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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.