California Family Dental PPO...California Family Dental PPO 4 | Page CA_IP_FAM_SOB_PPO_17 CLASSES OF...

CaliforniaFamilyDentalPPO

1|P a g eCA_IP_FAM_SOB_PPO_17

Thissummaryofbenefits,alongwiththeexclusionsandlimitationsdescribethebenefitsoftheCaliforniaFamilyDentalPPOPlan.Pleasereviewcloselytounderstandallbenefits,exclusionsandlimitations.MemberCostShareamountsdescribetheEnrollee'soutofpocketcosts.

Child‐ONLY*EssentialHealthBenefit

MemberCostShare

In‐Network

CoveredPercentage

InNetwork

MemberCostShareOut‐of‐

Network**

CoveredPercentageOut‐of‐

Network**Network

ClassI/Preventive‐Cleanings,Exams,Fluoride,Sealants,SpaceMaintainers,EmergencyPain,andRadiographs

(Bitewings,FullMouthX‐ray,PanoramicFilm).0% 100% 10% 90%

ClassII/Basic‐Restorations(AmalgamsandAnteriorResins),SimpleExtractions,Anesthesia(General

AnesthesiaandIntravenousSedation)PeriodonticsandPeriodontalMaintenance.

20% 80% 30% 70%

ClassIII/Major‐SurgicalExtractions,OralSurgery,Endodontics,Inlay,Onlays,Crowns,CrownRepair,Bridges,

BridgeRepairs,DenturesandDentureRepair.50% 50% 50% 50%

ClassIV/Orthodontia(Onlyforpre‐authorizedMedicallyNecessaryOrthodontia) 50% 50% 50% 50%

Deductible(waivedforClassI)(perperson) $65 N/A $65 N/AFamilyDeductible(waivedforClassI)(2+children) $130 N/A $130 N/A

OutofPocketMaximum(OOP)(perperson) $350 N/A N/A N/A

FamilyOutofPocketMaximum***(OOP)(2+children) $700 N/A N/A N/AAnnualMaximum N/A

OrthoLifetimeMaximum N/AWaitingPeriod N/A

* Thisplanisavailableforindividualsuptoage19.**BenefitsarebasedontheUsualandCustomarychargesofthemajorityofdentistsinthesamegeographicarea.

***2familymembersmusteachmeettheoutofpocketmaximuminaplanyear.Oncefulfilledthefamilymaximumhasbeenmetandwillnotbeappliedtoadditionalfamilymembers

THERE IS NO OUT OF POCKET MAXIMUM WHEN SERVICES ARE RECEIVED OUT‐OF‐NETWORK.


2|P a g eCA_IP_FAM_SOB_PPO_17

Adult‐ONLY*PPOPlan MemberCostShareIn‐Network

CoveredPercentageInNetwork MemberCostShare

Out‐of‐Network**

CoveredPercentageOut‐of‐Network**

NetworkClassI/Preventive‐Cleanings,Exams,EmergencyPain,

Radiographs‐BitewingsandRadiographs(FullMouthX‐ray,PanoramicFilm).

0% 100% 10% 90%

ClassII/Basic‐Restorations(Amalgams&AnteriorResin),SimpleExtractions,PeriodontalMaintenanceand

Anesthesia.20% 80% 30% 70%

ClassIII/Major‐Inlay,Onlays,Crowns,CrownRepair,Bridges,BridgeRepairs,Dentures,DentureRepair,SurgicalExtractions,OralSurgery,EndodonticsandPeriodontics.

50% 50% 50% 50%

ClassIV/Orthodontia N/A

Deductible(waivedforClassI) $50FamilyDeductible(waivedforClassI)(2+children) N/A

OutofPocketMaximum(OOP)(perperson) N/A

OutofPocketMaximum(OOP)(perfamily‐2+children) N/A

AnnualMaximum $1,500OrthoLifetimeMaximum N/A

WaitingPeriod 6monthsforMajorServices(Waivedwithproofofpriorcoverage)**** Thisplanisavailableforindividualsages19andover.**BenefitsarebasedontheUsualandCustomarychargesofthemajorityofdentistsinthesamegeographicarea.***Priorcoveragewithagroupplannotmorethan30dayslapsepriortoeffectivedate.


3|P a g e

CA_IP_FAM_SOB_PPO_17

PremierAccess'sserviceareaincludesthefollowingcountiesinCalifornia:Alameda,Butte,Colusa,ContraCosta,ElDorado,Fresno,Kern,LosAngeles,Marin,Merced,Monterey,Napa,Orange,Placer,Riverside,Sacramento,SanBenito,SanBernardino,SanDiego,SanFrancisco,SanJoaquin,SanMateo,SantaBarbara,SantaClara,SantaCruz,Solano,Sonoma,Stanislaus,Tulare,VenturaandYolo

ProviderAvailability

Ifanetworkgeneralorspecialistdentistisunavailableandthememberhasnooptionbuttoreceivemedicallynecessarycoveredtreatmentfromanon‐networkgeneralorspecialistdentist,PremierAccesswillbeavailabletoassistamemberinidentifyinganon‐networkgeneralorspecialistdentistandwillcoverthetreatmentatthein‐networkcostshare,whichincludesapplicabilityofthein‐networkdeductibleandout‐of‐pocketmaximum.Considerationforin‐networkreimbursementoftreatmentperformedbyanon‐networkgeneralorspecialistdentistwillbe limitedtocoveredmedicallynecessarydentalservices. Pleaserefertotheproviderdirectoryforacomplete listingofPremierAccess'scontracteddentists.Oryoumayaccessourwebsiteatwww.premierlife.com/providersearchtoviewPremierAccesscontracteddentists.

PremierAccessshallprovideaccessibilitytodentallyrequiredspecialistswhoarecertifiedoreligibleforcertificationbytheappropriatespecialtyboard,throughcontractingorreferral.Theprovideraccessibilitystandardsareasfollows:

1. Ageneraldentistisnotlocated:a)within30minutesor15milesofamember'shomeorplaceofemployment;2. Aspecialistdentistisnotlocated:a)within60minutesor30milesofamember'shomeorplaceofemployment.

PremierAccesswillverifyinformationrelatedtothenotificationfromthememberthatanetworkgeneralorspecialistdentistwasnotavailablewithintheparametersabove. The informationverifiedmay include,butmaynotbe limited to, reviewof thenetworkgeneralandspecialistdentistsavailablewithin the requireddrivingdistancefromthemember’shomeorplaceofemployment.


4|P a g e


CLASSESOFCOVEREDSERVICESANDSUPPLIES(IndividualsuptoAge19)

Coverageisprovidedforthedentalservicesandsuppliessummarizedbelow.Foracompletelistofcoveredservices,pleasereferencethelistingattheendofthissection.

Pleasenotetheageandfrequencylimitationsthatapplyforcertainprocedures.Allfrequencylimitsspecifiedareappliedtotheday.

ForYourPolicy,specificCoveredServicesandSuppliesmayfallunderaClasscategoryotherthanwhatisstatedbelow.IfYourPolicyhasClasscategorizationsdifferentfrombelow,itisspecifiedontheScheduleofBenefits.

ClassI:PreventiveDentalServices

DiagnosticandPreventiveBenefitsBenefitincludes:

• Initialandperiodicoralexaminations• Consultations,includingspecialistconsultations• Topicalfluoridetreatment• Preventivedentaleducationandoralhygieneinstruction• Radiographs(x‐rays)• Prophylaxisservices(cleanings)• Dentalsealanttreatments• SpaceMaintainers,includingremovableacrylicandfixedbandtype• Preventivedentaleducationandoralhygieneinstruction

LimitationsX‐Raysarelimitedasfollows:

• Examsarelimitedtoone(1)inasix(6)consecutivemonthperiod• Bitewingx‐raysinconjunctionwithperiodicexaminationsare

limitedtoone(1)seriesoffour(4)filmsinanysix(6)consecutivemonthperiod.

• Fullmouthx‐raysinconjunctionwithperiodicexaminationsarelimitedtoonceeverythirty‐six(36)consecutivemonths

• Panoramicfilmx‐raysarelimitedtoonceeverythirty‐six(36)consecutivemonthsexceptwhendocumentedasessentialforafollow‐up/post‐operativeexam(suchasafteroralsurgery).

• Prophylaxisservices(cleanings)arelimitedtoone(1)inasix(6)consecutivemonthperiod

• Fluoridetreatmentsarelimitedtoone(1)inasix(6)consecutivemonthperiod

• Dentalsealanttreatmentsarelimitedtopermanentfirstandsecondmolarsonly.Limitedtooncepertoothinathirty‐six(36)consecutivemonthperiod.

ClassII:BasicDentalServices

RestorativeDentistryRestorationsinclude:

• Amalgam,compositeresin,acrylic,syntheticorplasticrestorationsforthetreatmentofcaries

• Microfilledresinrestorationswhicharenon‐cosmetic• Replacementofarestoration• Useofpinsandpinbuild‐upinconjunctionwitharestoration• Sedativebaseandsedativefillings

LimitationsRestorationsarelimitedtothefollowing:


5|P a g e


• Forthetreatmentofcaries,ifthetoothcanberestoredwithamalgam,compositeresin,acrylic,syntheticorplasticrestorations;anyotherrestorationsuchasacrownorjacketisconsideredoptional

• Replacementofarestorationiscoveredonlywhenitisdefective,asevidencedbyconditionssuchasrecurrentcariesorfracture,andreplacementisdentallynecessary.Limitedtooncepertoothinatwelve(12)consecutivemonthperiod.

Periodontics

Periodonticbenefits include:• Emergency treatment, including treatmentforperiodontal

abscess andacuteperiodontitis• Periodontalscaling androotplaning,andsubgingivalcurettage• Gingivectomy• Osseous ormuco‐gingival surgery

Limitation

• Periodontal scalingandrootplaning is limited tofour(4)quadrant treatments inany twenty‐four(24)consecutivemonths

PeriodontalMaintenance• Periodontalmaintenanceprocedure(followingactivetreatment).

Benefitlimitedtoone(1)periodontalmaintenanceprocedureperthree(3)consecutivemonthperiod.

• Periodontalmaintenanceproceduresmaybeusedinthosecasesinwhichapatienthascompletedactiveperiodontaltherapy.Theprocedureincludesanyexaminationforevaluation,curettage,rootplaningand/orpolishingasmaybenecessary.

ClassIII:MajorDentalServices

OralSurgery

OralSurgery includes:

• Extractions,including surgicalextractions• Removalofimpacted teeth• Biopsyoforaltissues• Alveolectomies• Excisionofcystsandneoplasms• Treatment ofpalataltorus• Treatment ofmandibular torus• Frenectomy• Incision anddrainage ofabscesses• Post‐operative services, including exams,sutureremovaland

treatment ofcomplications• Rootrecovery (separate procedure)

Limitation

• Thesurgicalremovalofimpactedteethisacoveredbenefit onlywhen evidence ofpathology exists

Endodontics

• Directpulpcapping• Therapeuticpulpotomy• Pulpaldebridement• Partialpulpotomy• Pulpaltherapy(bothanteriorandposterior)• Apexification fillingwithcalciumhydroxide• Rootamputation• Rootcanaltherapy, including culturecanalandlimited

retreatment ofprevious rootcanaltherapyasspecified below• Apicoectomy• Vitalitytests


6|P a g e


LimitationsRootcanaltherapy,including culturecanal,islimitedasfollows:

• Retreatment ofrootcanals isacoveredbenefitonlyifclinicalorradiographicsignsofabscess formationarepresent and/orthepatient isexperiencing symptoms

• Removalorretreatment ofsilverpoints,overfills,underfills,incomplete fills,orbrokeninstruments lodged inacanal,intheabsence ofpathology, isnotacoveredbenefit

Crown andFixedBridge

Crownandfixedbridgebenefits include:

• Crowns, including thosemadeofacrylic,acrylicwithmetal,porcelain, porcelain withmetal,fullmetal,goldonlayorthreequartercrown,andstainless steel

• Relateddowelpins andpinbuild‐up• Fixedbridges,whicharecast,porcelainbakedwithmetal,or

plasticprocessed togold• Recementation ofcrowns,bridges,inlays andonlays• Castpostandcore,including castretentionunder crowns• Repair orreplacement ofcrowns,abutmentsorpontics

LimitationsThecrownbenefitislimitedasfollows:

• Replacement ofeachunit islimitedtoonceeverysixty (60)consecutive months,exceptwhenthecrown isnolongerfunctionalasdetermined by thedentalplan

• Onlyacrylic crowns andstainlesssteelcrowns areabenefit forchildren undertwelve(12)years ofage.Limitedtooncepertoothinatwelve(12)consecutivemonthperiod.Ifothertypesofcrownsarechosen asanoptionalbenefitforchildren under twelve(12)yearsofage,thecovered dentalbenefit levelwillbethatofanacrylic crown

• Crownswillbecovered onlyifthereisnotenoughretentivequality leftinthe toothtoholdafilling.Forexample, ifthebuccalorlingualwallsareeither fractured ordecayed totheextent thattheywillnotholdafilling

• Veneersposterior tothesecondbicuspidareconsideredoptional. Anallowance willbemade foracast fullcrown

Thefixedbridgebenefit islimitedasfollows:

• Fixedbridges willbeusedonlywhenapartialcannotsatisfactorily restore thecase.

Iffixedbridges areusedwhenapartialcouldsatisfactorily restore thecase,itisconsideredoptionaltreatment

• Afixedbridge iscovered whenitisnecessary toreplace amissing permanentanterior toothinaperson sixteen(16)yearsofageorolderand thepatient's oralhealthandgeneral dentalconditionpermits.Forchildren under theageofsixteen(16),itisconsidered optionaldentaltreatment. Ifperformed onaMemberunder theageofsixteen(16),theapplicantmustpaythedifference incostbetweenthefixedbridge andaspacemaintainer

• Fixedbridgesusedtoreplacemissingposteriorteethareconsidered optionalwhentheabutment teetharedentallysoundandwouldbecrowned only forthepurpose ofsupporting apontic

• Fixedbridges areoptionalwhenprovided inconnection withapartialdentureonthesamearch

• Replacement ofanexisting fixedbridge iscovered onlywhenitcannot bemadesatisfactory byrepair

• Theprogram allows uptofive(5)unitsofcrownorbridgeworkperarch.Upon thesixthunit,thetreatment isconsidered fullmouth reconstruction, which isoptionaltreatment

Removable Prosthetics


7|P a g e


Theremovable prosthetics benefit includes:

• Dentures, fullmaxillary, fullmandibular,partialupper,partiallower, teeth,clasps andstressbreakers

• Officeorlaboratory relinesorrebases• Denturerepair• Denture adjustment• Tissueconditioning• Denture duplication• SpaceMaintainer• Stayplate

LimitationsTheremovable prosthetics benefit islimitedasfollows:

• Partialdentureswillnotbereplacedwithinsixty(60)consecutivemonths,unless:1. Itisnecessary duetonaturaltoothlosswhere theaddition

orreplacement ofteethtotheexistingpartialisnotfeasible;or

2. Thedentureisunsatisfactory andcannotbemadesatisfactory

• Thecovereddentalbenefit forpartialdentureswillbelimited tothecharges foracastchromeoracrylicdentureifthiswouldsatisfactorily restore anarch.Ifamoreelaborateorprecisionappliance ischosenbythepatient andthedentist,andisnotnecessary tosatisfactorily restoreanarch,thepatientwillberesponsible foralladditionalcharges

• A removable partial denture is considered an adequaterestoration ofacase whenteetharemissing onboth sidesof thedental arch. Other treatments of such cases are consideredoptional

• Fullupperand/orlowerdenturesarenottobereplaced withinsixty(60)consecutivemonthsunless theexistingdentureis

unsatisfactory andcannotbemadesatisfactorybyreline orrepair

• Thecovereddentalbenefit forcompletedentureswillbe limitedtothebenefit levelforastandardprocedure.Ifamorepersonalizedorspecialized treatment ischosenbythepatientandthedentist,thepatientwillberesponsible foralladditionalcharges

• Officeorlaboratory relines arelimitedtoone(1)perarchinanytwelve(12)consecutivemonths

• Tissueconditioningislimitedtotwiceperdentureinathirty‐six(36)consecutivemonthperiod

• Stayplates areabenefit onlywhenusedasanteriorspacemaintainers forchildren

ImplantsImplant services are a benefit onlywhen exceptionalmedical conditions aredocumentedandshallbereviewedformedicalnecessity.Priorauthorizationisrequired.


8|P a g e


ClassIV:MedicallyNecessaryOrthodontia

OrthodonticsOrthodonticproceduresareabenefitonlywhen thediagnosticcastsverifyaminimum score of 26 points on the Handicapping Labio‐Lingual Deviation(HLD)IndexCaliforniaModificationScoreSheetForm,DC016(06/09)oroneofthesixautomaticqualifyingconditionsbelowexistorwhenthereiswrittendocumentation of a craniofacial anomaly from a credentialed specialist ontheirprofessionalletterhead.f.Theautomaticqualifyingconditionsare:i) cleftpalatedeformity.Ifthecleftpalateisnotvisibleonthediagnosticcastswritten documentation from a credentialed specialist shall be submitted, ontheirprofessionalletterhead,withthepriorauthorizationrequest,ii) craniofacialanomaly.Writtendocumentationfromacredentialedspecialistshall be submitted, on their professional letterhead, with the priorauthorizationrequest,iii) adeep impingingoverbite inwhich the lower incisorsaredestroyingthesofttissueofthepalate,iv) acrossbiteofindividualanteriorteethcausingdestructionofsofttissue,v) anoverjetgreaterthan9mmorreverseoverjetgreaterthan3.5mm,vi) a severe traumatic deviation (such as loss of a premaxilla segment byburns, accident or osteomyelitis or other gross pathology). Writtendocumentationof the traumaorpathologyshallbe submittedwith thepriorauthorizationrequest.MembercostshareforMedicallyNecessaryOrthodontiaservicesappliestocourseoftreatment,notindividualbenefityearswithinamulti‐yearcourseoftreatment.Thismembercostshareappliestothecourseoftreatmentaslongasthememberremainsenrolledintheplan.Please see the list of covered procedures listed below in the CDT Code andProcedureCodeDescriptionlisting.

OtherBenefits

Otherdentalbenefits include:• Localanesthetics• Oralsedativeswhendispensedinadentalofficebyapractitioner

actingwithinthescopeoftheirlicensure• Nitrousoxidewhendispensedinadentalofficebyapractitioner

actingwithinthescopeoftheirlicensure• Emergencytreatment,palliativetreatment• CoordinationofbenefitswithMember'shealthplan in theevent

hospitalization or outpatient surgery setting is medicallyappropriatefordentalservices

GeneralExclusions

CoveredServicesandSuppliesdonotinclude:

1. Treatmentwhichis:a. notincludedinthelistofCoveredServicesandSuppliesexcept

MedicallyNecessaryOrthodontia;b. notDentallyNecessary;orc. Experimentalinnature.

2. AnyChargeswhichare:a. Payableorreimbursablebyorthroughaplanorprogramof

anygovernmentalagency,exceptifthechargeisrelatedtoanon‐militaryservicedisabilityandtreatmentisprovidedbyagovernmentalagencyoftheUnitedStates.However,thePlanwillalwaysreimburseanystateorlocalmedicalassistance(Medicaid)agencyforCoveredServicesandSupplies.

b. Notimposedagainstthepersonorforwhichthepersonisnotliable.

c. ReimbursablebyMedicarePartAandPartB.IfapersonatanytimewasentitledtoenrollintheMedicareprogram(includingPartB)butdidnotdoso,hisorherbenefitsunderthisPolicywillbereducedbyanamountthatwouldhavebeenreimbursedbyMedicare,wherepermittedbylaw.

3. ServicesorsuppliesresultingfromorinthecourseofYourregularoccupationforpayorprofitforwhichYouorYourDependentarepaid


9|P a g e CA_IP_FAM_SOB_PPO_17

benefitsunderanyWorkers’CompensationLaw,Employer’sLiabilityLaworsimilarlaw.YoumustpromptlyclaimandnotifythePlanofallsuchbenefits.BenefitspaidunderthisplanthatarealsopaidunderanyWorkers’CompensationLaw,Employer’sLiabilityLaworsimilarlawmayberecovered.

4. ServicesorsuppliesprovidedbyaDentist,DentalHygienist,denturistordoctorwhoisaCloseRelativeorapersonwhoordinarilyresideswithYouoraDependent.

5. Servicesandsuppliesprovidedasonedentalprocedure,andconsideredoneprocedurebasedonstandarddentalprocedurecodes,butseparatedintomultipleprocedurecodesforbillingpurposes.TheCoveredChargefortheServicesisbasedonthesingledentalprocedurecodethataccuratelyrepresentsthetreatmentperformed.

6. Servicesandsuppliesprovidedprimarilyforcosmeticpurposesincludingbleaching/whitening.

7. ServicesandsuppliesobtainedwhileoutsideoftheUnitedStates,exceptforEmergencyDentalCare.

8. Diagnosticcasts.9. Educationalprocedures,includingbutnotlimitedtooralhygiene,

plaquecontrolordietaryinstructions.10. Personalsuppliesorequipment,includingbutnotlimitedtowaterpiks,

toothbrushes,orflossholders.11. Restorativeprocedures,rootcanalsandappliances,whichareprovided

becauseofattrition,abrasion,erosion,abfraction,wear,orforcosmeticpurposesintheabsenceofdecay.

12. Veneers13. Appliances,inlays,castrestorations,crownsandbridges,orother

laboratorypreparedrestorationsusedprimarilyforthepurposeofsplinting(temporarytoothstabilization).

14. ReplacementofalostorstolenApplianceorProsthesis.15. Replacementofstayplates.16. Extractionofpathology‐freeteeth,includingsupernumeraryteeth

(unlessformedicallynecessaryorthodontia)17. Socketpreservationbonegraphs18. Hospitalorfacilitychargesforroom,suppliesoremergencyroom

expenses,orroutinechestx‐raysandmedicalexamspriortooralsurgery.

19. Treatmentforajawfracture.20. Orthodonticservices,supplies,appliancesandOrthodontic‐related

services,unlessanOrthodonticriderwasincludedinthePolicy.21. Oralsedationandnitrousoxideanalgesiaarecoveredonlyasdescribed

inthecoveredservicessection.22. Therapeuticdruginjection.23. Chargesforcompletionofclaimforms.24. Misseddentalappointments.25. Thedifferenceincostbetweenacoveredserviceandanoptional

service.Forinstance,whenanamalgamisanappropriaterestorativetreatmentandacrownisoptedinstead.Theamountofthebenefitpaymentwillbefortheamalgamonly.


10|P a g e


COVEREDDENTALPROCEDURES(IndividualsuptoAge19)

CDTCodeandProcedureCodeDescription

DiagnosticD0120Periodicoralevaluation‐establishedpatientD0140Limitedoralevaluation–problemfocusedD0145OralevaluationforapatientunderthreeyearsofageandcounselingwithprimarycaregiverD0150Comprehensiveoralevaluation–neworestablishedpatientD0160Detailedandextensiveoralevaluation–problemfocused,byreportD0170Re‐evaluation–limited,problemfocused(establishedpatient;notpostoperativevisit)D0180Comprehensiveperiodontalevaluation–neworestablishedpatientD0210Intraoral‐completeseriesofradiographicimagesD0220Intraoral‐periapicalfirstradiographicimageD0230Intraoral‐periapicaleachadditionalradiographicimageD0240Intraoral‐occlusalradiographicimageD0250Extraoral‐firstradiographicimageD0260Extraoral‐eachadditionalradiographicimageD0270Bitewing‐singleradiographicimageD0272Bitewings‐tworadiographicimagesD0273Bitewings‐threeradiographicimagesD0274Bitewings‐fourradiographicimagesD0277Verticalbitewings‐7to8radiographicimagesD0290Posterior‐anteriororlateralskullandfacialbonesurveyradiographicimageD0310SialographyD0320Temporomandibularjointarthrogram,includinginjectionD0322TomographicsurveyD0330PanoramicradiographicimageD0340CephalometricradiographicimageD0350Oral/FacialphotographicimagesD0460Pulpvitalitytests

D0470DiagnosticcastsD0502Otheroralpathologyprocedures,byreportD0999Unspecifieddiagnosticprocedure,byreport

PreventiveD1110Prophylaxis–adultD1120Prophylaxis–childD1206Topicalapplicationoffluoridevarnish‐child0to20D1208Topicalapplicationoffluoride‐child0‐20D1310NutritionalcounselingforcontrolofdentaldiseaseD1320TobaccocounselingforthecontrolandpreventionoforaldiseaseD1330OralhygieneinstructionsD1351Sealant–pertoothD1352Preventiveresinrestorationinamoderatetohighcariesriskpatient‐permanenttoothD1510Spacemaintainer‐fixed–unilateralD1515Spacemaintainer‐fixed–bilateralD1520Spacemaintainer‐removable–unilateralD1525Spacemaintainer‐removable–bilateralD1550Re‐cementationofspacemaintainerD1555Removaloffixedspacemaintainer

RestorativeD2140Amalgam–onesurface,primaryorpermanentD2150Amalgam–twosurfaces,primaryorpermanentD2160Amalgam–threesurfaces,primaryorpermanentD2161Amalgam–fourormoresurfaces,primaryorpermanentD2330Resin‐basedcomposite–onesurface,anteriorD2331Resin‐basedcomposite–twosurfaces,anteriorD2332Resin‐basedcomposite–threesurfaces,anteriorD2335Resin‐basedcomposite–fourormoresurfacesorinvolvingincisalangle(anterior)D2390Resin‐basedcompositecrown,anteriorD2391Resin‐basedcomposite–onesurface,posteriorD2392Resin‐basedcomposite–twosurfaces,posteriorD2393Resin‐basedcomposite–threesurfaces,posterior


11|P a g e


D2394Resin‐basedcomposite–fourormoresurfaces,posteriorD2710Crown–resin‐basedcomposite(indirect)D2712Crown‐3/4resin‐basedcomposite(indirect)D2721Crown–resinwithpredominantlybasemetalD2740Crown–porcelain/ceramicsubstrateD2751Crown–porcelainfusedtopredominantlybasemetalD2781Crown–3/4castpredominantlybasemetalD2783Crown–3/4porcelain/ceramicD2791Crown–fullcastpredominantlybasemetalD2910Recementinlay,onlay,orpartialcoveragerestorationD2915RecementcastorprefabricatedpostandcoreD2920RecementcrownD2929Prefabricatedporcelain/ceramiccrown‐primarytoothD2930Prefabricatedstainlesssteelcrown–primarytoothD2931Prefabricatedstainlesssteelcrown–permanenttoothD2932PrefabricatedresincrownD2933PrefabricatedstainlesssteelcrownwithresinwindowD2940ProtectiverestorationD2950Corebuildup,includinganypinsD2951Pinretention–pertooth,inadditiontorestorationD2952Postandcoreinadditiontocrown,indirectlyfabricatedD2953Eachadditionalindirectlyfabricatedpost–sametoothD2954PrefabricatedpostandcoreinadditiontocrownD2955PostremovalD2957Eachadditionalprefabricatedpost‐sametoothD2970Temporarycrown(fracturedtooth)D2971AdditionalprocedurestoconstructnewcrownunderexistingpartialdentureframeworkD2980Crownrepair,necessitatedbyrestorativematerialfailureD2999Unspecifiedrestorativeprocedure,byreport

EndodonticsD3110Pulpcap–direct(excludingfinalrestoration)D3120Pulpcap–indirect(excludingfinalrestoration)D3220Therapeuticpulpotomy(excludingfinalrestoration)–removalofpulpcoronaltothedentinocementaljunctionapplicationofmedicament

D3221Pulpaldebridement,primaryandpermanentteethD3222Partialpulpotomyforapexogenesis‐permanenttoothwithincompleterootdevelopmentD3230Pulpaltherapy(resorbablefilling)–anterior,primarytooth(excludingfinalrestoration)D3240Pulpaltherapy(resorbablefilling)–posterior,primarytooth(excludingfinalrestoration)D3310Endodontictherapy,anteriortooth(excludingfinalrestoration)D3320Endodontictherapy,bicuspidtooth(excludingfinalrestoration)D3330Endodontictherapy,molartooth(excludingfinalrestoration)D3331Treatmentofrootcanalobstruction;non‐surgicalaccessD3333InternalrootrepairofperforationdefectsD3346Retreatmentofpreviousrootcanaltherapy–anteriorD3347Retreatmentofpreviousrootcanaltherapy–bicuspidD3348Retreatmentofpreviousrootcanaltherapy–molarD3351Apexification/Recalcification/Pulpalregeneration‐initialvisit(apicalclosure/calcificrepairofperforations,rootresorption,pulpspacedisinfectionetc.)D3352Apexification/Recalcification/Pulpalregeneration‐interimmedicationreplacementD3410Apicoectomy/Periradicularsurgery–anteriorD3421Apicoectomy/Periradicularsurgery–bicuspid(firstroot)D3425Apicoectomy/Periradicularsurgery–molar(firstroot)D3426Apicoectomy/Periradicularsurgery–(eachadditionalroot)D3430Retrogradefilling–perrootD3910SurgicalprocedureforisolationoftoothwithrubberdamD3999Unspecifiedendodonticprocedure,byreport

PeriodonticsD4210Gingivectomyorgingivoplasty–fourormorecontiguousteethortoothboundspacesperquadrantD4211Gingivectomyorgingivoplasty–onetothreecontiguousteethortoothboundedspacesperquadrantD4249Clinicalcrownlengthening–hardtissue



D4260Osseoussurgery(includingflapentryandclosure)–fourormorecontiguousteethortoothboundedspacesperquadrantD4261Osseoussurgery(includingflapentryandclosure)–onetothreecontiguousteethortoothboundedspaces,perquadrantD4265BiologicmaterialstoaidinsoftandosseoustissueregenerationD4341Periodontalscalingandrootplaning–fourormoreteethperquadrantD4342Periodontalscalingandrootplaning–onetothreeteeth,perquadrantD4355FullmouthdebridementtoenablecomprehensiveevaluationanddiagnosisD4381Localizeddeliveryofantimicrobialagentsviaacontrolledreleasevehicleintodiseasedcreviculartissue,pertoothD4910PeriodontalmaintenanceD4920Unscheduleddressingchange(bysomeoneotherthantreatingdentist)D4999Unspecifiedperiodontalprocedure,byreportByReportProsthodontics(Removable)D5110Completedenture–maxillaryD5120Completedenture–mandibularD5130Immediatedenture–maxillaryD5140Immediatedenture–mandibularD5211Maxillarypartialdenture–resinbase(includinganyconventionalclasps,restsandteeth)D5212Mandibularpartialdenture–resinbase(includinganyconventionalclasps,restandteeth)D5213Maxillarypartialdenture–castmetalframeworkwithresindenturebases(includinganyconventionalclasps,restandteeth)D5214Mandibularpartialdenture–castmetalframeworkwithresindenturebases(includinganyconventionalclasps,restandteeth)D5410Adjustcompletedenture–maxillaryD5411Adjustcompletedenture–mandibularD5421Adjustpartialdenture–maxillaryD5422Adjustpartialdenture–mandibularD5510Repairbrokencompletedenturebase

D5520Replacemissingorbrokenteeth–completedenture(eachtooth)D5610RepairresindenturebaseD5620RepaircastframeworkD5630RepairorreplacebrokenclaspD5640Replacebrokenteeth–pertoothD5650AddtoothtoexistingpartialdentureD5660AddclasptoexistingpartialdentureD5730Relinecompletemaxillarydenture(chairside)D5731Relinecompletemandibulardenture(chairside)D5740Relinemaxillarypartialdenture(chairside)D5741Relinemandibularpartialdenture(chairside)D5750Relinecompletemaxillarydenture(laboratory)D5751Relinecompletemandibulardenture(laboratory)D5760Relinemaxillarypartialdenture(laboratory)D5761Relinemandibularpartialdenture(laboratory)D5850Tissueconditioning,maxillaryD5851Tissueconditioning,mandibularD5860Overdenture–complete,byreportD5862Precisionattachment,byreportD5899Unspecifiedremovableprosthodonticprocedure,byreportByReportMaxillofacialProstheticsD5911Facialmoulage(sectional)D5912Facialmoulage(complete)D5913NasalprosthesisD5914AuricularprosthesisD5915OrbitalprosthesisD5916OcularprosthesisD5919FacialprosthesisD5922NasalseptalprosthesisD5923Ocularprosthesis,interimD5924CranialprosthesisD5925FacialaugmentationimplantprosthesisD5926Nasalprosthesis,replacementD5927Auricularprosthesis,replacement



D5928Orbitalprosthesis,replacementD5929Facialprosthesis,replacementD5931Obturatorprosthesis,surgicalD5932Obturatorprosthesis,definitiveD5933Obturatorprosthesis,modificationD5934MandibularresectionprosthesiswithguideflangeD5935MandibularresectionprosthesiswithoutguideflangeD5936Obturatorprosthesis,interimD5937Trismusappliance(notforTMDtreatment)D5951FeedingaidD5952Speechaidprosthesis,pediatricD5953Speechaidprosthesis,adultD5954PalatalaugmentationprosthesisD5955Palatalliftprosthesis,definitiveD5958Palatalliftprosthesis,interimD5959Palatalliftprosthesis,modificationD5960Speechaidprosthesis,modificationD5982SurgicalstentD5983RadiationcarrierD5984RadiationshieldD5985RadiationconelocatorD5986FluoridegelcarrierD5987CommissuresplintD5988SurgicalsplintD5991TopicalMedicamentCarrierD5999Unspecifiedmaxillofacialprosthesis,byreportImplantServicesImplantservicesareabenefitonlywhenexceptionalmedicalconditionsaredocumentedandshallbereviewedformedicalnecessity.Priorauthorizationisrequired.

D6010Surgicalplacementofimplantbody:endostealimplantD6040Surgicalplacement:epostealimplant

D6050Surgicalplacement:transostealimplantD6053Implant/AbutmentsupportedremovabledentureforcompletelyedentulousarchD6054Implant/AbutmentsupportedremovabledentureforpartiallyedentulousarchD6055Connectingbar‐implantsupportedorabutmentsupportedD6056Prefabricatedabutment‐includesmodificationandplacementD6057Customfabricatedabutment‐includesplacementD6058Abutmentsupportedporcelain/ceramiccrownD6059Abutmentsupportedporcelainfusedtometalcrown(highnoblemetal)D6060Abutmentsupportedporcelainfusedtometalcrown(predominantlybasemetal)D6061Abutmentsupportedporcelainfusedtometalcrown(noblemetal)D6062Abutmentsupportedcastmetalcrown(highnoblemetal)D6063Abutmentsupportedcastmetalcrown(predominantlybasemetal)D6064Abutmentsupportedcastmetalcrown(noblemetal)D6065Implantsupportedporcelain/ceramiccrownD6066Implantsupportedporcelainfusedtometalcrown(titanium,titaniumalloy,highnoblemetal)D6067Implantsupportedmetalcrown(titanium,titaniumalloy,highnoblemetal)D6068Abutmentsupportedretainerforporcelain/ceramicFPDD6069AbutmentsupportedretainerforporcelainfusedtometalFPD(highnoblemetal)D6070AbutmentsupportedretainerforporcelainfusedtometalFPD(predominantlybasemetal)D6071AbutmentsupportedretainerforporcelainfusedtometalFPD(noblemetal)D6072AbutmentsupportedretainerforcastmetalFPD(highnoblemetal)D6073AbutmentsupportedretainerforcastmetalFPD(predominantlybasemetal)D6074AbutmentsupportedretainerforcastmetalFPD(noblemetal)D6075ImplantsupportedretainerforceramicFPDD6076ImplantsupportedretainerforporcelainfusedtometalFPD(titanium,titaniumalloy,orhighnoblemetal)



D6077ImplantsupportedretainerforcastmetalFPD(titanium,titaniumalloy,orhighnoblemetal)D6078Implant/AbutmentsupportedfixeddentureforcompletelyedentulousarchD6079Implant/AbutmentsupportedfixeddentureforpartiallyedentulousarchD6080Implantmaintenanceprocedures,includingremovalofprosthesis,cleansingofprosthesisandabutmentsandreinsertionofprosthesisD6090Repairimplantsupportedprosthesis,byreportD6091Replacementofsemi‐precisionorprecisionattachment(maleorfemalecomponent)ofimplant/abutmentsupportedprosthesis,perattachmentD6092Recementimplant/abutmentsupportedcrownD6093Recementimplant/abutmentsupportedfixedpartialdentureD6094Abutmentsupportedcrown(titanium)D6095Repairimplantabutment,byreportD6100Implantremoval,byreportD6101DebridementofaperiimplantdefectandsurfacecleaningofexposedD6190Radiographic/Surgicalimplantindex,byreportD6194AbutmentsupportedretainercrownforFPD(titanium)D6199Unspecifiedimplantprocedure,byreportFixedProsthodonticsD6211Pontic–castpredominantlybasemetalD6241Pontic–porcelainfusedtopredominantlybasemetalD6245Pontic–porcelain/ceramicD6251Pontic–resinwithpredominantlybasemetalD6721Crown–resinwithpredominantlybasemetalD6740Crown–porcelain/ceramicD6751Crown–porcelainfusedtopredominantlybasemetalD6781Crown–3/4castpredominantlybasemetalD6783Crown–3/4porcelain/ceramicD6791Crown–fullcastpredominantlybasemetalD6930RecementfixedpartialdentureD6980Fixedpartialdenturerepair,necessitatedbyrestorativematerialfailure

D6999Unspecifiedfixedprosthodonticprocedure,byreportOralandMaxillofacialSurgeryD7111Extraction,coronalremnants–deciduoustoothD7140Extraction,eruptedtoothorexposedroot(elevationand/orforcepsremoval)D7210Surgicalremovaloferuptedtoothrequiringremovalofboneand/orsectioningoftooth,andincludingelevationofmucoperiostealflapifindicatedD7220Removalofimpactedtooth–softtissueD7230Removalofimpactedtooth–partiallybonyD7240Removalofimpactedtooth–completelybonyD7241Removalofimpactedtooth–completelybony,withunusualsurgicalcomplicationsD7250Surgicalremovalofresidualtoothroots(cuttingprocedure)D7260OroantralfistulaclosureD7261PrimaryclosureofasinusperforationD7270Toothreimplantationand/orstabilizationofaccidentallyevulsedordisplacedtoothD7280SurgicalaccessofanuneruptedtoothD7283PlacementofdevicetofacilitateeruptionofimpactedtoothD7285Biopsyoforaltissue–hard(bone,tooth)D7286Biopsyoforaltissue–softD7290SurgicalrepositioningofteethD7291Transseptalfiberotomy/supracrestalfiberotomy,byreportD7310Alveoloplastyinconjunctionwithextractions‐fourormoreteethortoothspaces,perquadrantD7311Alveoplastyinconjunctionwithextractions‐onetothreeteethortoothspaces,perquadrantD7320Alveoloplastynotinconjunctionwithextractions‐fourormoreteethortoothspaces,perquadrantD7321Alveoplastynotinconjunctionwithextractions‐onetothreeteethortoothspaces,perqaudrantD7340Vestibuloplasty–ridgeextension(secondaryepithelialization)



D7350Vestibuloplasty–ridgeextension(includingsofttissuegrafts,musclereattachment,revisionofsofttissueattachmentandmanagementofhypertrophiedandhyperplastictissue)D7410Excisionofbenignlesionupto1.25cmD7411Excisionofbenignlesiongreaterthan1.25cmD7412Excisionofbenignlesion,complicatedD7413Excisionofmalignantlesionupto1.25cmD7414Excisionofmalignantlesiongreaterthan1.25cmD7415Excisionofmalignantlesion,complicatedD7440Excisionofmalignanttumor–lesiondiameterupto1.25cmD7441Excisionofmalignanttumor–lesiondiametergreaterthan1.25cmD7450Removalofbenignodontogeniccystortumor–lesiondiameterupto1.25cmD7451Removalofbenignodontogeniccystortumor–lesiondiametergreaterthan1.25cmD7460Removalofbenignnonodontogeniccystortumor–lesiondiameterupto1.25cmD7461Removalofbenignnonodontogeniccystortumor–lesiondiametergreaterthan1.25cmD7465Destructionoflesion(s)byphysicalorchemicalmethod,byreportD7471Removaloflateralexostosis(maxillaormandible)D7472RemovaloftoruspalatinusD7473RemovaloftorusmandibularisD7485SurgicalreductionofosseoustuberosityD7490RadicalresectionofmaxillaormandibleD7510Incisionanddrainageofabscess–intraoralsofttissueD7511Incisionanddrainageofabscess‐intraoralsofttissue‐complicated(includesdrainageofmultiplefascialspaces)D7520Incisionanddrainageofabscess–extraoralsofttissueD7521Incisionanddrainageofabscess‐extraoralsofttissue–complicated(includesdrainageofmultiplefascialspaces)D7530Removalofforeignbodyfrommucosa,skin,orsubcutaneousalveolartissueD7540Removalofreactionproducingforeignbodies,musculoskeletalsystemD7550Partialostectomy/sequestrectomyforremovalofnon‐vitalbone

D7560MaxillarysinusotomyforremovaloftoothfragmentorforeignbodyD7610Maxilla–openreduction(teethimmobilized,ifpresent)D7620Maxilla–closedreduction(teethimmobilized,ifpresent)D7630Mandible–openreduction(teethimmobilized,ifpresent)D7640Mandible–closedreduction(teethimmobilized,ifpresent)D7650Malarand/orzygomaticarch–openreductionD7660Malarand/orzygomaticarch–closedreductionD7670Alveolus–closedreduction,mayincludestabilizationofteethD7671Alveolus–openreduction,mayincludestabilizationofteethD7680Facialbones–complicatedreductionwithfixationandmultiplesurgicalapproachesD7710Maxilla–openreductionD7720Maxilla–closedreductionD7730Mandible–openreductionD7740Mandible–closedreductionD7750Malarand/orzygomaticarch–openreductionD7760Malarand/orzygomaticarch–closedreductionD7770Alveolus–openreductionstabilizationofteethD7771Alveolus,closedreductionstabilizationofteethD7780Facialbones–complicatedreductionwithfixationandmultiplesurgicalapproachesD7810OpenreductionofdislocationD7820ClosedreductionofdislocationD7830ManipulationunderanesthesiaD7840CondylectomyD7850Surgicaldiscectomy,with/withoutimplantD7852DiscrepairD7854SynovectomyD7856MyotomyD7858JointreconstructionD7860ArthrostomyD7865ArthroplastyD7870ArthrocentesisD7871Non‐arthroscopiclysisandlavageD7872Arthroscopy–diagnosis,withorwithoutbiopsyD7873Arthroscopy–surgical:lavageandlysisofadhesions



D7874Arthroscopy–surgical:discrepositioningandstabilizationD7875Arthroscopy–surgical:synovectomyD7876Arthroscopy–surgical:discectomyD7877Arthroscopy–surgical:debridementD7880Occlusalorthoticdevice,byreportD7899UnspecifiedTMDtherapy,byreportD7910Sutureofrecentsmallwoundsupto5cmD7911Complicatedsuture–upto5cmD7912Complicatedsuture–greaterthan5cmD7920Skingraft(identifydefectcovered,locationandtypeofgraft)D7940Osteoplasty–fororthognathicdeformitiesD7941Osteotomy–mandibularramiD7943Osteotomy–mandibularramiwithbonegraft;includesobtainingthegraftD7944Osteotomy–segmentedorsubapicalD7945Osteotomy–bodyofmandibleD7946LeFortI(maxilla–total)D7947LeFortI(maxilla–segmented)D7948LeFortIIorLeFortIII(osteoplastyoffacialbonesformidfacehypoplasiaorretrusion)–withoutbonegraftD7949LeFortIIorLeFortIII–withbonegraftD7950Osseous,osteoperiosteal,orcartilagegraftofmandibleorfacialbones–autogenousornonautogenous,byreportD7951SinusaugmentationwithboneorbonesubstitutesviaalateralopenapproachD7952SinusaugmentationwithboneorbonesubstituteviaaverticalapproachD7955Repairofmaxillofacialsoftand/orhardtissuedefectD7960Frenulectomyalsoknownasfrenectomyorfrenotomy–separateprocedurenotincidentaltoanotherprocedureD7963FrenuloplastyD7970Excisionofhyperplastictissue–perarchD7971ExcisionofpericoronalgingivaD7972SurgicalreductionoffibroustuberosityD7980SialolithotomyD7981Excisionofsalivarygland,byreport

D7982SialodochoplastyD7983ClosureofsalivaryfistulaD7990EmergencytracheotomyD7991CoronoidectomyD7995Syntheticgraft–mandibleorfacialbones,byreportD7997Applianceremoval(notbydentistwhoplacedappliance),includesremovalofarchbarD7999Unspecifiedoralsurgeryprocedure,byreportOrthodonticsD8080ComprehensiveorthodontictreatmentoftheadolescentdentitionD8210RemovableappliancetherapyD8220FixedappliancetherapyD8660Pre‐orthodontictreatmentvisitD8670Periodicorthodontictreatmentvisit(aspartofcontract)D8680Orthodonticretention(removalofappliances,constructionandplacementofretainer(s))D8691RepairoforthodonticapplianceD8692ReplacementoflostorbrokenretainerD8693Rebondingorrecementing:and/orrepair,asrequired,offixedretainersD8999Unspecifiedorthodonticprocedure,byreportAdjunctivesD9110Palliative(emergency)treatmentofdentalpain–minorprocedureD9120FixedpartialdenturesectioningD9210LocalanesthesianotinconjunctionwithoperativeorsurgicalproceduresD9211RegionalblockanesthesiaD9212TrigeminaldivisionblockanesthesiaD9215LocalanesthesiainconjunctionwithoperativeorsurgicalproceduresD9220Deepsedation/generalanesthesia–first30minutesD9221Deepsedation/generalanesthesia–eachadditional15minutesD9230Inhalationofnitrousoxide/anxiolysisanalgesia



D9241Intravenousconscioussedation/analgesia–first30minutesD9242Intravenousconscioussedation/analgesia–eachadditional15minutesD9248Non‐intravenousconscioussedationD9310ConsultationdiagnosticserviceprovidedbydentistorphysicianotherthanrequestingdentistorphysicianD9410House/ExtendedcarefacilitycallD9420HospitalorambulatorysurgicalcentercallD9430Officevisitforobservation(duringregularlyscheduledhours)‐nootherservicesperformedD9440Officevisit–afterregularlyscheduledhoursD9610Therapeuticparenteraldrug,singleadministrationD9612Therapeuticparenteraldrug,twoormoreadministrations,differentmedicationsD9910ApplicationofdesensitizingmedicamentD9930Treatmentofcomplications(post‐surgical)–unusualcircumstances,byreportD9950Occlusionanalysis–mountedcaseD9951Occlusaladjustment–limitedD9952Occlusaladjustment–completeD9999Unspecifiedadjunctiveprocedure,byreport



CLASSESOFCOVEREDSERVICESANDSUPPLIES(Individualsage19andover)

Coverageisprovidedforthedentalservicesandsuppliesdescribedinthissection.

Pleasenotetheageandfrequencylimitationsthatapplyforcertainprocedures.Allfrequencylimitsspecifiedareappliedtotheday.ForYourPolicy,specificCoveredServicesandSuppliesmayfallunderaClasscategoryotherthanwhatisstatedbelow.IfYourPolicyhasClasscategorizationsdifferentfrombelow,itisspecifiedontheScheduleofBenefits.

ClassI:PreventiveDentalServices

Comprehensiveexams,periodicexams,evaluations,re‐evaluations,limitedoralexams,orperiodontalevaluations.Limitedto1per6monthperiod

Dentalprophylaxis(cleaningandscaling).Benefitlimitedtoeither1dentalprophylaxisor1periodontalmaintenanceprocedureper6monthperiod,butnotboth.

Topicalfluoridetreatment.o Limitedtooneper6monthperiod.

Palliative(emergency)treatmentofdentalpaino Consideredforpaymentasaseparatebenefitonlyifnoother

treatment(exceptx‐rays)isrenderedduringthesamevisit. Sealantapplicationsarelimitedtooneper36monthperiod,onun‐

restoredpitandfissuresofa1stand2ndpermanentmolar. X‐rays:

o Intraoralcompleteseriesx‐rays,includingbitewingsand10to14periapicalx‐rays,orpanoramicfilm.Limitedtooneper60monthperiod.Payableamountforthetotalofbitewingand

intraoralperiapicalx‐raysislimitedtothemaximumallowanceforanintraoralcompleteseriesx‐raysinacalendaryear.

o Bitewingx‐rays(twoorfourfilms).Limitedtooneper12monthperiod.Payableamountforthetotalofbitewingandintraoralperiapicalx‐raysislimitedtothemaximumallowanceforanintraoralcompleteseriesx‐raysinacalendaryear.

OtherX‐rays:o Intraoralperiapicalx‐rays.o Payableamountforthetotalofbitewingandintraoral

periapicalx‐raysislimitedtothemaximumallowanceforanintraoralcompleteseriesx‐raysinacalendaryear.

o Intraoralocclusalx‐rays,limitedtoonefilmperarchper6monthperiod.

o Extraoralx‐rays,limitedtoonefilmper6monthperiod.o Otherx‐rays(exceptfilmsrelatedtoorthodonticproceduresor

temporomandibularjointdysfunction).

ClassII:BasicDentalServices

Amalgamandcompositerestorations,limitedasfollows:o Multiplerestorationsononesurfacewillbeconsideredasingle

filling.o Multiplerestorationsondifferentsurfacesofthesametooth

willbeconsideredconnected.o Benefitsforreplacementofanexistingrestorationwillonlybe

consideredforpaymentifatleast36monthshavepassedsincetheexistingrestorationwasplaced(exceptinextraordinarycircumstancesinvolvingexternal,violentandaccidentalmeansorduetoradiationtherapy).

o Additionalfillingsonthesamesurfaceofatoothinlessthan36



months,bythesameofficeorsameDentistarenotcovered,exceptinextraordinarycircumstancesinvolvingexternal,violentandaccidentalmeansorduetoradiationtherapy.

o Sedativebasesandlinersareconsideredpartoftherestorativeserviceandarenotpaidasseparateprocedures.

o Compositerestorationsarealsolimitedasfollows: Mesial‐lingual,distal‐lingual,mesial‐facial,anddistal‐

facialrestorationsonanteriorteethwillbeconsideredsinglesurfacerestorations

Acidetchisnotcoveredasaseparateprocedure Benefitslimitedtoanteriorteethonly. Benefitsforcompositeresinrestorationsonposterior

teetharelimitedtothebenefitforthecorrespondingamalgamrestoration.

Pins,inconjunctionwithafinalamalgamrestoration Spacemaintainers,includingalladjustmentsmadewithin6monthsof

installation. Stainlesssteelcrowns,limitedtooneper36monthperiodforteethnot

restorablebyanamalgamorcompositefilling. Periodontalmaintenanceprocedure(followingactivetreatment).

Benefitlimitedtoeither1periodontalmaintenanceprocedureor1dentalprophylaxisper6monthperiod,butnotboth.

Periodontalmaintenanceproceduresmaybeusedinthosecasesinwhichapatienthascompletedactiveperiodontaltherapy,andcommencingnosoonerthan3monthsthereafter.Theprocedureincludesanyexaminationforevaluation,curettage,rootplaningand/orpolishingasmaybenecessary.

Generalanesthesiaandintravenoussedation,limitedasfollows:o Consideredforpaymentasaseparatebenefitonlywhen

medicallynecessary(asdeterminedbythePlan)andwhenadministeredintheDentist’sofficeoroutpatientsurgical

centerinconjunctionwithcomplexoralsurgicalserviceswhicharecoveredunderthePolicy.

o Notabenefitforthemanagementoffearandanxiety;o Oralsedationisnotacoveredbenefit.

Consultation,includingspecialistconsultations,limitedasfollows:o Consideredforpaymentasaseparatebenefitonlyifnoother

treatment(exceptx‐rays)isrenderedonthesamedate.o Benefitswillnotbeconsideredforpaymentifthepurposeof

theconsultationistodescribetheDentalTreatmentPlan.

ClassIII:MajorDentalServices

Inlaysandonlays(metallic),limitedasfollows:o Coveredonlywhenthetoothcannotberestoredbyan

amalgamorcompositefilling.o Covered only ifmore than5yearshaveelapsed since last

placement.o Build‐upprocedureisconsideredcoveredandisinclusivein

thefee.o Benefitsarebasedonthedateofcementation.

Porcelainrestorationsonanteriorteeth,limitedasfollows:o Coveredonlywhenthetoothcannotberestoredbyan

amalgamorcompositefilling.o Coveredonlyifmorethan5yearshaveelapsedsincelast

placement.o Limitedtopermanentteeth.Porcelainrestorationsonover‐

retainedprimaryteetharenotcovered.o Build‐upprocedureisconsideredcoveredandisinclusivein

thefee.o Benefitsarebasedonthedateofcementation.

Castcrowns,limitedasfollows:o Coveredonlywhenthetoothcannotberestoredbyan



amalgamorcompositefilling.o Coveredonlyifmorethan5yearshaveelapsedsincelast

placement.o Limitedtopermanentteeth.Castcrownsonover‐retained

primaryteetharenotcovered.o Crownsonthirdmolarsarecoveredwhenadjacentfirstor

secondmolarsaremissingandthetoothisinfunctionwithanopposingnaturaltooth.

o Build‐upprocedureisconsideredcoveredandinclusiveinthefee.

o Benefitsarebasedonthedateofcementation. Crownlengtheningislimitedtoasinglesitewhencontiguousteethare

involved. Re‐cementinginlays,crownsandbridgesarelimitedtothreepertooth,

12monthsafterlastcementation. Postandcore:

o Coveredonlyforendodontically‐treatedteeth,whichrequirecrowns.

o 1postandcoreiscoveredpertooth. Fulldentures,limitedasfollows:

o Limitedto1fulldentureperarch.o Replacementcoveredonlyif5yearshaveelapsedsincelast

replacementANDthefulldenturecannotbemadeserviceable(pleaserefertotheDentureorBridgeReplacement/AdditionprovisionunderExclusionsandLimitationsforexceptions).

o Servicesincludeanyadjustmentsorrelineswhichareperformedwithin12monthofinitialinsertion.

o Wewillnotpayadditionalbenefitsforpersonalizeddenturesoroverdenturesorassociatedtreatment.

o Benefitsfordenturesarebasedonthedateofdelivery. Partialdentures,includinganyclaspsandrestsandallteeth,limitedas

follows:

o Limitedtoonepartialdentureperarch.o Replacementcoveredonlyif5yearshaveelapsedsincelast

placementANDthepartialdenturecannotbemadeserviceable(pleaserefertothedentureorbridgereplacement/additionprovisionunderexclusionsandlimitationsforexceptions).

o Servicesincludeanyadjustmentsorrelineswhichareperformedwithin12monthsofinitialinsertion.

o Therearenobenefitsforprecisionorsemi‐precisionattachments.

o Benefitsforpartialdenturesarebasedonthedateofdelivery. Dentureadjustmentsarelimitedto:

o Onetimeinany12monthperiod;ando Adjustmentsmademorethan12monthsaftertheinsertionof

thedenture. Repairstofullorpartialdentures,bridges,andcrownsarelimitedto

repairsoradjustments performedupto3timesaftertheinitialinsertion.

Rebasingdenturesarelimitedtoonetimeper12monthperiod. Reliningdenturesisacoveredbenefit12monthsafterinitialinsertion

ofthedenture.o Limitedtoonetimeper12monthperiod

Tissueconditioningislimitedtoonetimeina12monthperiod. Fixedbridges(includingMarylandbridges)arelimitedasfollows:

o Benefitsforthereplacementofanexistingfixedbridgearepayableonlyiftheexistingbridge:

Ismorethan5yearsold(seetheDentureorBridgeReplacement/AdditionprovisionunderExclusionsandLimitationsforexceptions);and

Cannotbemadeserviceable.o Afixedbridgereplacingtheextractedportionofahemisected

toothisnotcovered.



o Placementandreplacementofacantileverbridgeonposteriorteethwillnotbecovered.

o Benefitsforbridgesarebasedonthedateofcementation. Re‐cementingbridgesislimitedtorepairsoradjustmentperformed

morethan12monthsaftertheinitialinsertion. Oralsurgeryservicesaslistedbelow,includinganallowanceforlocal

anesthesiaandroutinepost‐operativecare:o Simpleextractionso Surgicalextractions,includingextractionofthirdmolarswith

pathology(wisdomteeth)o Alveoplastyo Vestibuloplastyo Removalofexostoses(includingtori)–maxillaormandibleo Frenulectomy(frenectomyorfrenotomy)o Excisionofhyperplasictissue–perarch

Toothre‐implantationand/orstabilizationofaccidentallyavulsedordisplacedtoothand/oralveolus,limitedtopermanentteethonly.

Rootremoval–exposedroots. Biopsy Incisionanddrainage Themostinclusiveprocedurewillbeconsideredforpaymentwhentwo

ormoresurgicalproceduresareperformed. Pulpotomy(primaryteethonly). Rootcanaltherapy:

o Includingallpre‐operative,operativeandpost‐operativex‐rays,bacteriologiccultures,diagnostictests,localanesthesia,allirrigants,obstructionofrootcanalsandroutinefollow‐upcare

o Limitedtoonetimeonthesametoothper24monthperiodbythesameprovider.

o Limitedtopermanentteethonly.

Apicoectomy/periradicularsurgery(anterior,bicuspid,molar,eachadditionalroot),includingallpreoperative,operativeandpost‐operativex‐rays,bacteriologiccultures,diagnostictests,localanesthesiaandroutinefollow‐upcare.

Retrogradefilling‐perroot. Rootamputation‐perroot. Hemisection,includinganyrootremovalandanallowanceforlocal

anesthesiaandroutinepost‐operativecaredoesnotincludeabenefitforrootcanaltherapy.

Periodontalscalingandrootplaning,limitedasfollows:o 4ormoreteethperquadrant,limitedtoaminimumof5mm

pockets(pertooth),withradiographicevidenceofboneloss,covered1timeperquadrantper24monthperiod.

o 1to3teethperquadrant,limitedtominimumof5mmpockets(pertooth),withradiographicevidenceofboneloss,covered1timeperareaper24monthperiod.

o Underunusualcircumstances,additionaldocumentationcanbesubmittedtothePlanforreview.

o Followingosseoussurgeryrootplaningisabenefitafter36monthsinthesamearea.

Periodontalrelatedservicesaslistedbelow,limitedtoonetimeperquadrantofthemouthinany36monthperiodwithchargescombinedforproceduresaslistedbelow:

o Gingivalflapprocedures.o Gingivectomyprocedures.o Osseoussurgery.o Pedicletissuegrafts.o Softtissuegrafts.o Subepithelialtissuegrafts.o Bonereplacementgrafts.o Guidedtissueregeneration.



o Crownlengtheningprocedures‐hardtissue.o Themostinclusiveprocedurewillbeconsideredforpayment

when2ormoresurgicalproceduresareperformed.

EXCLUSIONSANDLIMITATIONS

TreatmentOutsideoftheCoveredServiceArea

Treatmentoutsideofyourcoveredstateand/orUnitedStatesisnotcovered,unlessthetreatmentisforEmergencyTreatment.

MissingTeethLimitation

Initialplacementofafulldenture,partialdentureorfixedbridgewillnotbecoveredbythePlantoreplaceteeththatweremissingpriortotheeffectivedateofcoverageforYouorYourDependents.However,expensesforthereplacementofteeththatweremissingpriortotheeffectivedatewillonlybeconsideredforcoverage,ifthetoothwasextractedwithin12monthsoftheeffectivedateofthePolicyandwhileYouorYourDependentwerecoveredunderaPriorPlan.

DentureorBridgeReplacement/Addition

Replacementofafulldenture,partialdenture,orfixedbridgeiscoveredwhen:

o 5yearshaveelapsedsincelastreplacementofthedentureorbridge;OR

o ThedentureorbridgewasdamagedwhileintheCoveredPerson’smouthwhenaninjurywassufferedinvolvingexternal,violentandaccidentalmeans.TheinjurymusthaveoccurredwhileinsuredunderthisPolicy,andtheappliance

cannotbemadeserviceable.

However,thefollowingexceptionswillapply:

o Benefitsforthereplacementofanexistingpartialdenturethatislessthan5yearsoldwillbecoveredifthereisaDentallyNecessaryextractionofanadditionalFunctioningNaturalTooththatcannotbeaddedtotheexistingpartialdenture.

o Benefitsforthereplacementofanexistingfixedbridgethatislessthan5yearsoldwillbepayableifthereisaDentallyNecessaryextractionofanadditionalFunctioningNaturalTooth,andtheextractedtoothwasnotanabutmenttoanexistingbridge.

ReplacementofalostbridgeisnotaCoveredBenefit. Abridgetoreplaceextractedrootswhenthemajorityofthenatural

crownismissingisnotaCoveredBenefit. ReplacementofanextractedtoothwillnotbeconsideredaCovered

BenefitifthetoothwasanabutmentofanexistingProsthesisthatislessthan5yearsold.

Replacementofanexistingpartialdenture,fulldenture,crownorbridgewithmorecostlyunits/differenttypeofunitsislimitedtothecorrespondingbenefitfortheexistingunitbeingreplaced.

Implants

Implants,andproceduresandappliancesassociatedwiththem,arenotcovered.

GeneralExclusions

CoveredServicesandSuppliesdonotinclude:

1. Treatmentwhichis:a. notincludedinthelistofCoveredServicesandSupplies;



b. notDentallyNecessary;orc. Experimentalinnature.

2. AnyChargeswhichare:d. Payableorreimbursablebyorthroughaplanorprogramof

anygovernmentalagency,exceptifthechargeisrelatedtoanon‐militaryservicedisabilityandtreatmentisprovidedbyagovernmentalagencyoftheUnitedStates.However,thePlanwillalwaysreimburseanystateorlocalmedicalassistance(Medicaid)agencyforCoveredServicesandSupplies.

e. Notimposedagainstthepersonorforwhichthepersonisnotliable.

f. ReimbursablebyMedicarePartAandPartB.IfapersonatanytimewasentitledtoenrollintheMedicareprogram(includingPartB)butdidnotdoso,hisorherbenefitsunderthisPolicywillbereducedbyanamountthatwouldhavebeenreimbursedbyMedicare,wherepermittedbylaw.

3. ServicesorsuppliesresultingfromorinthecourseofYourregularoccupationforpayorprofitforwhichYouorYourDependentarepaidunderanyWorkers’CompensationLaw,Employer’sLiabilityLaworsimilarlaw.YoumustpromptlyclaimandnotifythePlanofallsuchbenefits.BenefitspaidunderthisplanthatarealsopaidunderanyWorkers’CompensationLaw,Employer’sLiabilityLaworsimilarlawmayberecovered.

4. ServicesorsuppliesprovidedbyaDentist,DentalHygienist,denturistordoctorwhoisaCloseRelativeorapersonwhoordinarilyresideswithYouoraDependent.

5. ServicesandsupplieswhichmaynotreasonablybeexpectedtosuccessfullycorrecttheCoveredPerson’sdentalconditionforaperiodofatleast3years,asdeterminedbythePlan.

6. Allservicesforwhichaclaimisreceivedmorethan6monthsafterthedateofservice.

7. Servicesandsuppliesprovidedasonedentalprocedure,andconsideredoneprocedurebasedonstandarddentalprocedurecodes,butseparatedintomultipleprocedurecodesforbillingpurposes.TheCoveredChargefortheServicesisbasedonthesingledentalprocedure

codethataccuratelyrepresentsthetreatmentperformed.8. Servicesandsuppliesprovidedprimarilyforcosmeticpurposes,

includingbleaching/whitening.9. ServicesandsuppliesobtainedwhileoutsideoftheUnitedStates,

exceptforEmergencyDentalCare.10. Correctionofcongenitalconditionsorreplacementofcongenitally

missingpermanentteeth,regardlessofthelengthoftimethedeciduoustoothisretained.

11. Diagnosticcasts.12. Educationalprocedures,includingbutnotlimitedtooralhygiene,

plaquecontrolordietaryinstructions.13. Personalsuppliesorequipment,includingbutnotlimitedtowaterpiks,

toothbrushes,orflossholders.14. Restorativeprocedures,rootcanalsandappliances,whichareprovided

becauseofattrition,abrasion,erosion,abfraction,wear,orforcosmeticpurposesintheabsenceofdecay.

15. Veneers16. Appliances,inlays,castrestorations,crownsandbridges,orother

laboratorypreparedrestorationsusedprimarilyforthepurposeofsplinting(temporarytoothstabilization).

17. ReplacementofalostorstolenApplianceorProsthesis.18. Replacementofstayplates.19. Extractionofpathology‐freeteeth,includingsupernumeraryteeth.20. Socketpreservationbonegraphs21. Hospitalorfacilitychargesforroom,suppliesoremergencyroom

expenses,orroutinechestx‐raysandmedicalexamspriortooralsurgery.

22. Treatmentforajawfracture.23. Services,suppliesandappliancesrelatedtothechangeofvertical

dimension,restorationormaintenanceofocclusion,splintingandstabilizingteethforperiodonticreasons,biteregistration,biteanalysis,attrition,erosionorabrasion,andtreatmentfortemporomandibularjointdysfunction(TMJ),unlessaTMJbenefitriderwasincludedinthePolicy.

24. Non‐MedicallyNecessaryOrthodonticservices,supplies,appliances



andOrthodontic‐relatedservices.25. Oralsedationandnitrousoxideanalgesiaarenotcovered.26. Therapeuticdruginjection.27. Chargesforthecompletionofclaimforms.28. Misseddentalappointments.29. Replacementofmissingteethpriortocoverageeffectivedate.

IMPORTANT NOTICE REGARDING LANGUAGE ASSISTANCE & DISCRIMINATION AVISO IMPORTANTE SOBRE LA ASISTENCIA DE IDIOMA Y DISCRIMINACIÓN

GC017586 Critical Docs 9/13/16 Port

English

If you or the person you are helping has questions about your insurance benefits, claims, or coverage, you have the right to get help and information in your language at no cost. To talk to an interpreter: if you have insurance from your employer, call the telephone number on your identification card; for all other members, please call 844-561-5600. The Guardian and its subsidiaries* comply with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Spanish Español

Si usted o la persona que está ayudando tiene preguntas acerca de su seguro, las reclamaciones o cobertura, usted tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete: si tiene seguro de su empleador, llame al número de teléfono que aparece en su tarjeta de identificación; para todos los demás miembros, por favor llame al 844-561-5600. The Guardian y sus subsidiarias * cumplir con las leyes federales aplicables de derechos civiles y no discrimina por motivos de raza, color, origen nacional, edad, discapacidad, o sexo.

Chinese

中文

如果你或你正在帮助的人拥有约你的保险利益，索赔或覆盖的问题，你有没有成本，以获取帮助和信息在你的语言的权利。要交谈

的解释：如果您从您的雇主有保险，打电话给你的身份证上的电话号码;所有其他成员，请致电 844-561-5600。

卫报及其子公司*遵守适用的联邦民权法和种族，肤色，国籍，年龄，残疾，或性的基础上不歧视。

Vietnamese Tiếng Việt

Nếu bạn hoặc người bạn đang giúp đỡ có câu hỏi về quyền lợi bảo hiểm, yêu cầu của bạn, hoặc bảo hiểm, bạn có quyền được trợ giúp và thông tin trong ngôn ngữ của bạn miễn phí. Để nói chuyện với một thông dịch viên: nếu bạn có bảo hiểm từ công ty của bạn, hãy gọi số điện thoại trên thẻ nhận dạng của bạn; cho tất cả các thành viên khác, xin vui lòng gọi 844-561-5600. The Guardian và các công ty con của nó * tuân thủ pháp luật quyền dân sự liên bang áp dụng và không phân biệt đối xử trên cơ sở chủng tộc, màu da, nguồn gốc quốc gia, tuổi tác, khuyết tật, hoặc quan hệ tình dục.

Korean

한국어

당신이나 당신이 도움이되고 사람이 당신의 보험 혜택, 청구, 또는 범위에 대한 질문이있는 경우, 당신은 무료로 귀하의 언어로

도움과 정보를 얻을 수있는 권리가 있습니다. 통역 얘기하려면, 당신은 당신의 고용주로부터 보험이있는 경우, 귀하의 ID 카드에

전화 번호로 전화; 다른 모든 구성원에 대해, 844-561-5600로 전화 해주십시오.

가디언과 그 자회사는 해당 연방 민권법을 준수하고 인종, 피부색, 출신 국가, 연령, 장애, 또는 성별에 근거하여 차별하지 않습니다 *.

Tagalog Tagalog

Kung ikaw o ang taong ikaw ay pagtulong ay may mga katanungan tungkol sa inyong mga benepisyo sa insurance, claims, o coverage, ikaw ay may karapatan upang makakuha ng tulong at impormasyon sa iyong wika nang walang gastos. Upang makipag-usap sa isang interpreter: kung mayroon kang insurance mula sa iyong tagapag-empleyo, tawagan ang numero ng telepono sa iyong identification card; para sa lahat ng iba pang mga miyembro, mangyaring tumawag sa 844-561-5600. The Guardian at ang mga subsidiaries * sumusunod sa naaangkop na mga Pederal na batas sa mga karapatang sibil at hindi maaaring makita ang kaibhan sa batayan ng lahi, kulay, bansang pinagmulan, edad, kapansanan, o sex.

Russian Pусский

Если вы или человек, которому вы помогаете есть вопросы по поводу вашего страховых выплат, претензий, или покрытия, вы имеете право получить помощь и информацию на вашем языке без каких-либо затрат. Для того, чтобы поговорить с переводчиком: если у вас есть страхование от Вашего работодателя, позвоните по номеру телефона на вашей идентификационной карточки; для всех остальных членов, просьба звонить по телефону 844-561-5600. The Guardian и его дочерние компании * соответствии с действующими федеральными законами о гражданских правах и не допускать дискриминации по признаку расы, цвета кожи, национального происхождения, возраста, инвалидности или пола.

Arabic العربية

التحدث الى . في لغتك دون أي تكلفة إذا كنت أنت أو الشخص الذي يساعد ديه أسئلة حول فوائد التأمين والمطالبات، أو تغطية، لديك الحق في الحصول على المساعدة والمعلومات

.1655-165-844لجميع األعضاء، يرجى االتصال . الهاتف على بطاقة الهوية الخاصة بكإذا كان لديك التأمين من صاحب العمل الخاص بك، االتصال على رقم : مترجم

..لجنسااللتزام بالقوانين االتحادية المطبقة الحقوق المدنية وال تميز على أساس العرق أو اللون أو األصل القومي أو السن أو اإلعاقة، أو ا* الجارديان والشركات التابعة لها

French Creole-Haitian Creole

Kreyòl Ayisyen

Si ou menm oswa moun nan w ap ede gen kesyon sou benefis asirans ou, reklamasyon, oswa pwoteksyon, ou gen dwa pou jwenn èd ak enfòmasyon nan lang ou a pa koute. Pou pale ak yon entèprèt: si ou gen asirans nan men anplwayè ou, rele nimewo telefòn sou kat idantifikasyon ou; pou tout lòt manm, tanpri rele 844-561-5600. The Guardian ak filiales li yo * konfòme yo avèk lwa sou dwa sivil Federal aplikab yo, epi pa fè diskriminasyon sou baz ras, koulè, orijin nasyonal, laj, andikap, oswa fè sèks.

Polish Polskie

Jeśli Ty lub osoba, do której pomoc ma pytania dotyczące świadczeń z ubezpieczenia, roszczenia lub pokrycia, masz prawo do uzyskania pomocy i informacji w swoim języku, bez żadnych kosztów. Aby rozmawiać z tłumacza: jeśli masz ubezpieczenie od pracodawcy, należy zadzwonić pod numer telefonu na karcie identyfikacyjnej; dla wszystkich pozostałych członków, zadzwoń 844-561-5600. The Guardian i jej spółek zależnych * przestrzegania obowiązujących przepisów federalnych praw obywatelskich i nie dyskryminacji ze względu na rasę, kolor skóry, pochodzenie narodowe, wiek, niepełnosprawność, czy płeć.

GC017586 Critical Docs 9/13/16 Port

French Français

Si vous ou la personne que vous aidez a des questions sur vos prestations d'assurance, les prétentions ou la couverture, vous avez le droit d'obtenir de l'aide et de l'information dans votre langue, sans frais. Pour parler à un interprète: si vous avez l'assurance de votre employeur, appelez le numéro de téléphone sur votre carte d'identité; pour tous les autres membres, s'il vous plaît appelez 844-561-5600. The Guardian et ses filiales * sont conformes aux lois fédérales relatives aux droits civils applicables et ne fait pas de discrimination sur la base de la race, la couleur, l'origine nationale, l'âge, le handicap ou le sexe.

Italian Italieno

Se voi o la persona che state aiutando ha domande circa la vostra prestazioni assicurative, reclami, o la copertura, si ha il diritto di richiedere assistenza e informazioni nella propria lingua, senza alcun costo. Per parlare con un interprete: se avete l'assicurazione dal datore di lavoro, chiamare il numero di telefono sulla carta d'identità; per tutti gli altri membri, si prega di chiamare 844-561-5600. The Guardian e le sue controllate * conformi alle leggi federali vigenti diritti civili e non discrimina sulla base di razza, colore, nazionalità, età, disabilità, o di sesso.

Persian-Farsi

سی ار سی-ف ار ف

و اطالعات به زبان خود را بدون هيچ هزينه اگر شما يا شخصی که شما در حال کمک به سواالت در مورد مزايای بيمه خود را، ادعا می کند، و يا پوشش، شما حق دريافت کمک

تماس 1655-165-844برای همه اعضای ديگر، لطفا . اگر بيمه از کارفرمای خود، تماس با شماره تلفن بر روی کارت شناسايی خود را: برای صحبت با يک مترجم. داشته باشد

..بگيريد

.ل حقوق مدنی قابل اجرا می کند و بر اساس نژاد، رنگ پوست، مليت، سن، معلوليت و يا رابطه جنسی قائل نمی شودمطابق با قوانين فدرا* * * * گاردين و شرکتهای تابعه آن

Armenian

Hայերեն Եթե դուք կամ այն անձը, դուք օգնում ունի հարցեր ձեր ապահովագրական հատուցումներից, պահանջների, կամ

լուսաբանման, դուք իրավունք ունեք ստանալու օգնություն եւ տեղեկատվություն Ձեր լեզվով ոչ մի գնով: Խոսել է թարգմանչի:

Եթե ունեք ապահովագրություն Ձեր գործատուի, զանգահարեք հեռախոսահամարը Ձեր նույնականացման քարտ. բոլոր մյուս

անդամների համար, խնդրում ենք զանգահարել 844-561-5600.

The Guardian եւ իր դուստր ձեռնարկություններն * համապատասխանեն կիրառելի դաշնային քաղաքացիական իրավունքների

օրենքների եւ չի խտրականություն հիման վրա ռասայի, մաշկի գույնի, ազգային ծագման, տարիքի, հաշմանդամության, կամ

սեռից:

German Deutsche

Wenn Sie oder die Person, die Sie helfen, Fragen zu Ihrem Versicherungsleistungen , Ansprüche oder Abdeckung, haben Sie das Recht auf kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um auf einen Dolmetscher sprechen: Wenn Sie eine Versicherung von Ihrem Arbeitgeber haben, rufen Sie die Telefonnummer auf der Ausweiskarte ; für alle anderen Mitglieder, rufen Sie bitte 844-561-5600. The Guardian und ihre Tochtergesellschaften * mit den geltenden Bundes Bürgerrechte Gesetze einhalten und nicht zu diskriminieren auf der Grundlage von Rasse, Hautfarbe , nationaler Herkunft, Alter, Behinderung oder Geschlecht.

Portuguese Português

Se você ou a pessoa que você está ajudando tem dúvidas sobre seus benefícios de seguro, reivindicações, ou cobertura, você tem o direito de obter ajuda e informações na sua língua, sem nenhum custo. Para falar com um intérprete: se você tem seguro de seu empregador, ligue para o número de telefone no seu cartão de identificação; para todos os outros membros, ligue para 844-561-5600. Este aviso tem informações importantes sobre a sua aplicação ou sua cobertura de seguro. Olhe para as datas-chave neste The Guardian e suas subsidiárias * cumprir com as leis federais aplicáveis direitos civis e não discriminar com base em raça, cor, nacionalidade, idade, deficiência ou sexo.

*Guardian Life Insurance Company of America subsidiaries includes First Commonwealth Companies, Managed Dental Care, Inc., Managed Dental Guard, Inc., Premier

Access Insurance Company and Access Dental Plan, Inc.

California Family Dental PPO...California Family Dental PPO 4 | Page CA_IP_FAM_SOB_PPO_17 CLASSES OF...

Documents

Transcript of California Family Dental PPO...California Family Dental PPO 4 | Page CA_IP_FAM_SOB_PPO_17 CLASSES OF...