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Solstice
Dental Benefits
DENTAL
Smiles. We cover those.
The Solstice dental plan is easy to use and cost effective. It covers a
wide range of dental services—all designed to keep your smile healthy.
Say yes to no.
How does the plan work?
You can see any general dentist who is part of our large network. You do
not need to choose a primary care dentist. That dentist will provide most
of your dental care. If you need to see a specialist, you have two options:
•You can get a pre-authorization (approval prior to receiving
services) from us and pay a co-pay. Co-pays are listed in your plan
document, which you can find online at myuhc.com®. To get a preauthorization, simply contact us at the number on your ID card.
No deductibles
o annual maximums
N
when you receive
services from a
network provider
o exclusions for
N
pre-existing conditions
•If you do not want to get a referral, you may go to a specialist in the
Solstice network and receive a 25% discount off the specialist’s
Usual and Customary charge, which is the average fee dentists in
your area charge for a procedure.
If you are traveling outside of Florida and need dental services to relieve
pain, you’ll need to pay for the service and mail us your receipt and
treatment information. We will pay up to $100 per occurrence. Send the
information to:
UnitedHealthcare Dental
Att: Claims Unit
PO Box 30567
Salt Lake City, UT 84130-0567
“Highest in Customer
Satisfaction with
Dental Plans,
Two Years in a Row1”
[Drafting Note: Plan 150]
Benefits that help you save money and stay healthy
What’s covered?
Preventive
services covered at 100% on most plans when
you see a dentist in the network. Preventive services include
exams, cleanings and bitewing X-rays, as well as sealants for
children.
Hundreds
of other services at a co-pay, including fillings,
crowns, and cosmetic procedures—such as teeth whitening,
bonding, veneers and orthodontia for adults and children.
See your plan documents for details.
Manage your
health and your
plan online and
on the go.
Extra
visits for cleanings and gum treatments during
pregnancy and three months following delivery, as
prescribed by the general dentist. Pregnant women are more
prone to bacteria that causes tooth decay and gum disease
during this time.2
Network
dentists provide a 25% discount for services not
covered by the plan. That discount will come directly from
the dental office. There are no claims to submit.
A Solstice plan is a smart plan for those who want savings and
broad coverage.
Sign up today!
Start receiving the care you need to enjoy better oral health.
It’s all yours with the Solstice dental plan.
Find a dentist in the network
Use “Find a Dentist” on myuhc.com®. Login so
you only see dentists in your network, or call the
number on your ID card.
1
nitedHealthcare received the highest numerical score in the proprietary J.D. Power
U
2014-2015 Dental Plan Satisfaction ReportsSM. 2015 report measures opinions of
consumers with dental plans, includes seven plans, and is based on responses
from 2,449 consumers. Proprietary study results are based on experiences and
perceptions of consumers surveyed September-October 2015. Your experiences may
vary. Visit www.jdpower.com
2
http://www.cda.org/Portals/0/journal/journal_062010.pdf
Offered by Solstice Benefits, Inc. a Licensed Prepaid Limited Health Service Organization;
Chapter 636 F. S., and administered by Dental Benefit Providers, Inc.
MT-991630.1 12/15
© 2015 United HealthCare Services, Inc. 15-0877-I 213-9521
As a member, you can see plan
details and learn about oral
health on myuhc.com.
Review coverage.
Find network providers.
Check your claims.
Estimate costs.
iew and print your ID
V
cards and more.
Solstice S700B-SHP/D1058
Dental Plan Schedule of Benefits
Members of the S700B-SHP Dental Plan are eligible to receive benefits immediately upon the effective date of coverage with: ● No waiting Periods
● No Deductibles or Maximums
● No claim forms to submit
The Member co‐payments listed are offered by a participating in‐network general dentist. The member receives:
● Most diagnostic & preventive care at No Charge
● Cosmetic & Orthodontia treatment covered
Members can locate a participating provider at
www.myuhc.com
Member Services Department: 800‐955‐4137
The member is ultimately responsible for verifications of the accuracy and appropriateness of all fees applicable to any dental benefit provided by a network provider. We urge all of members to verify all fees for proposed treatment via this "Schedule of Benefits" and/or with our Member Services Department prior to treatment.
The following Member co‐payments apply when a participating General Dentist performs services. An "*" denotes limitations on certain benefits (see "Exclusions/Limitations").
CODE DESCRIPTION
D0120
D0140
D0145
D0150
D0160
D0170
D0171
D0180
D9310
D9430
D9440
D9450
D9986
MEMBER CODE DESCRIPTION
COPAY
CLINICAL ORAL EVALUATIONS
*Periodic oral evaluation ‐ established patient
Limited oral evaluation ‐ problem focused
*Oral evaluation for a patient under three years of age and counseling with primary caregiver
*Comprehensive oral evaluation ‐ new or established patient
*Detailed and extensive oral evaluation ‐ problem focused, by report
Re‐evaluation ‐ limited, problem focused (established patient; not post‐operative visit)
Re‐evaluation ‐ post‐operative office visit
*Comprehensive periodontal evaluation ‐ new or established patient
Consultation ‐ diagnostic service provided by dentist or physician other than requesting dentist or physician
Office visit for observation (during regularly scheduled hours) ‐ no other services performed
Office visit ‐ after regularly scheduled hours
Case presentation, detailed and extensive treatment planning
Missed appointment
D1058 213-11619
MEMBER COPAY
0 D0210
0 D0220
0 D0230
DIAGNOSTIC IMAGING
*Intraoral ‐ complete series (including bitewings)
Intraoral ‐ periapical first radiographic images
Intraoral ‐ periapical each additional radiographic images
0
4
2
0 D0240
Intraoral ‐ occlusal radiographic images
0
0 D0250
Extraoral ‐ first radiographic images
0
0 D0260
Extraoral ‐ each additional radiographic images
0
0 D0270
0 D0272
*Bitewing ‐ single radiographic images
*Bitewings ‐ two radiographic images
0
0
25 D0273
*Bitewings ‐ three radiographic images
0
0 D0274
*Bitewings ‐ four radiographic images
0
35 D0277
0 D0290
25 D0310
*Vertical bitewings ‐ 7 to 8 radiographic images
Posterior‐anterior or lateral skull and facial bone survey radiographic images
Sialography
Underwritten by Solstice Benefits, Inc. Administered by Dental Benefit Providers, Inc.
29
150
150
CODE DESCRIPTION
MEMBER CODE DESCRIPTION
COPAY
D0320
Temporomandibular joint arthrogram, including injection
250 D0431
D0321
Other temporomandibular joint radiographic images, by report
Tomographic survey
*Panoramic radiographic images
Cephalometric radiographic images
150 D0460
D0322
D0330
D0340
150 D0470
50
125 D0472
Adjunctive pre‐diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures
Pulp vitality tests
65
Diagnostic casts
ORAL PATHOLOGY LABORATORY
Accession of tissue, gross examination, preparation and transmission of written report
Accession of tissue, gross and microscopic examination, preparation and transmission of written report
0
0
0
D0350
2D oral/facial photographic image obtainedintra‐orally or extra‐orally
D0364
*Cone beam CT capture and interpretation with limited field of view ‐ less than one whole jaw
149 D0474
Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report
0
D0365
*Cone beam CT capture and interpretation with field of view of one full dental arch ‐ mandible
139 D0480
0
D0366
139 D0486
189 D0602
D0370
*Maxillofacial ultrasound capture and interpretation
169 D0603
D0371
D0380
*Sialoendoscopy capture and interpretation
*Cone beam CT image capture with limited field of view ‐ less than one whole jaw
*Cone beam CT image capture with field of view of one full dental arch ‐ mandible
*Cone Beam CT image capture with field of view of one full dental arch ‐ maxilla, with or without cranium
169
149 D1110
Caries risk assessment and documentation, with a finding of low risk
Caries risk assessment and documentation, with a finding of moderate risk
Caries risk assessment and documentation, with a finding of high risk
DENTAL PROPHYLAXIS
*Prophylaxis ‐ adult
0
D0369
*Cone beam CT capture and interpretation with field of view of one full dental arch ‐ maxilla, with or without cranium
*Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium
*Cone beam CT capture and interpretation for TMJ series including two or more exposures
*Maxillofacial MRI capture and interpretation
Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report
Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report
Other oral pathology procedures, by report
139 D1110 Additional prophylaxis ‐ adult
139 D1120
*Prophylaxis ‐ child
184 D1120 Additional prophylaxis ‐ child
139
TOPICAL FLUORIDE TREATMENT (OFFICE PROCEDURE)
169 D1206
169 D1208
*Topical fluoride varnish
*Topical application of fluoride ‐ excluding varnish
15
0
20
D0367
D0368
D0381
D0382
D0383
D0384
D0385
D0386
D0393
D0394
*Cone beam CT image capture with field of view of both jaws, with or without cranium
*Cone beam CT image capture for TMJ series including two or more exposures
*Maxillofacial MRI image capture
*Maxillofacial ultrasound image capture
20 D0473
MEMBER COPAY
184 D0502
139 D0601
0
0
0
0
0
0
20
0
20
*Treatment simulation using 3D image volume
*Digital subtraction of two or more images or image volumes of the same modality
*Fusion of two or more 3D image volumes of one or more modalities
TESTS AND EXAMINATIONS
9 D9910
9
*Application of desensitizing medicament
OTHER PREVENTIVE SERVICES
9 D1310
Nutritional counseling for control of dental disease
0
0
D0415
Collection of microorganisms for culture and sensitivity
0 D1330
Tobacco counseling for the control and prevention of oral disease
Oral hygiene instructions
0
D0425
Caries susceptibility tests
0 D1351
*Sealant ‐ per tooth
0
D0395
D1058 213-11619
D1320
Underwritten by Solstice Benefits, Inc. Administered by Dental Benefit Providers, Inc.
CODE DESCRIPTION
D1352
MEMBER CODE DESCRIPTION
COPAY
MEMBER COPAY
0 D2644
Onlay ‐ porcelain/ceramic ‐ four or more surfaces
D1510
*Preventive resin restoration in a moderate to high caries risk patient ‐ permanent tooth
Sealant repair ‐ per tooth
SPACE MAINTAINERS (PASSIVE APPLIANCES)
*Space maintainer ‐ fixed ‐ unilateral
0 D2650
D2651
0 D2652
Inlay ‐ resin‐based composite ‐ one surface
Inlay ‐ resin‐based composite ‐ two surfaces
Inlay ‐ resin‐based composite ‐ three or more surfaces
200
220
260
D1515
D1520
D1525
*Space maintainer ‐ fixed ‐ bilateral
*Space maintainer ‐ removable ‐ unilateral
*Space maintainer ‐ removable ‐ bilateral
0 D2662
0 D2663
0 D2664
Onlay ‐ resin‐based composite ‐ two surfaces
Onlay ‐ resin‐based composite ‐ three surfaces
Onlay ‐ resin‐based composite ‐ four or more surfaces
240
260
283
D1550
D1555
Re‐cementation or re‐bond space maintainer
Removal of fixed space maintainer
AMALGAMS RESTORATIONS (INCLUDING POLISHING)
CROWNS ‐ SINGLE RESTORATIONS ONLY
*Crown ‐ resin‐based composite (indirect)
*Crown ‐ ¾ resin‐based composite (indirect)
195
195
D2140
D2150
D2160
D2161
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
D2330
RESIN BASED COMPOSITE RESTORATIONS ‐ DIRECT
Resin‐based composite ‐ one surface, anterior
D2390
D2391
D2392
D2393
D2394
Resin‐based composite ‐ two surfaces, anterior
Resin‐based composite ‐ three surfaces, anterior
Resin‐based composite ‐ four or more surfaces or involving incisal angle (anterior)
Resin‐based composite crown, anterior
Resin‐based composite ‐ one surface, posterior
Resin‐based composite ‐ two surfaces, posterior
Resin‐based composite ‐ three surfaces, posterior
Resin‐based composite ‐ four or more surfaces, posterior
D2410
GOLD FOIL RESOTRATIONS
Gold foil ‐ one surface
D2420
D2430
Gold foil ‐ two surfaces
Gold foil ‐ three surfaces
D1353
D2331
D2332
D2335
15
15 D2710
D2712
0
0
0
0
*Crown‐ resin with high noble metal
*Crown ‐ resin with predominantly base metal
*Crown ‐ resin with noble metal
*Crown ‐ porcelain/ceramic substrate
245*
245*
245*
245*
D2750
30 D2751
*Crown ‐ porcelain fused to high noble metal
*Crown ‐ porcelain fused to predominantly base metal
245*
245*
37 D2752
50 D2780
80 D2781
*Crown ‐ porcelain fused to noble metal
*Crown ‐ 3/4 cast high noble metal
*Crown ‐ 3/4 cast predominantly base metal
245*
245*
245*
*Crown ‐ 3/4 cast noble metal
*Crown ‐ 3/4 porcelain/ceramic
*Crown ‐ full cast high noble metal
*Crown ‐ full cast predominantly base metal
*Crown ‐ full cast noble metal
245*
245*
245*
245*
245*
*Crown ‐ titanium
*Provisional crown ‐ further treatment or completion of diagnosis necessary prior to final impression
245*
125
115
65
75
90
115
D2720
D2721
D2722
D2740
400*
D2782
D2783
D2790
D2791
D2792
D2794
75 D2799
95
125 D2910
D2510
D2520
Inlay ‐ metallic ‐ one surface
Inlay ‐ metallic ‐ two surfaces
225 D2920
235 D2921
OTHER RESTORATIVE SERVICES
Re‐cement or re‐bond inlay, onlay, veneer, or partial coverage restoration
Re‐cement or re‐bond indirectly fabricated or prefabricated post and core
Re‐cement or re‐bond crown
Reattachment of tooth fragment, incisal edge or cusp
D2530
Inlay ‐ metallic ‐ three or more surfaces
245 D2929
*Prefabricated porcelain/ceramic crown ‐ primary tooth
D2542
Onlay ‐ metallic‐two surfaces
325 D2930
Prefabricated stainless steel crown ‐ primary tooth
45
D2543
Onlay ‐ metallic‐three surfaces
340 D2931
Prefabricated stainless steel crown ‐ permanent tooth
55
D2544
D2610
Onlay ‐ metallic‐four or more surfaces
Inlay ‐ porcelain/ceramic ‐ one surface
350 D2932
275* D2933
Prefabricated resin crown
Prefabricated stainless steel crown with resin window
95
145
D2620
D2630
Inlay ‐ porcelain/ceramic ‐ two surfaces
Inlay ‐ porcelain/ceramic ‐ three or more surfaces
300* D2940
325* D2941
Protective restoration
Interim therapeutic restoration ‐ primary dentition
15
15
D2642
D2643
Onlay ‐ porcelain/ceramic ‐ two surfaces
Onlay ‐ porcelain/ceramic ‐ three surfaces
360* D2949
390* D2950
Restorative foundation for an indirect restoration
Core buildup, including any pins
20
70
INLAY/ONLAY RESTORATIONS
D1058 213-11619
D2915
Underwritten by Solstice Benefits, Inc. Administered by Dental Benefit Providers, Inc.
15
20
15
15
49*
CODE DESCRIPTION
MEMBER CODE DESCRIPTION
COPAY
D2951
Pin retention ‐ per tooth, in addition to restoration
15
D2952
Post and core in addition to crown, indirectly fabricated
88 D3310
D2953
Each additional indirectly fabricated post ‐ same tooth
95 D3320
D2954
Prefabricated post and core in addition to crown
D2955
MEMBER COPAY
75 D3330
ENDODONTIC THERAPY (INCLUDING TREATMENT PLAN, CLINICAL PROCEDURES & FOLLOW‐UP CARE)
Endodontic therapy, anterior tooth (excluding final restoration)
Endodontic therapy, bicuspid tooth (excluding final restoration)
Endodontic therapy, molar (excluding final restoration)
245
Post removal
30 D3331
Treatment of root canal obstruction; non‐surgical access
85
D2957
Each additional prefabricated post ‐ same tooth
30 D3332
75
D2960
D2961
D2962
Labial veneer (resin laminate) ‐ chairside
Labial veneer (resin laminate) ‐ laboratory
Labial veneer (porcelain laminate) ‐ laboratory
Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth
Internal root repair of perforation defects
ENDODONTIC RETREATMENT
Retreatment of previous root canal therapy ‐ anterior
300
D2970
Temporary crown (fractured tooth)
75 D3347
Retreatment of previous root canal therapy ‐ bicuspid
350
D2971
45 D3348
Retreatment of previous root canal therapy ‐ molar
440
D2975
D2980
Additional procedures to construct new crown under existing partial denture framework
Coping
Crown repair necessitated by restorative material failure
95
95 D3351
APEXIFICATION/RECALCIFICATION PROCEDURES
Apexification/recalcification
D2981
Inlay repair necessitated by restorative material failure
95 D3352
Apexification/recalcification ‐ interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)
90
D2982
Onlay repair necessitated by restorative material failure
95 D3353
Apexification/recalcification ‐ final visit (includes completed
root canal therapy ‐ apical closure/calcific repair of perforations, root resorption, etc.)
90
D2983
Veneer repair necessitated by restorative material failure
95
APICOECTOMY/PERIRADICULAR SERVICES
D2990
Resin infiltration of incipient smooth surface lesions
29 D3410
Apicoectomy ‐ anterior
100
PULP CAPPING
Pulp cap ‐ direct (excluding final restoration)
Pulp cap ‐ indirect (excluding final restoration)
PULPOTOMY
Therapeutic pulpotomy (excluding final restoration) ‐ removal of pulp coronal to the dentinocemental junction and application of medicament
D3421
25 D3425
25 D3426
D3427
30 D3428
Apicoectomy ‐ bicuspid (first root)
Apicoectomy ‐ molar (first root)
Apicoectomy (each additional root)
Periradicular surgery without apicoectomy
Bone graft in conjunction with periradicular surgery ‐ per tooth, single site
315
340
95
100
47
D3221
Pulpal debridement, primary and permanent teeth
95 D3429
Bone graft in conjunction with periradicular surgery ‐ each additional contiguous tooth in the same surgical site
42
D3222
Partial pulpotomy for apexogenesis ‐ permanent tooth with incomplete root development
ENDODONTIC THERAPY ON PRIMARY TEETH
75 D3430
Retrograde filling ‐ per root
75
Pulpal therapy (resorbable filling) ‐ anterior, primary tooth (excluding final restoration)
Pulpal therapy (resorbable filling) ‐ posterior, primary tooth
(excluding final restoration)
50 D3432
D3110
D3120
D3220
D3230
D3240
200 D3333
255*
390* D3346
D3431
50 D3450
D3460
D3470
D1058 213-11619
110
195
125
90
Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery
150
Guided tissue regeneration in conjunction with periradicular
Root amputation ‐ per root
150
Endodontic endosseous implant
Intentional reimplantation (including necessary splinting)
545
175
Underwritten by Solstice Benefits, Inc. Administered by Dental Benefit Providers, Inc.
110
CODE DESCRIPTION
MEMBER CODE DESCRIPTION
COPAY
OTHER ENDODONTIC PROCEDURES
Surgical procedure for isolation of tooth with rubber dam
D4275
95 D4276
D3920
Hemisection (including any root removal), not including root canal therapy
90 D4277
D3950
Canal preparation and fitting of preformed dowel or post
75 D4278
D3910
D4210
SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE CARE)
Gingivectomy or gingivoplasty ‐ four or more contiguous teeth or tooth bounded spaces per quadrant
MEMBER COPAY
Soft tissue allograft
Combined connective tissue and double pedicle graft, per tooth
Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft
502
65
Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site
NON SURGICAL PERIODONTAL SERVICE
75
215
175 D4320
Provisional splinting ‐ intracoronal
115
D4211
Gingivectomy or gingivoplasty ‐ one to three contiguous teeth or tooth bounded spaces per quadrant
81 D4321
Provisional splinting ‐ extracoronal
105
D4212
Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth
Gingival flap procedure, including root planing ‐ four or more contiguous teeth or tooth bounded spaces per quadrant
Gingival flap procedure, including root planing ‐ one to three contiguous teeth or tooth bounded spaces per quadrant
Apically positioned flap
49 D4341
*Periodontal scaling and root planing ‐ four or more teeth per quadrant
*Periodontal scaling and root planing ‐ one to three teeth per quadrant
50†
D4240
D4241
D4245
195 D4342
43†
185 D4355
*Full mouth debridement to enable comprehensive evaluation and diagnosis
50†
150 D4381
60†
100
D4249
D4260
Clinical crown lengthening ‐ hard tissue
Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant
230
375 D4910
*Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by
report
OTHER PERIODONTAL SERVICES
*Periodontal maintenance
D4261
Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant
325 D4910 Additional periodontal maintenance
D4263
Bone replacement graft ‐ first site in quadrant
450 D4920
D4264
Bone replacement graft ‐ each additional site in quadrant
325 D4921
Unscheduled dressing change (by someone other than treating dentist)
Gingival irrigation ‐ per quadrant
D4265
Biologic materials to aid in soft and osseous tissue regeneration
Guided tissue regeneration ‐ resorbable barrier, per site
325 D4999
Unspecified periodontal procedure, by report
325
325*
325*
350*
350*
D4266
D4267
osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant
325 D5110
COMPLETE DENTURES (INCLUDING ROUTINE POST‐
DELIVERY CARE)
*Complete denture ‐ maxillary
D4268
D4270
D4273
Surgical revision procedure, per tooth
Pedicle soft tissue graft procedure
Subepithelial connective tissue graft procedures, per tooth
0 D5120
250 D5130
335 D5140
*Complete denture ‐ mandibular
*Immediate denture ‐ maxillary
*Immediate denture ‐ mandibular
D4274
Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)
125
PARTIAL DENTURES (INCLUDING ROUTINE POST‐
DELIVERY CARE)
D5211
D1058 213-11619
*Maxillary partial denture ‐ resin base (including any conventional clasps, rests and teeth)
Underwritten by Solstice Benefits, Inc. Administered by Dental Benefit Providers, Inc.
50
25
15
0
400*
CODE DESCRIPTION
MEMBER CODE DESCRIPTION
COPAY
MEMBER COPAY
D5212
*Mandibular partial denture ‐ resin base (including any conventional clasps, rests and teeth)
400* D5761
*Reline mandibular partial denture (laboratory)
D5213
*Maxillary partial denture ‐ cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)
*Mandibular partial denture ‐ cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)
*Maxillary partial denture ‐ flexible base (including any clasps, rests and teeth)
*Mandibular partial denture ‐ flexible base (including any clasps, rests and teeth)
*Removable unilateral partial denture ‐ one piece cast metal (including clasps and teeth
ADJUSTMENTS TO DENTURES
Adjust complete denture ‐ maxillary
Adjust complete denture ‐ mandibular
Adjust partial denture ‐ maxillary
Adjust partial denture ‐ mandibular
425*
INTERIM PROSTHESIS
425* D5810
*Interim Complete denture (maxillary)
250*
425* D5811
*Interim complete denture (mandibular)
250*
425* D5820
*Interim partial denture (maxillary)
175*
245* D5821
*Interim partial denture (mandibular)
175*
D5214
D5225
D5226
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5670
REPAIRS TO COMPLETE DENTURES
*Repair broken complete denture base
*Replace missing or broken teeth ‐ complete denture (each
tooth)
REPAIRS TO PARTIAL DENTURES
*Repair resin denture base
*Repair cast framework
*Repair or replace broken clasp
*Replace broken teeth ‐ per tooth
*Add tooth to existing partial denture
15
15
15
15
D5850
D5851
D5862
D5899
35* D5982
35* D5987
D5988
35*
35* D6190
35*
35* D6010
35* D6012
OTHER REMOVABLE PROSTHESIS
Tissue conditioning, maxillary
Tissue conditioning, mandibular
Precision attachment, by report
Unspecified removable prosthodontic procedure, by report
NON‐CLINICAL PROCEDURES
Surgical stent
Commissure splint
85*
20
20
150
0
150*
150*
35* D6100
155*
Surgical splint
PRE‐SURGICAL SERVICES
Radiographic/surgical implant index, by report
SURGICAL SERVICES
*Surgical placement of implant body
*Surgical placement of interim body for transitional prosthesis
Implant removal, by report
IMPLANT SUPPORTED PROSTHETICS
150*
155* D6056
*Prefabricated Abutment
440
135* D6057
135* D6058
155* D6059
*Custom Abutment
*Abutment supported porcelain/ceramic crown
*Abutment supported porcelain fused to metal crown (high noble metal)
*Abutment supported porcelain fused to metal crown (predominantly base metal)
*Abutment supported porcelain fused to metal crown (noble metal)
*Abutment supported cast metal crown (high noble metal)
550
750
750
235
1010
1010
D5710
D5711
D5720
*Add clasp to existing partial denture
*Replace all teeth and acrylic on cast metal framework (maxillary)
*Replace all teeth and acrylic on cast metal framework (mandibular)
*Rebase complete maxillary denture
*Rebase complete mandibular denture
*Rebase maxillary partial denture
D5721
*Rebase mandibular partial denture
155* D6060
D5730
*Reline complete maxillary denture (chairside)
65* D6061
D5731
*Reline complete mandibular denture (chairside)
65* D6062
D5740
*Reline maxillary partial denture (chairside)
65* D6063
D5741
*Reline mandibular partial denture (chairside)
65* D6064
D5750
D5751
*Reline complete maxillary denture (laboratory)
*Reline complete mandibular denture (laboratory)
85* D6065
85* D6066
*Implant supported porcelain/ceramic crown
*Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
750
750
D5760
*Reline maxillary partial denture (laboratory)
85* D6067
*Implant supported metal crown (titanium, titanium alloy, high noble metal)
750
D5671
D1058 213-11619
*Abutment supported cast metal crown (predominantly base metal)
*Abutment supported cast metal crown (noble metal)
Underwritten by Solstice Benefits, Inc. Administered by Dental Benefit Providers, Inc.
700
750
750
750
750
750
CODE DESCRIPTION
MEMBER CODE DESCRIPTION
COPAY
MEMBER COPAY
D6068
*Abutment supported retainer for porcelain/ceramic FPD
750 D6241
*Pontic ‐ porcelain fused to predominantly base metal
245*
D6069
*Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
*Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
*Abutment supported retainer for porcelain fused to metal FPD (noble metal)
*Abutment supported retainer for cast metal FPD (high noble metal)
*Abutment supported retainer for cast metal FPD (predominantly base metal)
*Abutment supported retainer for cast metal FPD (noble metal)
750 D6242
*Pontic ‐ porcelain fused to noble metal
245*
750 D6245
*Pontic ‐ porcelain/ceramic
245*
750 D6250
*Pontic ‐ resin with high noble metal
245*
750 D6251
*Pontic ‐ resin with predominantly base metal
245*
750 D6252
*Pontic ‐ resin with noble metal
245*
750 D6253
*Provisional Pontic ‐ further treatment or completion of diagnosis necessary prior to final impression
D6070
D6071
D6072
D6073
D6074
0
D6075
*Implant supported retainer for ceramic FPD
750
FIXED PARTIAL DENTURE RETAINERS ‐ INLAYS/ONLAYS
D6076
*Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)
750 D6545
Retainer ‐ cast metal for resin bonded fixed prosthesis
D6077
*Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)
*Abutment supported crown ‐ (titanium)
*Implant /abutment supported removable denture for edentulous arch – maxillary
*Implant /abutment supported removable denture for edentulous arch – mandibular
*Implant /abutment supported removable denture for partially edentulous arch – maxillary
*Implant /abutment supported removable denture for partially edentulous arch – mandibular
750 D6548
750 D6600
1255 D6601
Retainer ‐ porcelain/ceramic for resin bonded fixed prosthesis
Inlay ‐ porcelain/ceramic, two surfaces
Inlay ‐ porcelain/ceramic, three or more surfaces
245*
245*
1255 D6602
Inlay ‐ cast high noble metal, two surfaces
245*
995 D6603
Inlay ‐ cast high noble metal, three or more surfaces
245*
995 D6604
Inlay ‐ cast predominantly base metal, two surfaces
245*
245*
3855 D6606
Inlay ‐ cast predominantly base metal, three or more surfaces
Inlay ‐ cast noble metal, two surfaces
2255 D6607
Inlay ‐ cast noble metal, three or more surfaces
245*
2255 D6608
Onlay ‐porcelain/ceramic, two surfaces
245*
Onlay ‐ porcelain/ceramic, three or more surfaces
245*
180 D6610
Onlay ‐ cast high noble metal, two surfaces
245*
400 D6611
Onlay ‐ cast high noble metal, three or more surfaces
245*
D6094
D6110
D6111
D6112
D6113
D6114
D6115
D6116
D6117
D6080
*Implant /abutment supported fixed denture for edentulous arch – maxillary
*Implant /abutment supported fixed denture for edentulous arch – mandibular
*Implant /abutment supported fixed denture for partially edentulous arch – maxillary
*Implant /abutment supported fixed denture for partially edentulous arch – mandibular
OTHER IMPLANT SERVICES
3855 D6605
D6609
180
225*
245*
D6090
Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis, and abutments and reinsertion of prosthesis
Repair implant supported prosthesis, by report
D6092
Recement implant/abutment supported crown
45 D6612
Onlay ‐ cast predominantly base metal, two surfaces
245*
D6093
Recement implant/abutment supported fixed partial denture
Repair implant abutment, by report
FIXED PARTIAL DENTURE PONTICS
*Pontic ‐ indirect resin based composite
*Pontic ‐ cast high noble metal
*Pontic ‐ cast predominantly base metal
*Pontic ‐ cast noble metal
*Pontic ‐ titanium
*Pontic ‐ porcelain fused to high noble metal
65 D6613
Onlay ‐ cast predominantly base metal, three or more surfaces
Onlay ‐ cast noble metal, two surfaces
Onlay ‐ cast noble metal, three or more surfaces
Inlay ‐ titanium
Onlay ‐ titanium
FIXED PARTIAL DENTURE RETAINERS ‐ CROWNS
*Crown ‐ indirect resin based composite
*Crown ‐ resin with high noble metal
*Crown ‐ resin with predominantly base metal
245*
D6095
D6205
D6210
D6211
D6212
D6214
D6240
D1058 213-11619
220 D6614
D6615
750 D6624
245* D6634
245*
245* D6710
245* D6720
245* D6721
Underwritten by Solstice Benefits, Inc. Administered by Dental Benefit Providers, Inc.
245*
245*
245*
245*
245*
245*
245*
CODE DESCRIPTION
MEMBER CODE DESCRIPTION
COPAY
D6722
D6740
*Crown ‐ resin with noble metal
*Crown ‐ porcelain/ceramic
245* D7261
245* D7270
D6750
*Crown ‐ porcelain fused to high noble metal
245* D7272
D6751
*Crown ‐ porcelain fused to predominantly base metal
D6752
MEMBER COPAY
Primary closure of a sinus perforation
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)
275
50
245* D7280
Surgical access of an unerupted tooth
125
*Crown ‐ porcelain fused to noble metal
245* D7282
125
D6780
*Crown ‐ 3/4 cast high noble metal
245* D7283
D6781
D6782
D6783
D6790
D6791
*Crown ‐ 3/4 cast predominantly base metal
*Crown ‐ 3/4 cast noble metal
*Crown ‐ 3/4 porcelain/ceramic
*Crown ‐ full cast high noble metal
*Crown ‐ full cast predominantly base metal
245*
245*
245*
245*
245*
Mobilization of erupted or malpositioned tooth to aid eruption
Placement of device to facilitate eruption of impacted tooth
Incisional biopsy of oral tissue‐hard (bone, tooth)
Incisional biopsy of oral tissue‐soft
Exfoliative cytological sample collection
Brush biopsy ‐ transepithelial sample collection
Transseptal fiberotomy/supra crestal fiberotomy, by report
D6792
*Crown ‐ full cast noble metal
245*
D6793
*Provisional retainer crown ‐ further treatment or completion of diagnosis necessary prior to final impression
D6794
*Crown ‐ titanium
D7285
D7286
D7287
D7288
D7291
80
125
85
75
25
40
ALVEOLOPLASTY ‐ SURGICAL PREPARATION OF RIDGE
125 D7310
245* D7311
OTHER FIXED PARTIAL DENTURE SERVICES
D7320
D6930
Re‐cement or re‐bond fixed partial denture
15 D7321
D6940
D6950
Stress breaker
Precision attachment
D6980
Fixed partial denture repair necessitated by restorative material failure
125
195 D7340
80 D7350
EXTRACTIONS (INCLUDES LOCAL ANESTHESIA, SUTURING, IF NEEDED, AND ROUTINE POST OPERATIVE CARE)
D7111
D7140
100
Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant
40
Alveoloplasty in conjunction with extractions ‐ one to three teeth or tooth spaces, per quadrant
Alveoloplasty not in conjunction with extractions –four or more teeth or tooth spaces, per quadrant
40
Alveoloplasty not in conjunction with extractions ‐ one to three teeth or tooth spaces, per quadrant
60
VESTIBULOPLASTY
Vestibuloplasty ‐ ridge extension (secondary epithelialization)
Vestibuloplasty ‐ ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)
SURGICAL EXCISION OF SOFT TISSUE LESIOINS
60
370
990
50 D7410
20 D7411
Excision of benign lesion up to 1.25 cm
Excision of benign lesion greater than 1.25 cm
25
50
30 D7412
Excision of benign lesion, complicated
55
D7220
Extraction, coronal remnants ‐ deciduous tooth
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth
OTHER SURGICAL PROCEDURES
Removal of impacted tooth ‐ soft tissue
D7230
Removal of impacted tooth ‐ partially bony
65 D7451
D7240
D7241
80
135 D7471
D7250
Removal of impacted tooth ‐ completely bony
Removal of impacted tooth ‐ completely bony, with unusual surgical complications
Surgical removal of residual tooth roots (cutting procedure)
D7251
D7260
Coronectomy ‐ intentional partial tooth removal
Oroantral fistula closure
270 D7473
160 D7485
D7210
D1058 213-11619
50 D7450
40 D7472
SURGICAL EXCISION OF INTRA‐OSSEOUS LESIONS
Removal of benign odontogenic cyst or tumor ‐ lesion diameter up to 1.25 cm
Removal of benign odontogenic cyst or tumor ‐ lesion diameter greater than 1.25 cm
EXCISION OF BONE TISSUE
Removal of lateral exostosis (maxilla or mandible)
65
95
95
Removal of torus palatinus
95
Removal of torus mandibularis
Surgical reduction of osseous tuberosity
95
95
Underwritten by Solstice Benefits, Inc. Administered by Dental Benefit Providers, Inc.
CODE DESCRIPTION
MEMBER CODE DESCRIPTION
COPAY
SURGICAL INCISION
Incision and drainage of abscess ‐ intraoral soft tissue
D8670
20 D8680
D7511
Incision and drainage of abscess ‐ intraoral soft tissue ‐ complicated (includes drainage of multiple fascial spaces)
20 D8693
D7520
Incision and drainage of abscess ‐ extraoral soft tissue
D7521
Incision and drainage of abscess ‐ extraoral soft tissue ‐ complicated (includes drainage of multiple fascial spaces)
D7510
MEMBER COPAY
Periodic orthodontic treatment visit
Orthodontic retention (removal of appliances, construction and placement of retainer(s))
Rebonding or recementing; and/or repair, as required, of fixed retainers
0
300
20 D8999
Unspecified orthodontic procedure, by report
250
20
UNCLASSIFIED TREATMENT
REPAIR OF TRAUMATIC WOUNDS
350 D9211
Palliative (emergency) treatment of dental pain ‐ minor procedure
Fixed partial denture sectioning
ANESTHESIA
Local anesthesia not in conjunction with operative or surgical procedures
Regional block anesthesia
800 D9212
Trigeminal division block anesthesia
350 D9215
100 D9220
Local anesthesia
Deep sedation/general anesthesia ‐ first 30 minutes
105 D9221
D7963
D7970
Frenulectomy (frenectomy or frenotomy) ‐ separate procedure
Frenuloplasty
Excision of hyperplastic tissue ‐ per arch
D7971
Excision of Pericoronal Gingiva
102 D9242
D7972
125 D9248
D8010
Surgical reduction of fibrous tuberosity
LIMITED ORTHODONTIC TREATMENT
Limited orthodontic treatment of the primary dentition
1000 D9610
Deep sedation/general anesthesia – each additional 15 minutes
Analgesia, anxiolysis, inhalation of nitrous oxide
Intravenous moderate (conscious) sedation/analgesia – first 30 minutes
Intravenous moderate (conscious) sedation/analgesia – each additional 15 minutes
Non‐intravenous moderate (conscious) sedation
DRUGS
Therapeutic parenteral drug, single administration
D8020
Limited orthodontic treatment of the transitional dentition
1000 D9630
Other drugs and/or medicaments, by report
D8030
Limited orthodontic treatment of the adolescent dentition
1000
MISCELLANEOUS SERVICES
D8040
Limited orthodontic treatment of the adult dentition
1350 D9910
*Application of desensitizing medicament
20
COMPREHENSIVE ORTHODONTIC TREATMENT
Comprehensive orthodontic treatment of the transitional dentition
Comprehensive orthodontic treatment of the adolescent dentition
Comprehensive orthodontic treatment of the adult dentition
MINOR TREATMENT TO CONTROL HARMFUL HABITS
Removable appliance therapy
Fixed appliance therapy
OTHER ORTHODONTIC SERVICES
Pre‐orthodontic treatment examination to monitor growth and development
D9910
2200 D9930
20
0
2250 D9931
*Application of desensitizing medicament
Treatment of complications (post‐surgical) ‐ unusual circumstances, by report
Cleaning and inspection of a removable appliance
2350 D9940
*Occlusal guard, by report
250
Repair and/or reline of Occlusal guard
Occlusion analysis ‐ mounted case
Occlusal adjustment ‐ limited
Occlusal adjustment ‐ complete
External bleaching ‐ per tooth
40
75
30
100
30
External bleaching for home application, per arch; includes materials and fabrication of custom trays
240
D7910
D7921
D7950
D7951
D7952
D7953
D7960
D8070
D8080
D8090
D8210
D8220
D8660
D9110
0
Suture of recent small wounds up to 5 cm
OTHER REPAIR PROCEDURES
Collection and application of autologous blood concentrate product
Osseous, osteoperiosteal, or cartilage graft of the mandible
or maxilla ‐ autogeneous or nonautogeneous, by report
Sinus augmentation with bone or bone substitutes via a lateral open approach
Sinus augmentation via a vertical approach
Bone replacement graft for ridge preservation – per site
35 D9120
#N/A
125 D9210
105 D9230
140 D9241
D9942
103 D9950
103 D9951
D9952
35 D9973
D9975
D1058 213-11619
Underwritten by Solstice Benefits, Inc. Administered by Dental Benefit Providers, Inc.
0
0
0
0
0
0
125
15
20
125
55
15
15
15
0
Specialty Services
1
This Member Schedule of Benefits applies when listed dental services are performed by a participating General Dentist, unless otherwise authorized by Solstice.
2
Procedures not listed on the Schedule of Benefits that are performed by a participating General Dentist will be charged at the participating General Dentist’s usual and customary fee less 25%.
The participating General Dentist you select may not perform all procedures listed. The copayments shown apply to participating General Dentists.
Should the services of a specialist (Oral Surgeon, Endodontist, Periodontist, or Pediatric Dentist) be necessary, you may receive this care in either of two ways: (1) You may go directly to a participating specialist with no referral and receive a 25% reduction off the provider’s usual and customary fee; or (2) You may obtain prior written authorization from Solstice and receive specialty treatment by an approved participating specialist at the listed copayments. Please refer to the Specialty Care Referral Policy in your Member handbook.
3
4
5
Should the services of an Orthodontist be necessary, you may receive care in either of two ways: (1) You may go directly to a participating specialist with no referral and receive a 25% reduction off the provider’s usual and customary fee; or (2) You may contact Member Services to locate your nearest participating Orthodontist who will perform covered services at the listed member co‐pay.
6
Members seeking implant treatment should refer to their participating implantologist, a select network of providers. Not all providers perform the implant procedures at the copay listed on the Schedule of Benefits. Exclusions
1
2
3
4
5
6
7
Services performed by a dentist or dental specialist, not contracted with Solstice without prior approval.
Any dental services or appliances which are determined to be not reasonable and/or necessary for maintaining or improving the Member’s dental health or experimental in nature, as determined by the participating Solstice dentist.
Orthographic surgery or procedures and appliances for the treatment of myofunctional, myoskeletal or temporomandibular joint disorders unless otherwise specified as an orthodontic benefit on the Schedule of Benefits.
Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions, or medications. Treatment of malignancies, cysts, or neoplasms, without proof of medical necessity and prior Solstice approval.
Dental procedures initiated prior to the Member’s eligibility under this benefit plan or started after the Member’s termination from the plan.
Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the Member, including but not limited to, physical or emotional resistance, inability to visit the dental office, or allergy to commonly utilized local anesthetics
Limitations
1
2
3
4
5
6
7
8
9
10
Any oral evaluation (excluding problem) is limited to One (1) time per consecutive six (6) months;Comprehensive exams can only be covered one (1) time per 36 months, if and only if patient is considered to be new or an established patient. All subsequent oral evaluations will be at a 25% reduction off the dentist’s usual and customary fee without a frequency limitation.
All bitewing X‐rays are limited to one set in any twelve (12) consecutive month period.
The dental prophylaxis or periodontal maintenance procedure is limited to one (1) time in any consecutive six (6) month period. Any additional procedures will follow
D1110 and D4910 Member copayments as listed in the Schedule of Benefits.
Fluoride treatment is limited to one (1) in any twelve (12) consecutive month period for children under the age of 16.
Sealants (D1351 or D1352) are limited to one (1) time per tooth in any three (3) consecutive year period. This is only allowed for unrestored permanent molar teeth for children under the age of 16.
Space maintainers and all adjustments are limited to children under the age of 16.
Harmful habit appliances are limited to one (1) time per person under the age of 16.
General anesthesia or IV sedation is available when listed on the Schedule of Benefits, medically necessary, and previously approved by Solstice.
New dentures include one (1) reline within the first six (6) months
Replacement of crowns, implants, and fixed bridges or dentures is limited to one (1) time every consecutive five (5) years.
D1058 213-11619
Underwritten by Solstice Benefits, Inc. Administered by Dental Benefit Providers, Inc.
Limitations Continued
When crown , implant and/or bridgework exceed six (6) consecutive units, there will be an additional charge of $30.00 per unit.
11
12
Copayments marked by ‘*’ do not include the cost of material and laboratory fees. Additional cost to patient is as follows: ‐ High noble metal (precious) up to $145.00
‐ Titanium metal up to $120 (covered with proof of allergy to other metals)
‐ Noble metal (semi‐precious) up to $120.00
‐ Predominantly base metal (non‐precious) up to $55.00
‐ Crown laboratory fees up to $155.00
‐ Laboratory fees on dentures up to $225.00
‐ Porcelain laboratory fees for D2610‐D2644, D2929, D2961, D2962, D6600, D6601, D6608, and D6609 up to $65.00
‐ Denture repair laboratory fees up to $50.00
‐ All ceramic and/or porcelain crown material fees up to $155.00
13
14
15
16
17
Copayments marked by “†” are not eligible at a specialist.
Either D0210 or D0330 are reimbursable one (1) time every five (5) consecutive years.
Copies of X‐rays can be obtained for $2 per periapical image up to a maximum of $30. Panoramic X‐ray can be obtained for a $15 fee.
D0274, D0277 or D0210 are payable only when other inclusive image have not been taken (paid) within the last six (6) months.
All denture adjustment fees are for dentures which were not fabricated at the present office; All denture adjustment for new dentures made within 12 months are at no fee to the member.
18
19
Emergency treatment is available for palliative treatment for the abatement of pain up to $100.00 per occurrence.
Surgical removal of wisdom tooth covered when pathology (disease) exists. Surgical removal of wisdom teeth/3rd molar when pathology does not exist will be covered at 25% off of the general dentists or specialists usual and customary fees. Orthodontic related surgeries (except D7280) needed to relieve crowding or to facilitate eruption are available at a 25% reduction off of the doctor’s usual and customary fees.
21
Member may choose Invisalign in place of traditional Orthodontic treatment, and would pay the sum of the listed member Ortho co‐pay plus the difference in cost for the enhanced treatment.
Occlusal Guard(s) is limited to one (1) time in any consecutive thirty‐six (36) months for the purposes of habitual grinding/Bruxism.
D0364‐D0395 is limited to one (1) time per sixty (60) months, covered only in a dental setting and not in a radiographic imaging center.
22
23
D1058 213-11619
Underwritten by Solstice Benefits, Inc. Administered by Dental Benefit Providers, Inc.