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LIBERTY Dental Plan | Missouri SHOP Exchange MO Pediatric High with Adult Option Individual Out-of-Pocket Maximum: $350 Plan Year (applies to Pediatric only) Family Out-of-Pocket Maximum: $700 Plan Year (applies to Pediatric only) The following is a complete list of the dental procedures for which benefits are payable under this Plan. Non-listed procedures are not covered. This Plan does not allow alternate benefits. Members must visit a contracted dental office to utilize covered benefits. The Member's dental office will initiate a treatment plan or recommend the Member see a specialist if the services are dentally necessary and outside the scope of general dentistry. Members may directly refer to a specialist. Pediatric Copay1 Adult Copay2 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $94 $40 $61 $0 $15 $15 $15 $15 $15 $50 $50 $14 $10 $15 $10 $28 $35 NPB NPB NPB NPB $49 $0 $0 $0 $0 $30 NPB NPB $25 D1351 Sealant, per tooth $0 NPB D1352 Preventive resin restoration, permanent tooth $0 NPB D1353 Sealant repair, per tooth $0 NPB D1510 D1515 D1520 D1525 D1550 D1575 ADA Code D0120 D0140 D0150 D0180 D0160 D0210 D0330 D0220 D0230 D0240 D0270 D0272 D0274 D0277 D0340 D0350 D0391 D0470 D1110 D1120 D1206 D1208 Description Diagnostic Services Periodic oral evaluation Limited oral evaluation Comprehensive oral evaluation Comprehensive periodontal evaluation Oral evaluation, problem focused Intraoral, complete series of radiographic images Panoramic radiographic image Intraoral, periapical, first radiographic image Intraoral, periapical, each add 'l radiographic image Intraoral, occlusal radiographic image Bitewing, single radiographic image Bitewings, two radiographic images Bitewings, four radiographic images Vertical bitewings, 7 to 8 radiographic images 2D cephalometric radiographic image, measurement and analysis 2D oral/facial photographic image, intra-orally/extra-orally Interpretation, diagnostic image by a practitioner, not associated with image, including report Diagnostic casts Preventive Services Prophylaxis, adult Prophylaxis, child Topical application of fluoride varnish Topical application of fluoride, excluding varnish $0 $0 $0 $0 $0 $0 $150 $175 $200 $225 $25 $150 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 Space maintainer, fixed, unilateral Space maintainer, fixed, bilateral Space maintainer, removable, unilateral Space maintainer, removable, bilateral Re-cement or re-bond space maintainer Distal shoe space maintainer, fixed, unilateral Restorative Services Amalgam, one surface, primary or permanent Amalgam, two surfaces, primary or permanent Amalgam, three surfaces, primary or permanent Amalgam, four or more surfaces, primary or permanent Resin-based composite, one surface, anterior Resin-based composite, two surfaces, anterior Resin-based composite, three surfaces, anterior Resin-based composite, four or more surfaces, involving incisal angle $40 $45 $50 $60 $50 $60 $70 $80 $65 $75 $90 $125 $80 $90 $105 $130 D2510 D2520 D2530 D2542 D2543 D2544 D2740 D2750 D2751 D2752 D2780 Inlay, metallic, one surface Inlay, metallic, two surfaces Inlay, metallic, three or more surfaces Onlay, metallic, two surfaces Onlay, metallic, three surfaces Onlay, metallic, four or more surfaces Crown, porcelain/ceramic substrate* Crown, porcelain fused to high noble metal* Crown, porcelain fused to predominantly base metal Crown, porcelain fused to noble metal* Crown, ¾ cast high noble metal* $225 $365 $325 $345 $350 $350 $350 $350 $350 $350 $350 $370 $395 $450 $500 $530 $615 $640 $675 $585 $630 $630 Limitations 1 of (D0120, D0140, D0150, D0180) every 6 months 1 of (D0210, D0330) every 60 months 1 of (D0270-D0277) every 6 months In conjunction with orthodontic coverage 1 of (D1110, D1120) every 6 months 2 of (D1206, D1208) every 12 months 1 of (D1351, D1352) per tooth every 36 months, 1st and 2nd permanent molars 1 per tooth every 36 months, 1st and 2nd permanent molars *GUIDELINES for Inlays, Onlays, and Single Crowns: 1. When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an additional $125.00 per unit, beyond the 6th unit. 2. Porcelain and other tooth-colored materials on molars are considered a material upgrade with a maximum additional charge to the Enrollee $150.00 per unit. 3. For a covered porcelain-fused-to-metal crown, a porcelain margin is considered a material upgrade with a maximum additional charge to the Enrollee of $75.00 per unit. 4. Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are material upgrades. The Contracted Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Copayment. MOLDP-PEDHIGH-20160919 1 of 7 1 of (D2510-D2794, D6058-D6077, D6210-D6794) per tooth every 60 months Making members shine, one smile at time™ LIBERTY Dental Plan | Missouri SHOP Exchange Pediatric Copay1 Adult Copay2 $350 $350 $350 $350 $350 $350 $45 $50 $100 $75 $100 $60 $95 $30 $115 $105 $65 $80 $65 $15 $575 $595 $620 $580 $595 $650 $47 $51 NPB NPB NPB NPB $145 $34 $160 $125 $65 $80 $65 $15 $75 $70 $80 $80 $270 $320 $350 $350 $350 $350 $105 $110 $230 $275 $285 $305 $115 $145 $105 $95 $75 $94 $105 $405 $490 $610 $405 $490 $590 NPB NPB NPB $225 $275 $295 $175 $160 $215 $205 $125 $125 $225 $225 $350 $200 $245 $245 $245 $265 $250 $120 $74 $425 $225 $450 $375 $450 $450 $450 $380 D4275 Non-autogenous connective tissue graft, first tooth $245 $300 D4277 D4278 D4249 D4283 $200 $200 $175 $265 $275 $135 $375 $380 D4285 Non-autogenous connective tissue graft procedure, each additional tooth, per site $245 $300 GUIDELINE: No more than two (2) quadrants of periodontal scaling and root planing per appointment/ per day are allowable. D4341 Periodontal scaling and root planing, four or more teeth per quadrant D4342 Periodontal scaling and root planing, one to three teeth per quadrant $120 $90 $145 $130 D4346 Scaling in presence of moderate or severe inflammation, full mouth after evaluation $0 $30 D4355 Full mouth debridement D4910 Periodontal maintenance $60 $80 $105 $85 ADA Code D2781 D2783 D2790 D2791 D2792 D2794 D2910 D2920 D2929 D2930 D2931 D2940 D2950 D2951 D2954 D2980 D2981 D2982 D2983 D2990 D3220 D3222 D3230 D3240 D3310 D3320 D3330 D3346 D3347 D3348 D3351 D3352 D3353 D3410 D3421 D3425 D3426 D3450 D3920 D4210 D4211 D4212 D4240 D4241 D4260 D4261 D4263 D4264 D4270 D4273 Description Restorative Services (continued) Crown, ¾ cast predominantly base metal Crown, ¾ porcelain/ceramic* Crown, full cast high noble metal* Crown, full cast predominantly base metal Crown, full cast noble metal* Crown, titanium* Re-cement or re-bond inlay, onlay, veneer, or partial coverage Re-cement or re-bond crown Prefabricated porcelain/ceramic crown, primary tooth Prefabricated stainless steel crown, primary tooth Prefabricated stainless steel crown, permanent tooth Protective restoration Core buildup, including any pins when required Pin retention, per tooth, in addition to restoration Prefabricated post and core in addition to crown Crown repair necessitated by restorative material failure Inlay repair necessitated by restorative material failure Onlay repair necessitated by restorative material failure Veneer repair necessitated by restorative material failure Resin infiltration of incipient smooth surface lesions Endodontic Services Therapeutic pulpotomy (excluding final restoration) Partial pulpotomy, apexogenesis, permanent tooth, incomplete root Pulpal therapy, anterior, primary tooth (excluding final restoration) Pulpal therapy, posterior, primary tooth (excluding finale restoration) Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) Endodontic therapy, molar (excluding final restoration) Retreatment of previous root canal therapy, anterior Retreatment of previous root canal therapy, bicuspid Retreatment of previous root canal therapy, molar Apexification/recalcification, initial visit Apexification/recalcification, interim medication replacement Apexification/recalcification, final visit Apicoectomy, anterior Apicoectomy, bicuspid (first root) Apicoectomy, molar (first root) Apicoectomy, (each additional root) Root amputation, per root Hemisection, not including root canal therapy Periodontal Services Gingivectomy or gingivoplasty, four or more teeth per quadrant Gingivectomy or gingivoplasty, one to three teeth per quadrant Gingivectomy or gingivoplasty, restorative procedure, per tooth Gingival flap procedure, four or more teeth per quadrant Gingival flap procedure, one to three teeth per quadrant Osseous surgery, four or more teeth per quadrant Osseous surgery, one to three teeth per quadrant Bone replacement graft, retained natural tooth, first site, quadrant Bone replacement graft, retained natural tooth, each additional site Pedicle soft tissue graft procedure Autogenous connective tissue graft procedure, first tooth Free soft tissue graft, first tooth Free soft tissue graft, each additional tooth Clinical crown lengthening, hard tissue Autogenous connective tissue graft procedure, each additional tooth, per site MOLDP-PEDHIGH-20160919 2 of 7 Limitations 1 of (D2510-D2794, D6058-D6077, D6210-D6794) per tooth every 60 months 1 of (D2929-D2931) per tooth every 60 months 1 per tooth every 60 months 1 per tooth every 60 months 1 every 36 months 1 of (D3230, D3240) per tooth per lifetime 1 of (D4210-D4264) per site/quad every 36 months 1 of (D4275, D4285) per tooth every 36 months 1 of (D4275, D4285) per tooth every 36 months 1 of (D4341, D4342) per site/quad every 24 months 1 of (D1110, D1120, D4346) every 6 months 1 per lifetime 4 every 12 months Making members shine, one smile at time™ LIBERTY Dental Plan | Missouri SHOP Exchange ADA Code D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5221 D5222 D5223 D5224 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5850 D5851 Description Removable Prosthodontic Services Complete denture, maxillary Complete denture, mandibular Immediate denture, maxillary Immediate denture, mandibular Maxillary partial denture, resin base Mandibular partial denture, resin base Maxillary partial denture, cast metal, resin base Mandibular partial denture, cast metal, resin base Immediate maxillary partial denture, resin base Immediate mandibular partial denture, resin base Immediate maxillary partial denture, cast metal framework, resin denture base Immediate mandibular partial denture, cast metal framework, resin denture base Removable unilateral partial denture, one piece cast metal Adjust complete denture, maxillary Adjust complete denture, mandibular Adjust partial denture, maxillary Adjust partial denture, mandibular Repair broken complete denture base Replace missing or broken teeth, complete denture Repair resin denture base Repair cast framework Repair or replace broken clasp, per tooth Replace broken teeth, per tooth Add tooth to existing partial denture Add clasp to existing partial denture, per tooth Rebase complete maxillary denture Rebase complete mandibular denture Rebase maxillary partial denture Rebase mandibular partial denture Reline complete maxillary denture, chairside Reline complete mandibular denture, chairside Reline maxillary partial denture, chairside Reline mandibular partial denture, chairside Reline complete maxillary denture, laboratory Reline complete mandibular denture, laboratory Reline maxillary partial denture, laboratory Reline mandibular partial denture, laboratory Tissue conditioning, maxillary Tissue conditioning, mandibular Implant Services Pediatric Copay1 Adult Copay2 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $305 $40 $40 $40 $40 $80 $70 $75 $105 $85 $95 $80 $100 $205 $205 $205 $215 $125 $125 $125 $115 $180 $180 $180 $170 $70 $80 $755 $755 $825 $825 $505 $505 $715 $715 $505 $505 $715 $715 NPB $38 $38 $38 $38 $96 $88 $95 $135 $135 $85 $115 $125 $307 $307 $290 $290 $180 $180 $175 $175 $235 $235 $220 $220 $105 $105 Limitations 1 of (D5110-D5224) per arch every 60 months 1 every 60 months 1 of (D5410-D5422) per arch every 12 months 1 of (D5710-D5761) per arch every 36 months *GUIDELINES for Implant Abutments: 1. When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an additional $125.00 per unit, beyond the 6th unit. 2. Porcelain and other tooth-colored materials on molars are considered a material upgrade with a maximum additional charge to the Enrollee $150.00 per unit. 3. For a covered porcelain-fused-to-metal crown, a porcelain margin is considered a material upgrade with a maximum additional charge to the Enrollee of $75.00 per unit. 4. Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are material upgrades. The Contracted Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Copayment. D6010 Surgical placement of implant body, endosteal $350 NPB D6012 D6040 D6050 D6055 D6056 D6057 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB Surgical placement of interim implant body, transitional prosthesis: endosteal implant Surgical placement: eposteal implant Surgical placement: transosteal implant Connecting bar, implant supported or abutment supported Prefabricated abutment, includes modification and placement Custom fabricated abutment, includes placement Abutment supported porcelain/ceramic crown Abutment supported porcelain fused to high noble crown Abutment supported porcelain fused to base metal crown Abutment supported porcelain fused to noble metal crown Abutment supported cast metal crown, high noble Abutment supported cast metal crown, base metal Abutment supported cast metal crown, noble metal Implant supported porcelain/ceramic crown Implant supported porcelain fused to high noble crown Implant supported metal crown Abutment supported retainer, porcelain/ceramic FPD Abutment supported retainer, metal FPD, high noble Abutment supported retainer, porcelain fused to metal FPD, base metal Abutment supported retainer, porcelain fused to metal FPD, noble Abutment supported retainer, cast metal FPD, high noble Abutment supported retainer, cast metal FPD, base metal Abutment supported retainer, cast metal FPD, noble MOLDP-PEDHIGH-20160919 3 of 7 1 of (D6010, D6040, D6050) per tooth every 60 months 1 per tooth every 60 months 1 of (D6010, D6040, D6050) per tooth every 60 months 1 per tooth every 60 months 1 of (D6056, D6057) per tooth every 60 months 1 of (D2510-D2794, D6058-D6077, D6210-D6794) per tooth every 60 months Making members shine, one smile at time™ LIBERTY Dental Plan | Missouri SHOP Exchange Pediatric Copay1 Adult Copay2 Limitations $350 $350 $350 $50 NPB NPB NPB NPB D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant $0 NPB D6090 Repair implant supported prosthesis, by report Replacement of semi-precision, precision attachment, implant/abutment supported prosthesis, D6091 per attachment D6095 Repair implant abutment, by report D6100 Implant removal, by report D6101 Debridement of a peri-implant defect(s), surrounding single implant, including flap entry/closure Debridement and osseous contouring of a peri-implant defect(s) surrounding single implant, D6102 including flap entry/closure D6103 Bone graft for repair of peri-implant defect, does not include flap entry and closure D6104 Bone graft at time of implant placement D6110 Implant/abutment supported removable denture, maxillary D6111 Implant/abutment supported removable denture, mandibular D6112 Implant/abutment supported removable denture, partial, maxillary D6113 Implant/abutment supported removable denture, partial, mandibular D6114 Implant/abutment supported fixed denture, maxillary D6115 Implant/abutment supported fixed denture, mandibular D6116 Implant/abutment supported fixed denture for partial, maxillary D6117 Implant/abutment supported fixed denture for partial, mandibular D6190 Radiographic/surgical implant index, by report Fixed Prosthodontic Services $80 NPB 1 of (D2510-D2794, D6058-D6077, D6210-D6794) per tooth every 60 months 1 per tooth every 60 months 1 every 12 months, not on same day or within 60 days of D1110, D1120, D4341, D4342, D4355, D4910 1 per tooth every 60 months $20 NPB 1 per tooth every 60 months $230 $180 $165 NPB NPB NPB 1 per tooth every 60 months 1 per tooth every 60 months $350 NPB $175 $165 $350 $350 $350 $350 $350 $350 $350 $350 $130 NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB NPB ADA Code D6075 D6076 D6077 D6080 Description Implant Services (continued) Implant supported retainer for ceramic FPD Implant supported retainer for porcelain fused metal FPD Implant supported retainer for cast metal FPD Implant maintenance procedures, prosthesis removed/reinserted, including cleansing 1 of (D6101, D6102) per site every 60 months 1 of (D6114-D6117) per arch every 60 months 1 every 60 months *GUIDELINES for Bridges: 1. When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an additional $125.00 per unit, beyond the 6th unit. 2. Porcelain and other tooth-colored materials on molars are considered a material upgrade with a maximum additional charge to the Enrollee $150.00 per unit. 3. For a covered porcelain-fused-to-metal crown, a porcelain margin is considered a material upgrade with a maximum additional charge to the Enrollee of $75.00 per unit. 4. Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are material upgrades. The Contract Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Copayment. D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6545 D6548 D6549 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6794 D6930 D6980 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7270 D7280 Pontic, cast high noble metal* Pontic, cast predominantly base metal Pontic, cast noble metal* Pontic, titanium* Pontic, porcelain fused to high noble metal* Pontic, porcelain fused to predominantly base metal Pontic, porcelain fused to noble metal* Pontic, porcelain/ceramic* Retainer, cast metal for resin bonded fixed prosthesis Retainer, porcelain/ceramic, resin bonded fixed prosthesis* Resin retainer, for resin bonded fixed prosthesis Retainer crown, porcelain/ceramic* Retainer crown, porcelain fused to high noble metal* Retainer crown, porcelain fused to predominantly base metal Retainer crown, porcelain fused to noble metal* Retainer crown, ¾ cast high noble metal* Retainer crown, ¾ cast predominantly base metal Retainer crown, ¾ cast noble metal* Retainer crown, ¾ porcelain/ceramic* Retainer crown, full cast high noble metal* Retainer crown, full cast predominantly base metal Retainer crown, full cast noble metal* Retainer crown, titanium* Re-cement or re-bond fixed partial denture Fixed partial denture repair, restorative material failure Oral & Maxillofacial Services Extraction, erupted tooth or exposed root Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth Removal of impacted tooth, soft tissue Removal of impacted tooth, partially bony Removal of impacted tooth, completely bony Removal impacted tooth, complete bony, complication Removal of residual tooth roots (cutting procedure) Coronectomy, intentional partial tooth removal Tooth reimplantation and/or stabilization, accident Exposure of an unerupted tooth MOLDP-PEDHIGH-20160919 4 of 7 $350 $350 $350 $350 $350 $380 $400 $350 $210 $210 $210 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $350 $60 $140 $575 $540 $560 NPB $600 $560 $575 $525 NPB NPB NPB $640 $675 $585 $630 $600 $575 $545 $590 $620 $580 $597 NPB $60 $175 $130 $160 $160 $200 $250 $250 $200 $35 $135 $105 $78 $150 $172 $220 $240 $278 $147 $230 NPB NPB 1 of (D2510-D2794, D6058-D6077, D6210-D6794) per tooth every 60 months Removal of impacted third molars in Enrollees under 19 is not covered unless specific documentation is provided that substantiates the need for removal and is approved the Plan Making members shine, one smile at time™ LIBERTY Dental Plan | Missouri SHOP Exchange ADA Code Pediatric Copay1 Description Adult Copay2 Limitations Oral & Maxillofacial Services (continued) $75 $162 Alveoloplasty with extractions, four or more teeth per quadrant $95 $130 Alveoloplasty with extractions, one to three teeth per quadrant $95 $210 Alveoloplasty, w/o extractions, four or more teeth per quadrant $145 $190 Alveoloplasty, w/o extractions, one to three teeth per quadrant $295 $360 Removal of lateral exostosis, maxilla or mandible $95 $85 Incision & drainage of abscess, intraoral soft tissue $75 NPB Suture of recent small wounds up to 5 cm $230 NPB Collection and application of autologous blood concentrate product 1 every 36 months $250 $265 Bone replacement graft for ridge preservation, per site $55 NPB Excision of pericoronal gingiva Orthodontic Services Orthodontic procedures are benefits for medically necessary handicapping malocclusion, cleft palate and facial growth management cases for Enrollees under the age of 19 and shall be prior authorized. All copayments paid by the enrollee, including orthodontic copayments, apply towards the annual Out of Pocket Maximum. D8010 Limited orthodontic treatment of the primary dentition $350 NPB D8020 Limited orthodontic treatment of the transitional dentition $350 NPB D8030 Limited orthodontic treatment of the adolescent dentition $350 NPB D8050 Interceptive orthodontic treatment of the primary dentition $350 NPB D8060 Interceptive orthodontic treatment of the transitional dentition $350 NPB D8070 Comprehensive orthodontic treatment of the transitional dentition $350 NPB D8080 Comprehensive orthodontic treatment of the adolescent dentition $350 NPB D8090 Comprehensive orthodontic treatment of the adult dentition $350 NPB D8210 Removable appliance therapy $88 NPB D8220 Fixed appliance therapy $127 NPB D8660 Pre-orthodontic treatment examination to monitor growth and development $50 NPB D8670 Periodic orthodontic treatment visit $30 NPB D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $100 NPB Adjunctive General Services D9110 Palliative (emergency) treatment, minor procedure $0 $55 D7310 D7311 D7320 D7321 D7471 D7510 D7910 D7921 D7953 D7971 GUIDELINE: Deep sedation/general anesthesia is a covered benefit only when in conjunction with covered oral surgery and pedodontic procedures when dispensed in a dental office by a practitioner acting within the scope of his/her licensure; and when warranted by documented conditions that local anesthetic and contraindicated. General anesthesia, as used for dental pain control, means the elimination of all sensations accompanied by a state of unconsciousness. Patient apprehension and/or nervousness are not of themselves sufficient justification for deep sedation/general anesthesia or intravenous conscious sedation/analgesia. D9219 D9223 D9243 D9310 D9610 D9930 Evaluation for deep sedation or general anesthesia Deep sedation/general anesthesia, each 15 minute increment Intravenous moderate (conscious) sedation/analgesia, each 15 minute increment Consultation, other than requesting dentist Therapeutic parenteral drug, single administration Treatment of complications, post surgical, unusual, by report D9940 Occlusal guard, by report D9991 D9992 D9993 D9994 Dental case management, addressing appointment compliance barriers Dental case management, care coordination Dental case management, motivational interviewing Dental case management, patient education to improve oral health literacy NPB Not Plan Benefit Pediatric Benefits – Apply to dependents to the age of 19 2 Adult Benefits - Apply to Enrollees 19 and over $0 $60 $70 $0 $30 $30 $0 $82 $67 $55 $31 $42 $310 NPB $0 $0 $0 $0 $0 $0 $0 $0 1 every 12 months, age 13 and over 1 Out-of-Pocket Maximum means the maximum amount of money that a Pediatric Enrollee must pay for Benefits under this Program during a plan year. If more than one Pediatric Enrollee is covered, the financial obligation for covered services is not more than the multiple child annual Out of-Pocket maximum. Once the amount paid by all Pediatric Enrollee(s) equals the annual Out-of-Pocket Maximum shown above, no further payment will be required by any of the Pediatric Enrollee(s) for the remainder of the Plan Year for covered services. Payment for services that are Optional, that are upgraded treatment (such as precious or semi-precious metals and material upgrades) or that are not covered under the Contract will not count toward the Out-of-Pocket Maximum, and payment for such services still applies after the annual Out-of-Pocket Maximum is met. Record of payment for covered procedures should be kept by the Responsible Party. When the Out-of-Pocket Maximum has been reached; contact the Customer Service department at 877-877-1893 for instruction on how to submit. Proof that the Out-of-Pocket Maximum has been reached must be submitted to LIBERTY Dental Plan. MOLDP-PEDHIGH-20160919 5 of 7 Making members shine, one smile at time™ LIBERTY Dental Plan | Missouri SHOP Exchange Exclusions: Except as specifically provided, the following services, supplies, or charges are not covered: 1 Services and treatment not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, we will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law. 2 Services and treatment which are experimental or investigational. 3 Services and treatment which are for any illness or bodily injury which occurs in the course of employment if a benefit or compensation is available, in whole or in part, under the provision of any law or regulation or any government unit. This exclusion applies whether or not you claim the benefits or compensation. 4 Services and treatment received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, VA hospital or similar person or group. 5 Services and treatment performed prior to your effective date of coverage. 6 Services and treatment incurred after the termination date of your coverage unless otherwise indicated. 7 Services and treatment which are not dentally necessary or which do not meet generally accepted standards of dental practice. 8 Services and treatment resulting from your failure to comply with professionally prescribed treatment. 9 Telephone consultations. 10 Any charges for failure to keep a scheduled appointment. 11 Any services that are considered strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances. 12 Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMD). 13 Services or treatment provided as a result of intentionally self-inflicted injury or illness. 14 Services or treatment provided as a result of injuries suffered while committing or attempting to commit a felony, engaging in an illegal occupation, or participating in a riot, rebellion or insurrection. 15 Office infection control charges. 16 Charges for copies of your records, charts or x-rays, or any costs associated with forwarding/mailing copies of your records, charts or x-rays. 17 State or territorial taxes on dental services performed. 18 Those submitted by a dentist, which is for the same services performed on the same date for the same member by another dentist. 19 Those provided free of charge by any governmental unit, except where this exclusion is prohibited by law. 20 Those for which the member would have no obligation to pay in the absence of this or any similar coverage. 21 Those which are for specialized procedures and techniques. 22 Those performed by a dentist who is compensated by a facility for similar covered services performed for members. 23 Duplicate, provisional and temporary devices, appliances, and services. 24 Plaque control programs, oral hygiene instruction, and dietary instructions. 25 Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth. 26 Gold foil restorations. 27 Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan. 28 Treatment of services for injuries resulting from war or act of war, whether declared or undeclared, or from police or military service for any country or organization. 29 Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient). 30 Charges by the provider for completing dental forms. 31 Adjustment of a denture or bridgework which is made within 6 months after installation by the same Dentist who installed it. 32 Use of material or home health aids to prevent decay, such as toothpaste, fluoride gels, dental floss and teeth whiteners. 33 Cone Beam Imaging and Cone Beam MRI procedures. 34 Sealants for teeth other than permanent molars. 35 Replacement of dentures that have been lost, stolen or misplaced. 36 Orthodontic care for dependent children age 19 and over. 37 Repair of damaged orthodontic appliances. MOLDP-PEDHIGH-20160919 6 of 7 Making members shine, one smile at time™ LIBERTY Dental Plan | Missouri SHOP Exchange Exclusions Continued: 38 39 40 41 42 43 44 45 Replacement of lost or missing appliances. Fabrication of athletic mouth guard. Internal and external bleaching. Nitrous oxide. Oral sedation. Topical medicament center. Bone grafts when done in connection with extractions, apicoetomies or non-covered/non eligible implants. When two or more services are submitted and the services are considered part of the same service to one another the Plan will pay the most comprehensive service (the service that includes the other non-benefited service) as determined by the dental plan. 46 When two or more services are submitted on the same day and the services are considered mutually exclusive (when one service contradicts the need for the other service), the Plan will pay for the service that represents the final treatment as determined by the dental plan. MOLDP-PEDHIGH-20160919 7 of 7 Making members shine, one smile at time™