Talk to a LIVEMember Services Representative every step of the way!

© 2020 LIBERTY Dental Plan MO-Individual-Exchange RN 01 2020

MO Family Value Dental Plan

www.libertydentalplan.com/missouri-exchange

| Missouri Individual ExchangeLIBERTYDENTAL PLAN®

LIBERTY Dental Plan

Making members shine, one smile at a timeTM

LIBERTY’s Oral Health PhilosophyOur philosophy is simple and has remained the same since our inception. Weare committed to ensuring our members receive necessary preventive and diagnostic treatments on a routine basis, averting costly and damaging episodic treatment. Additionally, we reach out to members to provide them with valuable Oral Hygiene Instruction and Case Management when necessary to promote a lifetime of exceptional oral health.

Who We Are LIBERTY Dental Plan (LIBERTY) is a privately-held dental benefits corporation that has been providing dental services since 2001. We currently serve over 4 million members nationwide, and partner with some of the nation’s largest health plans, labor groups, and employer groups, as well as federal, state and local governments. Our Commitment to Our MembersLIBERTY’s Concierge Style Customer Service: • Multilingual Member Services staff with customer service backgrounds, allowing for 98% first call resolution• Communication in over 150 languages• Complete case management• Selection of pre-screened dentists• 24-hour access to emergency dental care coordinated by Dental Director

Online Services We Offer:• Real-time web access to online transactions, such as claims, provider services, pre-authorization submissions, eligibility & benefits inquiries, claims tracking and more.• LIBERTY Dental Plan’s mobile phone app gives members quick and easy access to: electronic ID cards, search for a network dentist, benefit & copay information and more.

https://www.libertydentalplan.com/Individual-Marketplace/Missouri/Missouri-Individual-Marketplace.aspx

© 2020 LIBERTY Dental Plan MO-Individual-Exchange RN 01 2020

MO Family Value Dental Plan

www.libertydentalplan.com/missouri-exchange

| Missouri Individual ExchangeLIBERTYDENTAL PLAN®

LIBERTY Dental Plan

Making members shine, one smile at a timeTM

Frequently Asked QuestionsWhat is a DEPO plan?LIBERTY’s DEPO plan is a copay plan that provides members the freedom to use any LIBERTY Dental Plan contracted provider. While the benefits work the same as a regular DHMO plan, there is no pre-selection or assignment to a network dentist. Each member of a family may choose a different contracted provider for their dental needs. This plan is offered to individuals and families that reside in Saint Louis, Missouri. This dental plan is not Medicaid and, depending on the services you receive, copayments are due at the time of the visit to the dental office. There are no waiting periods on this plan. Once you are an active member, you are eligible to receive care right away.

How do I see a specialist? Your network dentist will initiate a treatment plan, or will initiate the specialty referral process with LIBERTY Dental Plan if the services are dentally necessary and outside the scope of general dentistry.

When will I be eligible to receive dental benefits? You are eligible to receive dental benefits on the effective date for which you have applied, once you’ve activated your coverage. To activate your coverage, LIBERTY must receive your application and the first month’s premium (“initial binder payment”) by the payment deadline provided on your initial binder letter. Once your coverage is activated, you will receive a welcome kit and an ID card in the mail.

How do I make an initial binder payment? Complete your application first. Once completed, you can submit your first month’s payment by clicking on the payment URL at the end of your application submission. You can also wait for your initial binder letter for instructions. We encourage you to set up recurring payments to avoid cancellation or lapse in coverage. Do not delay in making a payment. Untimely payment will result in cancellation of your coverage due to non-payment.

How will I know what my copayment will be? The total copayments you will owe depend on the treatment plan your dentist recommends and the services you receive. A Copayment Schedule (links provided on next page) provides a complete list of covered procedures by code and copayment. Some services, such as crowns, may include lab fees in addition to your listed copayment. The Copayment Schedule will explain the maximum amount a contracted dentist may charge in addition to the listed copayment for lab fees.

For questions about the cost of your treatment plan, ask your network dentist before you receive services and/or call LIBERTY Member Services at 888.902.0407.

What is an Out-of-Pocket Maximum? “Out-of-Pocket Maximum” is the maximum dollar amount that a Pediatric Enrollee can pay in copays to a contracted dentist for Benefits during a Calendar Year. Pediatric Enrollees must pay the listed copay amount before the Out-of-Pocket Maximum is met. If more than one Pediatric Enrollee is covered, the maximum dollar amount applied is the family Out-of-Pocket Maximum amount. Once the amount paid by all Pediatric Enrollee(s) equals the annual Out-of-Pocket Maximum, no further copayment is required for the remainder of the Calendar Year. The Out-of-Pocket Maximum does not apply to services provided to members ages 19 and older, or to non-covered services.

Q

https://www.libertydentalplan.com/Individual-Marketplace/Missouri/Missouri-Individual-Marketplace.aspx

© 2020 LIBERTY Dental Plan MO-Individual-Exchange RN 01 2020

MO Family Value Dental Plan

www.libertydentalplan.com/missouri-exchange

| Missouri Individual ExchangeLIBERTYDENTAL PLAN®

LIBERTY Dental Plan

Making members shine, one smile at a timeTM

Individual Out-of-Pocket Maximum: $350 (applies to Pediatric only) Family Out-of-Pocket Maximum: $700 (applies to Pediatric only)

The following is a summary of the dental procedures for which benefits are payable under this Plan. Members must visit a contracted dental office to utilize covered benefits.For a full list of Covered Benefits, Copayments, Limitations & Exclusions click here: Copayment Schedule

ADACode Description

ChildCopayment*

AdultCopayment**

Diagnostic ServicesD0120 Periodic oral exam $0 $15D0150 Comprehensive oral exam $0 $15D0210 Full mouth x-ray $0 $50D0220 Individual tooth x-ray $0 $14D0270 Bitewing x-ray $0 $10

Preventive ServicesD1110 Routine cleaning (adult) $0 $30D1120 Routine cleaning (child) $0 Not CoveredD1206 Topical application of fluoride varnish $0 Not CoveredD1208 Topical application of fluoride $0 $25D1351 Sealant, per tooth $0 Not CoveredD1510 Space maintainer, fixed, unilateral $0 $150

Restorative ServicesD2140 Amalgam (silver) - 1 surface $40 $65D2330 White filling, 1 surface, front teeth $50 $80D2930 Prefabricated stainless steel crown, primary tooth $75 Not Covered

Endodontic ServicesD3240 Pulpal therapy $80 $105D3330 Root canal - molar (excluding final restoration) $350 $610

Periodontal ServicesD4210 Gingivectomy/gingivoplasty, 4+ teeth/quad. $205 $250D4341 Periodontal scaling & root planing, 4+ teeth/quad. $120 $145

Removable Prosthodontic Services (Dentures)D5110 Complete denture, maxillary $350 $755

Oral and Maxillofacial SurgeryD7140 Extraction, erupted tooth or exposed root (simple extractions) $130 $78D7210 Surgical removal of erupted tooth (surgical extractions) $160 $150

Orthodontics (Services are limited to medically necessary treatment)D8080 Comprehensive orthodontic treatment adolescent dentition $350 Not Covered*Pediatric Benefits – Apply to dependents to the age of 19**Adult Benefits – Apply to Enrollees 19 and over

LIBERTY Dental Plan of Missouri, Inc.PO Box 26110, Santa Ana, CA 92799 Member Services: 888.902.0407

https://www.libertydentalplan.com/Individual-Marketplace/Missouri/Missouri-Individual-Marketplace.aspxhttps://www.libertydentalplan.com/Resources/Documents/2020-MO-Family-Value-Dental-Plan-SOB.pdf

LDP_MO_EX

Discrimination is against the law. LIBERTY Dental Plan (“LIBERTY”) complies with all applicable

Federal civil rights laws and does not discriminate, exclude people or treat them differently on the basis

of race, color, national origin, age, disability, or sex.

LIBERTY provides free aids and services to people with disabilities,

and free language services to people whose primary language is not

English, such as:

• Qualified interpreters, including sign language interpreters

• Written information in other languages and formats, including large print, audio, accessible electronic formats, etc.

If you need these services, please contact us at 1-888-902-0407.

If you believe LIBERTY has failed to provide these services or has discriminated on the basis of race,

color, national origin, age, disability, or sex, you can file a grievance with LIBERTY’s Civil Rights

Coordinator:

• Phone: 888-704-9833

• TTY: 800-735-2929

• Fax: 888-273-2718

• Email: compliance@libertydentalplan.com

• Online: https://www.libertydentalplan.com/About-LIBERTY-Dental/Compliance/Contact-Compliance.aspx

If you need help filing a grievance, LIBERTY’s Civil Rights Coordinator is available to help you. You

can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for

Civil Rights:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Online at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

LIBERTY’s HIPAA Privacy Notice provides you with information about your rights and our legal

duties and privacy practices with respect to Protected Health Information (PHI), including how we use

and disclose your PHI. You can always request a written copy of our most current privacy notice from

LIBERTY’s Privacy Officer by calling 888.704.9833, or online

at: www.libertydentalplan.com/HIPAA-Privacy-Notice.

http://www.libertydentalplan.com/HIPAA-Privacy-Notice

Notice of Language Assistance

LDP_MO_EX

If you, or someone you’re helping, has questions about LIBERTY Dental Plan, you have the right to get

help and information in your language at no cost. To talk to an interpreter, call (888) 902-0407.

Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de LIBERTY Dental Plan, tiene

derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete,

llame al (888) 902-0407. (Spanish)

如果您，或是您正在協助的對象，有關於 LIBERTY Dental Plan 方面的問題，您有權利免費以您

的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話 (888) 902-0407。(Chinese)

Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về LIBERTY Dental Plan, quý vị sẽ có quyền

được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch

viên, xin gọi (888) 902-0407. (Vietnamese)

Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa LIBERTY Dental Plan, may

karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap

ang isang tagasalin, tumawag sa (888) 902-0407. (Tagalog)

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 LIBERTY Dental Plan 에 관해서 질문이 있다면

귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다.

그렇게 통역사와 얘기하기 위해서는 (888) 902-0407 로 전화하십시오. (Korean)

Si oumenm oswa yon moun w ap ede gen kesyon konsènan LIBERTY Dental Plan, se dwa w pou

resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon

entèprèt, rele nan (888) 902-0407. (Haitian Creole)

Եթե Դուք կամ Ձեր կողմից օգնություն ստացող անձը հարցեր ունի LIBERTY Dental Plan

մասին, Դուք իրավունք ունեք անվճար օգնություն և տեղեկություններ ստանալու Ձեր

նախընտրած լեզվով։ Թարգմանչի հետ խոսելու համար զանգահարե՛ք (888) 902-0407։ (Armenian)

Если у вас или лица, которому вы помогаете, имеются вопросы по поводу LIBERTY Dental Plan,

то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для

разговора с переводчиком позвоните по телефону (888) 902-0407. (Russian)

ご本人様、またはお客様の身の回りの方でも、LIBERTY Dental Plan についてご質問がござい

ましたら、ご希望の言語でサポートを受けたり、情報を入手したりすることができます。料金

はかかりません。通訳とお話される場合、 (888) 902-0407 までお電話ください。 (Japanese)

(Arabic)

(Farsi)

Notice of Language Assistance

LDP_MO_EX

ਜੇਕਰ ਤੁਹਾਡਾ, ਜਾਂ ਕੋਈ ਹੋਰ ਜਜਸਦੀ ਤੁਸੀਂ ਸਹਾਇਤਾ ਕਰ ਰਹੇ ਹੋ, ਉਸਦਾ LIBERTY Dental Plan (ਜਿਬਰਟੀ ਡੈਂਟਿ ਪਿੈਨ) ਬਾਰੇ ਕੋਈ ਸਵਾਿ ਹੈ, ਤਾਂ ਤੁਹਾਡੇ ਕੋਿ ਮੁਫਤ ਆਪਣੀ ਭਾਸ਼ਾ ਜਵਿੱ ਚ ਸਹਾਇਤਾ ਅਤ ੇਜਾਣਕਾਰੀ ਪਾਉਣ ਦਾ ਅਜਿਕਾਰ ਹੈ| ਅਨੁਵਾਦਕ ਨਾਿ ਗਿੱਿ ਕਰਨ ਿਈ (888) 902-0407 ‘ਤੇ ਕਾਿ ਕਰੋ| (Punjabi) បបើសិនរបូអ្នក ឬជនណាម្នន ក់ដែលអ្នកជួយ ម្ននសំណួរអំ្ពី LIBERTY Dental Plan អ្នកម្ននសិទ្ធទិ្ទួ្លជំនួយ

និងព័ត៌ម្នន ជាភាសាដមែរ បោយឥតអ្ស់ថ្លៃប ើយ។ បែើម្បីនិយាយបៅកាន់អ្នកបកដរប សូម្បៅបលម

(888) 902-0407។ (Khmer)

Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog LIBERTY Dental Plan, koj muaj cai

kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog

ib tug neeg txhais lus tham, hu rau (888) 902-0407. (Hmong)

Se você, ou alguém a quem você está ajudando, tem perguntas sobre o LIBERTY Dental Plan, você tem

o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue

para (888) 902-0407. (Portuguese)