Missed appointment............................................................. According to office policy D9987 Cancelled appointment ........................................................ According to office policy Deductible ........................................................................................0 *Out-of-pocket maximum - Family ............................................700 *Out-of-pocket maximum - Individual ......................................350 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. Services must be performed by a Dental Health Services participating dentist. Specialty services must be pre-authorized and are only available for children 18 and under. Dental Check-up D0120 Periodic oral evaluation - established patient .............................12 D0140 Limited oral evaluation - problem focused ................................12 D0150 Comprehensive oral evaluation - new or established patient ..........................................................................12 D0190 Screening of a patient ....................................................................12 D0191 Assessment of a patient ................................................................12 D0210 Intraoral - complete series of radiographic images ..................12 D0220 Intraoral - periapical first radiographic image ............................12 D0230 Intraoral - periapical each additional radiographic image ........12 D0240 Intraoral - occlusal radiographic image .......................................12 D0270 Bitewing - single radiographic image...........................................12 D0272 Bitewings - two radiographic images...........................................12 D0273 Bitewings - three radiographic images ........................................12 D0274 Bitewings - four radiographic images..........................................12 D0330 Panoramic radiographic image .....................................................12 D0340 Cephalometric radiographic image ..............................................12 D0350 Oral/facial photographic images obtained intraorally or extraorally ...................................................................................12 D0460 Pulp vitality tests .............................................................................12 D0470 Diagnostic casts ..............................................................................12 D1110 Prophylaxis - adult (limited to 1 per 6 months) .........................12 D1120 Prophylaxis - child (limited to 1 in 6 months) ...........................12 D1206 Topical application of fluoride varnish .......................................12 D1208 Topical application of fluoride .....................................................12 D1330 Oral hygiene instructions ..............................................................12 D1351 Sealant - per tooth ..........................................................................12 D9630 Other drugs and/or medicaments, by report ............................12 D9930 Treatment of complications (post-surgical) - unusual circumstances, by report................................................................12 Copayment Basic Dental Care D1510 D1515 D1550 D1555 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2710 D2910 D2915 D2920 D2929 D2930 D2931 D2932 D2933 D2934 D2941 D2950 D2952 D2954 D3120 D3220 D3221 D3230 D3240 D3351 D3352 D3430 D4211 D4341 D4342 D4355 D4910 D5410 Space maintainer - fixed - unilateral.................... ..........................20 Space maintainer - fixed - bilateral.................................................20 Re-cementation of space maintainer................... ..........................20 Removal of fixed space maintainer................... ............................20 Amalgam - one surface, primary or permanent................... .......20 Amalgam - two surfaces, primary or permanent................... ......20 Amalgam - three surfaces, primary or permanent................... ....20 Amalgam - four or more surfaces, primary or permanent.........20 Resin-based composite - one surface, anterior................... .........20 Resin-based composite - two surfaces, anterior................... ........20 Resin-based composite - three surfaces, anterior................... .....20 Resin-based composite - four or more surfaces or involving incisal angle (anterior)................... .................................20 Resin-based composite crown, anterior................... .....................20 Resin-based composite - one surface, posterior................... .......20 Resin-based composite - two surfaces, posterior.........................20 Resin-based composite - three surfaces, posterior.......................20 Resin-based composite - four or more surfaces, posterior.........20 Crown - resin-based composite (indirect)................... .................20 Recement inlay, onlay, or partial coverage restoration.......... ......20 Recement cast or prefabricated post and core................... ..........20 Recement crown................... ............................................................20 Prefabricated porcelain/ceramic crown - primary tooth...... .....20 Prefabricated stainless steel crown - primary tooth............... .....20 Prefabricated stainless steel crown - permanent tooth...............20 Prefabricated resin crown................... ............................................20 Prefabricated stainless steel crown with resin window...... .........20 Prefabricated esthetic coated stainless steel crown primary tooth................... .................................................................20 Interim therapeutic restoration – primary dentition....................20 Core buildup, including any pins when required................... ......20 Post and core in addition to crown, indirectly fabricated...........20 Prefabricated post and core in addition to crown................... ....20 Pulp cap - indirect (excluding final restoration)...........................20 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament................... ..................................20 Pulpal debridement, primary and permanent teeth.....................20 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)................... ..............................20 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)................... ..............................20 Apexification/recalcification - initial visit (apical closure/ calcific repair of perforations, root resorption, pulp space disinfection, etc.)...............................................................................20 Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)................... ..........20 Retrograde filling - per root................... .........................................20 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant................... ............20 Periodontal scaling and root planing - four or more teeth per quadrant................... ...................................................................20 Periodontal scaling and root planing - one to three teeth per quadrant................... ...................................................................20 Full mouth debridement to enable comprehensive evaluation and diagnosis................... ...............................................20 Periodontal maintenance (limited to 1 per 3 months)......... .......20 Adjust complete denture - maxillary..............................................20 01.15WAFSECHX | Current Dental Terminology © 2016 American Dental Association. All rights reserved. Code Description D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5850 D5851 D5899 D6930 D7111 D7140 D7210 D7250 D7283 D7286 D7288 D7510 D7971 D9110 D9223 D9230 D9248 D9440 D9610 D9612 D9920 99201 99211 99231 99241 99251 Copayment Adjust complete denture - mandibular................... ......................20 Adjust partial denture - maxillary................... ................................20 Adjust partial denture - mandibular...............................................20 Repair broken complete denture base................... ........................20 Replace missing or broken teeth - complete denture (each tooth)................... ....................................................................20 Repair resin denture base.................................................................20 Repair cast framework................... ..................................................20 repair or replace broken clasp.........................................................20 replace broken teeth - per tooth.....................................................20 Add tooth to existing partial denture................... .........................20 Add clasp to existing partial denture................... ..........................20 Tissue conditioning, maxillary................... .....................................20 Tissue conditioning, mandibular................... .................................20 Unspecified removable prosthodontic procedure, by report................... .........................................................................20 Recement fixed partial denture.......................................................20 Extraction, coronal remnants - deciduous tooth.........................20 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)................... ..............................................20 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated................... ............................20 Surgical removal of residual tooth roots (cutting procedure)................... ........................................................20 Placement of device to facilitate eruption of impacted tooth................... ...............................................................20 Biopsy of oral tissue - soft................... ...........................................20 Brush biopsy - transepithelial sample collection................... ......20 Incision and drainage of abscess - intraoral soft tissue........ ......20 Excision of pericoronal gingiva................... ..................................20 Palliative (emergency) treatment of dental pain minor procedure................... ............................................................20 Deep sedation/general anesthesia each 15 minute increment...............................................................20 Inhalation of nitrous oxide / anxiolysis, analgesia......................20 Non-intravenous conscious sedation................... .........................20 Office visit - after regularly scheduled hours................... ............20 Therapeutic parenteral drug, single administration......................20 Therapeutic parenteral drugs, two or more administrations, different medications................... .......................20 Behavior management, by report...................................................20 Office/outpatient visit, new................... .........................................20 Office/outpatient visit, established................... ............................20 Subsequent hospital care................... ..............................................20 Office consultation...........................................................................20 Inpatient consultation................... ...................................................20 Major Dental Care D2720 D2721 D2722 D2740 D2750 D2751 D2752 D3310 D3320 D3330 D3346 D3347 D3348 D3410 D4210 D5110 Crown - resin with high noble metal ..........................................150 Crown - resin with predominantly base metal ..........................150 Crown - resin with noble metal ...................................................150 Crown - porcelain/ceramic substrate .........................................150 Crown - porcelain fused to high noble metal ...........................150 Crown - porcelain fused to predominantly base metal............150 Crown - porcelain fused to noble metal ....................................150 Endodontic therapy, anterior tooth (excluding final restoration) ............................................................................150 Endodontic therapy, bicuspid tooth (excluding final restoration) ............................................................................150 Endodontic therapy, molar (excluding final restoration) ........150 Retreatment of previous root canal therapy - anterior............150 Retreatment of previous root canal therapy - bicuspid...........150 Retreatment of previous root canal therapy - molar ...............150 Apicoectomy - anterior.................................................................150 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant ............................150 Complete denture - maxillary ......................................................150 Code Description Copayment D5120 Complete denture - mandibular ..................................................150 D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) ..........................................150 D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) ..........................................150 D5710 Rebase complete maxillary denture ............................................150 D5711 Rebase complete mandibular denture ........................................150 D5720 Rebase maxillary partial denture .................................................150 D5721 Rebase mandibular partial denture .............................................150 D5750 Reline complete maxillary denture (laboratory)........................150 D5751 Reline complete mandibular denture (laboratory)....................150 D5760 Reline maxillary partial denture (laboratory) .............................150 D5761 Reline mandibular partial denture (laboratory) .........................150 D5863 Overdenture - complete maxillary ..............................................150 D5865 Overdenture - complete mandibular ..........................................150 D5875 Modification of removable prosthesis following implant surgery................................................................................150 D7220 Removal of impacted tooth - soft tissue ...................................150 D7230 Removal of impacted tooth - partially bo .................................150 D7240 Removal of impacted tooth - completely bon..........................150 D7241 Removal of impacted tooth - completely bony, with unusual surgical complications ....................................................150 D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth ......................................150 D7280 Surgical access of an unerupted tooth .......................................150 D7285 Biopsy of oral tissue - hard (bone, tooth) .................................150 D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant .............................150 D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant .............................150 D7410 Excision of benign lesion up to 1.25 cm...................................150 D7471 Removal of lateral exostosis (maxilla or mandible) .................150 D7472 Removal of torus palatinus..........................................................150 D7473 Removal of torus mandibularis...................................................150 D7485 Surgical reduction of osseous tuberosity...................................150 D7520 Incision and drainage of abscess - extraoral soft tissue ..........150 D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue ........................................................150 D7880 Occlusal orthotic device, by report ............................................150 D7960 Frenulectomy - also known as frenectomy or frenotomy separate procedure not incidental to another procedure ........150 D7963 Frenuloplasty ..................................................................................150 D7970 Excision of hyperplastic tissue - per arch .................................150 D7972 Surgical reduction of fibrous tuberosity ....................................150 D9243 Intravenous conscious sedation/analgesia each 15 minute increment.............................................................150 D9410 House/extended care facility call ................................................150 D9420 Hospital or ambulatory surgical center call ...............................150 D9940 Occlusal guard, by report .............................................................150 Other Covered Services 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 D0277 Vertical bitewings - 7 to 8 radiographic images .........................20 D0391 Interpretation of diagnostic image by a practitioner not Code Description Copayment 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 D1354 Interim caries arresting medicament application........................20 D1520 Space maintainer - removable - unilateral..................................150 D1525 Space maintainer - removable - bilateral ....................................250 D1575 distal shoe space maintainer – fixed – unilateral .......................20 D2712 Crown - ¾ resin-based composite (indirect) ..............................0 D2940 Protective restoration.....................................................................35 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 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 D4346 scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation ........35 D4921 Gingival irrigation - per quadrant ................................................25 D5986 Fluoride gel carrier .........................................................................30 D6081 scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure ................20 D8010 Limited orthodontic treatment of the D8070 primary dentition ...................................................................... Prorated D8020 Limited orthodontic treatment of the D8070 transitional dentition ................................................................ Prorated D8030 Limited orthodontic treatment of the D8080 adolescent dentition ................................................................. Prorated D8040 Limited orthodontic treatment of the D8090 adult dentition ........................................................................... Prorated D8050 Interceptive orthodontic treatment of the D8070 primary dentition ...................................................................... Prorated D8060 Interceptive orthodontic treatment of the D8070 transitional dentition ................................................................ Prorated D8070 Comprehensive orthodontic treatment of the transitional dentition ....................................................................3395 D8080 Comprehensive orthodontic treatment of the adolescent dentition .....................................................................3395 D8090 Comprehensive orthodontic treatment of the adult dentition ...............................................................................3495 D8660 Pre-orthodontic treatment examination to monitor growth and development ..............................................................40 D8670 Periodic orthodontic treatment visit ...........................................10 Code Description Copayment D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) ...............................315 D8690 Orthodontic treatment (alternative billing to a contract fee)......................................................................................0 D8693 Re-cement or re-bond fixed retainer ...........................................45 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 D9311 consultation with a medical health care professional ................0 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 D9943 Occlusal guard adjustment.............................................................12 D9951 Occlusal adjustment - limited .......................................................35 D9952 Occlusal adjustment - complete ..................................................150 D9991 dental case management – addressing appointment compliance barriers .........................................................................0 D9992 dental case management – care coordination .............................0 D9993 dental case management – motivational interviewing ...............0 D9994 dental case management – patient education to improve oral health literacy ...........................................................................0 Congenital Anomalies Coverage for the treatment of congenital anomalies is available utilizing the services and copayments listed above. Orthodontia 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. 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 the 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 pre-authorized with Dental Health Services through a referral from your participating dentist. e. If you ever have questions about your dental coverage, call your Member Service Specialist at [800-637-6453]OM[855-495-0906]EX. We are happy to help you. Pediatric Exclusions and Limitations (18 years old and under) Limitations: Diagnostic Services are covered with the following limitations: a. Intraoral complete series (D0210) is covered once in a three-year 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 threeyear 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. 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 once per tooth 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 are for primary molars A, B, I, J, K, L, S and T. i. Replacement of space maintainers are covered. ii. Removal of fixed space maintainers for enrollees 18 years of age or younger. 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; 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 f. g. h. teeth for enrollees from 12 through 18 years of age. Must be preauthorized; All recementations of permanent indirect crowns for enrollees from 12 through 18 years of age; Prefabricated stainless steel crowns for primary posterior teeth once every 3 years; Prefabricated stainless steel crowns for permanent posterior teeth excluding 1, 16, 17, and 32 once every 3 years; Core buildup, including pins, only on permanent teeth, when performed in conjunction with a crown; 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 pre-authorized and evidenced by x-ray. c. Periodontal maintenance for enrollees aged 13 and older, once per enrollee, per 3 month period with pre-authorization. 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, orthodontist, or specialist. Services provided by a dentist other than the members designated participating dentist, orthodontist or 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. 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 are not covered. All cases in which the member selects a plan of treatment that is considered optional or unnecessary by the attending dentist. The member is responsible for all charges for option treamtent. This does not apply to standard covered restorative procedures which offer a choice of material. e. f. g. h. 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. 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. 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. Not all participating dentists can perform all dental procedures. Some complicated extractions, periodontal treatment, osseous surgery and i. j. k. root canal treatment may be referred to a participating specialist at the discretion of the participating general dentist. Coverage for services are only available while the member is eligible for coverage. 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 licensed dentist for the relief of pain, swelling or bleeding. This does not include routine treatment. Emergency dental care is limited to palliative treatment. 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. Exclusions: The following are not covered by your dental plan. a. Services not specifically listed in the “Schedule of Covered Services and Copayments.” b. Dental work in progress is not covered for new members. 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, orthodontist’s or specialist’s office. d. This Plan does not provide benefits for services or supplies to the extent that benefits are payable for them under workers compensation or employer liability laws, 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. e. Cosmetic dentistry – services for appearance only. This includes, but not limited to such services as the replacement of clinically acceptable amalgam fillings, composite fillings, clinically acceptable veneers, crowns and removable prosthetics. Non-Medically Necessary Orthodontic Limitations: The following are limitations on covered benefits. a. Malocclusions too severe or mutilated which are not amenable to ideal orthodontic therapy. Non-Medically Necessary Orthodontic Exclusions: The following are not covered by your dental plan. a. Cephalometric x-rays, dental x-rays for orthodontic purposes. b. Tracings and photographs. c. Study Models. d. Replacement of lost or broken appliances. e. Retreatment of orthodontic cases. f. Treatment of a case in progress at inception of eligibility. g. Treatment and/or surgical procedures related to cleft palate, micrognathia or microdontia. h. Orthodontic treatment rendered or required after the member is no longer eligible for coverage. During a member’s lapse of coverage, the member is responsible for the cost of the treatment in progress. The cost of the treatment in progress will be prorated and converted to the Orthodontist’s actual fee-for-service amount. Dental Health Services complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Este Aviso contiene información importante. Este aviso contiene información importante acerca de su solicitud o cobertura a través de [Washington Healthplanfinder]EX [Dental Health Services] OM. Preste atención a las fechas clave que contiene este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al 1-866-756-4259. 本通知有重要的訊息。本通知有關於您透過[插入SBM項目的名稱 [Washington Healthplanfinder]EX [Dental Health Services] OM提交的 申請或保險的重要訊息。請留意本通知內的重要日期。您可能需要 在截止日期之前採取行動，以保留您的健康保險或者費用補貼。您 有權利免費以您的母語得到本訊息和幫助。請撥電話 [在此插入數字 1-866-756-4259. Dental Health Services A Great Reason to Smile sm 100 W. Harrison St., Suite S-440, South Tower, Seattle, WA 98119 [800-637-6453]OM [855-495-0906]EX [www.dentalhealthservices.com]OM [www.dentalhealthservices.com/WA]EX 0415WM076 © 2016 Dental Health Services
