Delta Dental

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December 1969
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Individual/Family Dental Program Quality Care for You and Your Family Disclosure Form/Contract Provided by: Delta Dental of California 17871 Park Plaza Drive, Suite 200 Cerritos, CA 90703 deltadentalins.com Administered by: Delta Dental Insurance Company P.O. Box 1803 Alpharetta, GA 30023 800-422-4234 CAA54 V11 DISCLOSURE FORM/CONTRACT (~CONTRACT¨) This booklet is a Disclosure Form/Contract ('Contract¨) Ior your DeltaCare USA Individual/Family Dental Program ('Program¨) provided by: Delta Dental oI CaliIornia ('Delta Dental¨) a Specialized Health Care Service Plan 17871 Park Plaza Drive, Suite 200 Cerritos, CA 90703 This booklet discloses the terms and conditions oI the Program available in CaliIornia. PLEASE READ THE ENTIRE DOCUMENT COMPLETELY AND CAREFULLY. You have a right to review this Contract prior to enrollment. Persons with special health care needs should read, completely and careIully, the section entitled 'Special Needs¨. PLEASE READ THE FOLLOWING INFORMATION SO THAT YOU WILL KNOW HOW TO OBTAIN DENTAL SERVICES. YOU MUST OBTAIN DENTAL BENEFITS FROM (OR BE REFERRED FOR SPECIALTY SERVICES BY) YOUR ASSIGNED CONTRACT DENTIST. A matrix describing the Program`s major Benefts and coverage can be Iound on the Iollowing page. ADDITIONAL INFORMATION ABOUT YOUR BENEFITS IS AVAILABLE BY CALLING THE CUSTOMER SERVICE DEPARTMENT AT 800-422-4234, 5 a.m. - 6 p.m., PACIFIC TIME, MONDAY THROUGH FRIDAY. A STATEMENT DESCRIBING DELTA DENTAL`S POLICIES AND PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST. CAA54 V11 Information Concerning Beneñts Under The DeltaCare USA Program THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THIS DISCLOSURE FORM/CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF PROGRAM BENEFITS AND LIMITATIONS. (A) Deductibles None (B) LiIetime Maximums None (C) ProIessional Services An Enrollee may be required to pay a Copayment amount Ior each procedure as shown in the 'HVFULSWLRQRI%HQH¿WV DQG&RSD\PHQWV, subject to the /LPLWDWLRQVDQG([FOXVLRQV oI the program. Copayments range by category oI service. Examples are as Iollows: Diagnostic Services No Cost - $10.00 Preventive Services No Cost - $85.00 Restorative Services $10.00 - $495.00 Endodontic Services $10.00 - $725.00 Periodontic Services $64.00 - $650.00 Prosthodontic Services Removable $24.00 - $700.00 Prosthodontic Services Fixed $25.00 - $495.00 Oral and MaxilloIacial Surgery $30.00 - $230.00 Orthodontic Services No Cost - $2,800.00 Adjunctive General Services No Cost - $125.00 NOTE: Some services may not be covered. Certain services may be covered only iI provided by specifed providers, or may be subject to an additional charge. Limitations apply to the Irequency with which some services may be obtained. For example: cleanings are limited to once in each six month period; replacement oI removable and fxed dentures and crowns is limited to once in any fve year period. (D) Outpatient Services Not Covered (E) Hospitalization Services Not Covered (F) Emergency Dental Coverage The Enrollee may receive a maximum Beneft oI up to $100 per emergency, per Enrollee Ior out-oI-area Emergency Services. (G) Ambulance Services Not Covered (H) Prescription Drug Services Not Covered (I) Durable Medical Equipment Not Covered (J) Mental Health Services Not Covered (K) Chemical Dependency Services Not Covered (L) Home Health Services Not Covered (M) Other Not Covered Each individual procedure within each category listed above, and which is covered under the Program has a specifc Copayment, which is shown in the 'HVFULSWLRQRI%HQH¿WVDQG &RSD\PHQWVin this Disclosure Form/Contract. CAA54 V11 CAA54 CAA54 EOC - V11 Table Of Contents DeIinitions................................................................................................................... 1 What is the DeltaCare USA Individual/Family Dental Program ("Program")?.......... 2 How to use the DeltaCare USA Plan - Choice oI Contract Dentist............................ 3 Who is eligible Ior coverage?..................................................................................... 3 How do I enroll?......................................................................................................... 4 How much do I pay?.................................................................................................. 4 Choose a Payment Option.......................................................................................... 4 Mailing Instructions.................................................................................................... 5 What will my EIIective Date be?............................................................................... 5 Emergency Services.................................................................................................... 5 Specialist Services...................................................................................................... 6 Special Needs.............................................................................................................. 6 Facility Accessibility................................................................................................... 6 What iI I need to change Contract Dentists?.............................................................. 6 BeneIits, Limitations and Exclusions......................................................................... 7 Copayments and Other Charges................................................................................. 7 Dentist Compensation................................................................................................. 7 Second Opinion........................................................................................................... 7 Claims Ior Reimbursement......................................................................................... 8 Processing Policies...................................................................................................... 8 Enrollee Complaint Procedure.................................................................................... 8 CAA54 CAA54 EOC - V11 Renewal, Cancellation and Termination oI BeneIits.................................................. 9 Entire Contract.......................................................................................................... 10 Public Policy Participation by Enrollees.................................................................. 10 Governing Law......................................................................................................... 11 Description oI BeneIits and Copayments................................................................. 12 Limitations oI BeneIits............................................................................................. 23 Exclusions oI BeneIits.............................................................................................. 25 Organ and Tissue Donation...................................................................................... 26 CAA54 - 1 - CAA54 EOC - V11 Definitions As used in this Disclosure Form/Contract: Applicant means the individual contracting to obtain dental BeneIits as the primary Enrollee. YOU or YOUR reIers to the Applicant. Benefits mean those dental services that are provided under the terms oI this Contract and described in this booklet. Contract means this agreement between Delta Dental and the Applicant including the Enrollment and Payment Authorization Form, the attached schedules, and any appendices, endorsements or riders. This Contract constitutes the entire agreement between the parties. Contract Dentist means a Dentist who provides services in general dentistry, and has agreed to provide BeneIits under this Program. Contract Orthodontist means a Dentist who specializes in orthodontics, and has agreed to provide BeneIits under this Program. Contract Specialist means a Dentist who provides Specialist Services, and has agreed to provide BeneIits to Enrollees under this Program. Contract Term means the one-year period starting on the EIIective Date and each annual renewal period during which the Contract remains in eIIect. Copayment means the amount listed in Schedule A paid by an Enrollee to a Contract Dentist or Contract Specialist Ior the BeneIits provided under this Program. Enrollees are responsible Ior payment oI all Copayments at the time treatment is received. Dentist means a duly licensed Dentist legally entitled to practice dentistry at the time and in the state or jurisdiction in which services are perIormed. Domestic Partner means a person who, together with the primary Enrollee, has aIIirmed a domestic partnership through an aIIidavit oI domestic partnership provided to Delta Dental. Effective Date means the Iirst day oI the month Iollowing Delta Dental's timely receipt oI Premium and the Enrollment and Payment Authorization Form. Eligible Dependent means any dependent oI a primary Enrollee who is eligible Ior BeneIits as described in this booklet. Emergency Service means care provided by a Dentist to treat a dental condition that maniIests as a symptom oI suIIicient severity, including severe pain, such that the absence oI immediate attention could reasonably be expected by the Enrollee to result in either: (i) placing the Enrollee's dental health in serious jeopardy, or (ii) serious impairment to dental Iunctions. CAA54 - 2 - CAA54 EOC - V11 Enrollee means a person enrolled to receive BeneIits including the primary Enrollee and Eligible Dependent(s). Full-Time Student means a student who is regularly attending an accredited school with an academic schedule oI at least 12 credits. Out-of-Network means treatment by a Dentist who has not signed an agreement with Delta Dental to provide BeneIits under the terms oI this Contract. Preauthorization means the process by which Delta Dental determines iI a procedure or treatment is a reIerable BeneIit under the Enrollee's plan. Premium means the amount payable as provided in this Contract. Reasonable means that an Enrollee exercises prudent judgment in determining that a dental emergency exists and makes at least one attempt to contact his/her Contract Dentist to obtain Emergency Services and, in the event the Dentist is not available, makes at least one attempt to contact Delta Dental Ior assistance beIore seeking care Irom another Dentist. Special Health Care Need means a physical or mental impairment, limitation or condition that substantially interIeres with an Enrollee's ability to obtain BeneIits. Examples oI such a Special Health Care Need are 1) the Enrollee's inability to obtain access to the assigned Contract Dentist's Iacility because oI a physical disability and 2) the Enrollee's inability to comply with the Contract Dentist's instructions during examination or treatment because oI physical disability or mental incapacity. Specialist Services mean services perIormed by a Dentist who specializes in the practice oI oral surgery, endodontics, periodontics, orthodontics or pediatric dentistry. Specialist Services must be preauthorized by Delta Dental. Treatment In Progress means any single dental procedure, as deIined by the CDT Code, that has been started while the Enrollee was eligible to receive BeneIits, and Ior which multiple appointments are necessary to complete the procedure whether or not the Enrollee continues to be eligible Ior BeneIits under the DeltaCare USA plan. Examples include: teeth that have been prepared Ior crowns, root canals where a working length has been established, Iull or partial dentures Ior which an impression has been taken and orthodontics when bands have been placed and tooth movement has begun. We, Us or Our means Delta Dental oI CaliIornia or the Administrator as appropriate. What is the DeltaCare USA Individual/Family Dental Program ("Program")? The DeltaCare USA Individual/Family Dental Program ("Program") provides comprehensive dental care through a convenient network oI Contract Dentists in the State oI CaliIornia. These Dentists are screened to ensure that our standards oI quality, access and saIety are maintained. The network is composed oI established CAA54 - 3 - CAA54 EOC - V11 dental proIessionals. When you visit your assigned Contract Dentist, you pay only the applicable Copayment Ior BeneIits. There are no deductibles, liIetime maximums or claim Iorms. How to use the DeltaCare USA Plan - Choice of Contract Dentist To enroll in this Program, you must select a Contract Dentist Irom the list oI dental Iacilities Iurnished with this Contract. You must indicate the Contract Dentist's name and Iacility ID # on the Enrollment and Payment Authorization Form. YOU AND YOUR ELIGIBLE DEPENDENTS MAY OBTAIN TREATMENT FROM ANY CONTRACT DENTIST AT THAT SAME FACILITY. Shortly aIter enrollment, you will receive a DeltaCare USA membership packet that tells you the EIIective Date oI your coverage. The packet will also show the address and telephone number oI your Contract Dentist. You may obtain covered dental services any time aIter your EIIective Date. To make an appointment, simply call your Contract Dentist's Iacility and identiIy yourselI as a DeltaCare USA Enrollee. Initial appointments should be scheduled within Iour weeks unless a speciIic time has been requested. Inquiries regarding availability oI appointments and accessibility oI Contract Dentists should be directed to the Customer Service department at 800-422-4234. YOU AND YOUR ELIGIBLE DEPENDENTS MUST GO TO YOUR ASSIGNED CONTRACT DENTIST TO OBTAIN BENEFITS EXCEPT FOR EMERGENCY SERVICES OR SPECIALIST SERVICES PREAUTHORIZED BY US AS DESCRIBED BELOW. ANY OTHER TREATMENT IS NOT COVERED UNDER THIS PROGRAM. Who is eligible for coverage? You and your Eligible Dependents, as deIined below, are eligible provided you live or work in the DeltaCare USA service area. You and your Eligible Dependents become eligible: 1) on the Iirst day oI the month Iollowing our receipt oI timely Premium and complete enrollment inIormation; 2) as soon as they become your dependent, or at any time subject to a change in legal custody or lawIul order to provide BeneIits. Your Eligible Dependents include: 1) spouse (unless legally separated or divorced) or Domestic Partner (until such partnership is terminated by either or both parties); 2) unmarried children Irom birth up to age 19; 3) dependent children until they turn 23 iI they are wholly dependent on you Ior support and are Full-Time Students. Children include natural children, stepchildren, adopted children, Ioster children and children oI a Domestic Partner iI they are dependent on you Ior support. Newborn children (including newborn adopted children) are covered Irom and aIter the moment oI birth. Notice oI birth must be received within 31 days aIter the date oI birth Ior coverage to continue beyond 31 days. Foster children and legally adopted CAA54 - 4 - CAA54 EOC - V11 children (other than newborns) are eligible Irom and aIter the moment they are placed in your physical custody. Dependents in military service are not eligible. An unmarried child over the age oI 19 may remain eligible iI that child is incapable oI selI-sustaining employment because oI a physically or mentally disabling injury, illness or condition and is chieIly dependent on you Ior support and maintenance. See Renewal, Cancellation and Termination of Benefits. How do I enroll? First, please read all the inIormation contained in this Contract (particularly the Schedule of Benefits and Copayments, Limitations and Exclusions). This way you will know what procedures are covered and what your Copayments and Premium will be. Second, Irom the network directory, choose a dental Iacility that is convenient Ior you and Ior your Iamily's treatment. Third, complete the Enrollment and Payment Authorization Form and indicate which contract Iacility you have chosen. Remember - enrollment is Ior a minimum oI twelve (12) months. II coverage is voluntarily discontinued, you and your eligible dependents may not re-enroll during the 12-month period immediately Iollowing the voluntary termination. How much do I pay? The annual Premium Ior the initial Contract Term is: * Enrollee only (one person): plus a one-time enrollment fee of $10.00 $91.80 * Enrollee and one dependent (spouse or child): plus a one-time enrollment fee of $10.00 $148.53 * Enrollee and two or more dependents: plus a one-time enrollment fee of $10.00 $217.56 A Iull reIund oI Premium, including the one time enrollment Iee, is available iI the written request Ior reIund is made within the Iirst month oI the Contract Term. ThereaIter, requests Ior Premium reIund will be pro-rated based upon the number oI months remaining in the Contract Term subject to the Iollowing conditions: 1) The one-time enrollment Iee is not reIundable aIter the Iirst month oI coverage. 2) You, or your covered dependents, have not received any BeneIits under the DeltaCare USA program; 3) There is at least one month remaining in the Contract Term. 4) Coverage is based on a Iull calendar month. There are no partial month reIunds. Choose a Payment Option For your convenience, Delta Dental has made it possible to choose Irom two payment options. The annual Premium may be charged to your MasterCard, Visa, Discover or American Express account, or you may pay by personal check or money order. Be sure to indicate which payment option you have chosen on the Enrollment and Payment Authorization Form. CAA54 - 5 - CAA54 EOC - V11 * Credit Card Payment Option II you choose the Credit Card Payment Option, your annual Premium and the $10.00 one-time enrollment Iee will be charged to your MasterCard, Visa, Discover or American Express account. * Check/Money Order Payment Option II you preIer to pay by personal check or money order, select that option on the Enrollment and Payment Authorization Form and make your check payable to Delta Dental oI CaliIornia. Checks returned Ior insuIIicient Iunds are subject to a $25.00 processing Iee which must be paid beIore coverage will be reinstated. Mailing Instructions Please mail the completed Enrollment and Payment Authorization Form with either credit card inIormation or a check or money order Ior the Premium and the $10.00 enrollment Iee to: Delta Dental oI CaliIornia Dept. 0170 Los Angeles, CA 90084-0170 What will my Effective Date be? We must receive the enrollment materials by the 21st day oI the month Ior coverage to start the Iirst day oI the Iollowing month. II we receive the enrollment materials aIter the 21st day oI the month, coverage will begin the Iirst day oI the second month. Emergency Services Your assigned Contract Dentist maintains a 24-hour Emergency Services system seven days a week. II Emergency Services are needed, you should contact your Contract Dentist whenever possible. BeneIits Ior Emergency Services by any other Dentist are limited to necessary care to stabilize your condition and/or provide palliative relieI when you: 1) have made a Reasonable attempt to contact the Contract Dentist and the Contract Dentist is unavailable or is unable to see you within 24 hours oI making contact; or 2) have made a Reasonable attempt to contact Delta Dental prior to receiving Emergency Services, or it is Reasonable Ior you to access Emergency Services without prior contact with Delta Dental; or 3) reasonably believe that your condition makes it dentally/medically inappropriate to travel to the Contract Dentist to receive Emergency Services. BeneIits Ior Emergency Services not provided by the Contract Dentist are limited to a maximum oI $100.00 per emergency, per enrollee, less the applicable Copayment. II the maximum is exceeded, you are responsible Ior any charges Ior services by a Dentist other than your Contract Dentist. CAA54 - 6 - CAA54 EOC - V11 Specialist Services Specialist Services Ior oral surgery, endodontics, periodontics or pediatric dentistry, must be 1) reIerred by the assigned Contract Dentist, and 2) preauthorized in writing by us. You pay the speciIied Copayment. (ReIer to Schedule A.) II you require Specialist Services and there is no Contract Specialist to provide these services within 35 miles oI your home address, your assigned Contract Dentist must receive written Preauthorization Irom Delta Dental to reIer you to an Out-oI- Network specialist to provide the Specialist Services. Specialist Services perIormed by an Out-oI-Network specialist that are not preauthorized by Delta Dental may not be covered. II the services oI a Contract Orthodontist are needed, please reIer to Section XI, Orthodontics in Schedule A, and Schedule B, Orthodontic Limitations and Exclusions, to determine BeneIits. II you are reIerred to a dental school clinic Ior Specialist Services, those services may be provided by a Dentist, a dental student, a clinician or a dental instructor. Special Needs II an Enrollee believes he or she has a Special Health Care Need, the Enrollee should contact Delta Dental's Customer Service department at 800-422-4234. Delta Dental will conIirm that a Special Health Care Need exists, and what arrangements can be made to assist the Enrollee in obtaining such BeneIits. Delta Dental shall not be responsible Ior the Iailure oI any Contract Dentist to comply with any law or regulation concerning structural oIIice requirements that apply to a Dentist treating persons with Special Health Care Needs. Facility Accessibility Many dental Iacilities provide Delta Dental with inIormation about special Ieatures oI their oIIices, including accessibility inIormation Ior patients with mobility impairments. To obtain inIormation regarding dental Iacility accessibility, contact Delta Dental's Customer Service department at 800-422-4234. What if I need to change Contract Dentists? You may change your assigned Contract Dentist by directing a request to the Customer Service department or by visiting our website at deltadentalins.com. In order to ensure that your Contract Dentist is notiIied and our eligibility lists are correct, a change in Contract Dentist must be requested beIore the 21st day oI the month to be eIIective on the Iirst day oI the Iollowing month. We will provide an Enrollee written notice oI assignment to another Contract Dentist Iacility near the Enrollee's home, iI 1) a selected Iacility is closed to Iurther enrollment, 2) a chosen Contract Dentist withdraws Irom the Program, or 3) an assigned Iacility requests, Ior good cause, that the Enrollee be re-assigned to another Contract Dentist. All Treatment in Progress must be completed beIore you change to another Contract Dentist. For example, this would include 1) partial or Iull dentures Ior which Iinal impressions have been taken, 2) completion oI root canals in progress and 3) delivery oI crowns when teeth have been prepared. CAA54 - 7 - CAA54 EOC - V11 II your assigned Contract Dentist terminates participation in this Program, that Contract Dentist will complete all Treatment in Progress as described above. Benefits, Limitations and Exclusions This Program provides the BeneIits described in Schedule A subject to the limitations and exclusions described in Schedule B. BeneIits are only available in the state oI CaliIornia. The services are perIormed as deemed appropriate by your attending Contract Dentist. Copayments and Other Charges You are required to pay any Copayments listed in Schedule A. Copayments are paid directly to the Dentist who provides treatment. Charges Ior broken appointments and visits aIter normal visiting hours are listed in Schedule A. In the event that we Iail to pay a Contract Dentist, you will not be liable to that Dentist Ior any sums owed by us. By statute, every contract between Delta Dental and our Contract Dentists contains a provision prohibiting a Contract Dentist Irom charging an Enrollee Ior any sums owed by Delta Dental. II you have not received Preauthorization Ior treatment Irom an Out-oI-Network Dentist, and we Iail to pay that Out-oI-Network Dentist, you may be liable to that Dentist Ior the cost oI services. For Iurther clariIication see Emergency Services and Specialist Services. Dentist Compensation A Contract Dentist is compensated by Delta Dental through monthly capitation (an amount based on the number oI Enrollees assigned to the Iacility), and by Enrollees through required Copayments Ior treatment received. A Contract Specialist is compensated by Delta Dental through an agreed-upon amount Ior each covered procedure, less the applicable Copayment paid by the Enrollee. In no event does Delta Dental pay a Contract Dentist, a Contract Orthodontist, or a Contract Specialist any incentive as an inducement to deny, reduce, limit or delay any appropriate treatment. You may obtain Iurther inIormation concerning compensation by calling Delta Dental at the toll-Iree telephone number shown on the back cover oI this booklet. Second Opinion You may request a second opinion iI you disagree with or question the diagnosis and/or treatment plan determination made by your Contract Dentist. Delta Dental may also request that an Enrollee obtain a second opinion to veriIy the necessity and appropriateness oI dental treatment or the application oI BeneIits. Second opinions will be rendered by a licensed Dentist in a timely manner, appropriate to the nature oI your condition. Requests involving cases oI imminent and serious health threat will be expedited (authorization approved or denied within 72 hours oI receipt oI the request, whenever possible). For assistance or additional inIormation regarding the procedures and timeIrames Ior second opinion CAA54 - 8 - CAA54 EOC - V11 authorizations, contact Delta Dental's Customer Service department at 800-422-4234 or write to Delta Dental. Second opinions will be provided at another Contract Dentist's Iacility, unless otherwise authorized by Delta Dental. Delta Dental will authorize a second opinion by an Out-oI-Network Dentist iI an appropriately qualiIied Contract Dentist is not available. Delta Dental will only pay Ior a second opinion that Delta Dental has approved or authorized. You will be sent a written notiIication should Delta Dental decide not to authorize a second opinion. II you disagree with this determination, you may Iile a grievance with Delta Dental or with the Department oI Managed Health Care. ReIer to the Enrollee Complaint Procedure Ior inIormation regarding complaint procedures. Claims for Reimbursement Claims Ior covered Emergency Dental Services or preauthorized Specialist Services should be sent to us within 90 days oI the end oI treatment. Valid claims received aIter the 90-day period will be reviewed iI you can show that it was not reasonably possible to submit the claim within that time. The address Ior claims submission is: Claims Department, P.O. Box 1810, Alpharetta, GA 30023. Processing Policies The dental care guidelines Ior the DeltaCare USA Program explain to Contract Dentists what services are covered under the dental Contract. Contract Dentists will use their proIessional judgment to determine which services are appropriate Ior the Enrollee. Services perIormed by the Contract Dentist that Iall under the scope oI BeneIits oI the dental Program are provided subject to any Copayments. II a Contract Dentist believes that an Enrollee should seek treatment Irom a specialist, the Contract Dentist contacts Delta Dental Ior a determination oI whether the proposed treatment is a covered beneIit. Delta Dental will also determine whether the proposed treatment requires treatment by a specialist. An Enrollee may contact Delta Dental's Customer Service department at 800-422-4234 Ior inIormation regarding the dental care guidelines Ior DeltaCare USA. Enrollee Complaint Procedure Delta Dental shall provide notiIication iI any dental services or claims are denied, in whole or in part, stating the speciIic reason or reasons Ior the denial. II you have any complaint regarding eligibility, the denial oI dental services or claims, the policies, procedures or operations oI Delta Dental, or the quality oI dental services perIormed by a Contract Dentist, you may call the Customer Service department at 800-422-4234, or the complaint may be addressed in writing to: Quality Management Department P.O. Box 6050 Artesia, CA 90702 Written communication must include 1) the name oI the patient 2) the name, address, telephone number and identiIication number oI the primary Enrollee and 3) the Dentist's name and Iacility location. CAA54 - 9 - CAA54 EOC - V11 Within 5 calendar days oI the receipt oI any complaint, the quality management coordinator will Iorward to you an acknowledgment oI receipt oI the complaint. Certain complaints may require that you be reIerred to a regional dental consultant Ior clinical evaluation oI the dental services provided. Delta Dental will Iorward to you a determination, in writing, within 30 days oI receipt oI a complaint. II the complaint involves severe pain and/or imminent and serious threat to a patient's dental health, Delta Dental will provide the Enrollee written notiIication regarding the disposition or pending status oI the complaint within three days. II you have completed Delta Dental's grievance process, or you have been involved in Delta Dental's grievance procedure Ior more than 30 days, you may Iile a complaint with the CaliIornia Department oI Managed Health Care. You may Iile a complaint with the Department immediately in an emergency situation, which is one involving severe pain and/or imminent and serious threat to your health. The CaliIornia Department oI Managed Health Care is responsible Ior regulating health care service plans. II you have a grievance against your health plan, you should Iirst telephone your health plan at 800-422-4234 and use your health plan's grievance process beIore contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. II you need help with a grievance involving an emergency, a grievance that has not been satisIactorily resolved by your health plan, or a grievance that has remained unresolved Ior more than 30 days, you may call the Department Ior assistance. You may also be eligible Ior an Independent Medical Review (IMR). II you are eligible Ior IMR, the IMR process will provide an impartial review oI medical decisions made by a health plan related to the medical necessity oI a proposed service or treatment, coverage decisions Ior treatments that are experimental or investigational in nature and payment disputes Ior emergency or urgent medical services. The Department also has a toll-Iree telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) Ior the hearing and speech impaired. The Department's Internet Web site http://www.hmohelp.ca.gov has complaint Iorms, IMR application Iorms and instructions online. IMR is generally not applicable to a dental plan, unless that dental plan covers services related to the practice oI medicine or is oIIered pursuant to a contract with a health plan providing medical, surgical or hospital services. Renewal, Cancellation and Termination of Benefits No change in BeneIits or Premium will be made during a Contract Term. We will send you a written renewal notice, including any proposed changes in BeneIits and/or Premium at least 30 days beIore your coverage expires. Your coverage will terminate at the end oI the Contract Term unless you renew by paying the applicable Premium on or beIore the expiration date oI your Contract. Receipt oI the applicable Premium by us aIter termination oI your coverage will reinstate your coverage unless payment is received more than 15 days aIter termination and we reIund such payment within 20 business days. II reinstatement is not requested within 15 days oI termination, you must wait 12 months beIore you may re-enroll in the program. CAA54 - 10 - CAA54 EOC - V11 Enrollment will be cancelled by Delta Dental in the Iollowing events: 1) For any Eligible Dependent, immediately upon receipt oI a written notice regarding the loss oI dependent status; however, an unmarried dependent child may continue eligibility iI: a) he or she is incapable oI selI-sustaining employment because oI a physically or mentally disabling injury, illness or condition that began prior to reaching the limiting age, b) he or she is chieIly dependent on you Ior support; and c) prooI oI dependent's disability or incapacity is provided within 60 days oI request by Delta Dental and subsequently as required. Such requests will not be made more than once a year Iollowing a two year period aIter the Eligible Dependent reaches age 23. Eligibility will continue as long as the dependent relies on you Ior support because oI a physically or mentally disabling injury, illness or condition that began beIore he or she reached the limiting age. 2) Upon 15 days written notice iI: a) the Enrollee is guilty oI misconduct detrimental to saIe operations and the delivery oI services while in a Contract Dentist's Iacility; b) the Enrollee knowingly commits or permits another person to commit Iraud or deception in obtaining BeneIits. 3) Upon 30 days written notice iI the Enrollee Iails to pay Copayments; provided, however, that the Enrollee may be reinstated during the term oI this Program upon payment oI all delinquent charges. Coverage Ior an Enrollee will terminate as oI the date enrollment is cancelled under the terms oI this Disclosure Form/Contract. However, we will continue to provide BeneIits Ior completion oI any treatment in progress (less any applicable Copayment). Cancellation oI a Primary Enrollee's enrollment, as described above, shall automatically cancel the enrollment oI any oI his or her Dependent Enrollees. Any cancellation is subject to the written notiIication requirements set Iorth in this booklet. An Enrollee who believes that enrollment has been cancelled or not renewed because oI dental condition or the need Ior dental care may request a review oI the cancellation by the Director oI the Department oI Managed Health Care oI the State oI CaliIornia. Please reIer to Enrollee Complaint Procedure. Entire Contract This Disclosure Form/Contract, and any attached schedules, appendices, endorsements and riders, constitute the entire agreement governing the Program. No amendment is valid unless approved by an executive oIIicer oI Delta Dental and attached to this booklet. No agent or broker has authority to amend this Contract or waive any oI its provisions. Public Policy Participation by Enrollees Delta Dental's Board oI Directors includes Enrollees who participate in establishing Delta Dental's public policy regarding Enrollees through periodic review oI Delta CAA54 - 11 - CAA54 EOC - V11 Dental's Quality Assessment program reports and communication Irom Enrollees. Enrollees may submit any suggestions regarding Delta Dental's public policy in writing to: Customer Service department, P.O. Box 1803, Alpharetta, GA 30023. Governing Law This Program is a health care service plan subject to the requirements oI Chapter 22 oI Division 2 oI the CaliIornia Health & SaIety Code and Chapter 1 oI Division 1 oI Title 28 oI the CaliIornia Code oI Regulations. Any provision required to be included in this Disclosure Form/Contract by the above law and regulation binds this Program whether or not stated. Delta Dental shall comply in all respects with all applicable Iederal, state and local laws and regulations relating to administrative simpliIication, security, and privacy oI individually identiIiable enrollee inIormation. Both parties agree that this Contract may be amended as necessary to comply with Iederal regulations issued under the Health Insurance Portability and Accountability Act oI 1996 or to comply with any other enacted administrative simpliIication, security or privacy laws or regulations. DeltaCare USA INDIVIDUAL/FAMILY DENTAL PROGRAM CAA54 ENROLLMENT AND PAYMENT AUTHORIZATION FORM Broker #: _____________ I understand that, iI I have indicated that coverage under the Program is to be provided only Ior the dependent child(ren) named on this Iorm, I am responsible Ior payment oI the required annual Premium and compliance with all oI the provisions and conditions oI the Disclosure Form/Contract. I understand that I must select a DeltaCare USA Contract Dentist Irom the list oI dental Iacilities. II the selected Iacility is not available, non-contracted or closed to Iurther enrollment, Delta Dental reserves the right to assign me to another dental oIfce as close as possible to my home. In the event that Delta Dental cannot assign me to a Contract Dentist my premium will be reIunded. In accordance with the disclosure requirements oI CaliIornia Health & SaIety Code Section 1363(h), this is to advise you that Delta Dentalis ratio oI health care expense to premiums received Ior the last calendar year, with respect to the DeltaCare USA Individual/Family Dental Program, was 67.91°. Delta Dental of California 17871 Park Plaza Drive, Suite 200 Cerritos, CA 90703 (800) 422-4234 Applicant/Dependent Information PLEASE LIST ELIGIBLE DEPENDENTS TO BE COVERED IN ADDITION TO YOURSELF Relationship Code* Dependent Name Male/ Female Date oI Birth * Relationship Codes: Place the Iollowing two character code in the frst column to designate each dependent as Iollows: Spouse - SP Domestic Partner - DP Child - CH Other Child - OC VERY IMPORTANT - PLEASE PRINT LEGIBLY (To add additional dependents please attach a separate sheet) Name: Mailing Address: Date oI Birth: SSN/ID #: Contract Facility Name: Male Female Home Phone # Last First MI Address City State Zip Month Day Year Contract Facility # E-mail For internal use only Return Iorm to Delta Dental oI CaliIornia at Dept. 0170, Los Angeles, CA 90084-0170 or enroll online at deltadentalins.com CAA54 Signature: ¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸ Date ¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸ PROGRAM COST AND PAYMENT OPTION (choose only one) PAYMENT OPTIONS CHECK/MONEY ORDER PAYMENT OPTION Please make check or money order payable to Delta Dental oI CaliIornia. You will have the opportunity to renew prior to the end oI the Contract Term to avoid interruption oI coverage. CREDIT CARD PAYMENT OPTION VISA MASTERCARD DISCOVER AMERICAN EXPRESS CARD # ¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸ EXPIRATION DATE ¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸ NAME AS IT APPEARS ON THE CARD ¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸ SIGNATURE ¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸ DATE ¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸¸ By signing above you authorize Delta Dental oI CaliIornia to charge your credit card account Ior the cost oI the DeltaCare USA Program. Note: Any credit card reIunds under the Program may be made by check or credit card. Check appropriate box based on the inIormation below: Plan CAA54 Individual annual Premium $ 91.80 Individual plus one dependent annual Premium $148.53 Individual plus two or more dependents annual Premium $217.56 One-time non reIundable Enrollment Fee (required Ior new enrollment) $ 10.00 TOTAL $¸¸¸¸¸¸¸¸¸ This Enrollment and Payment Authorization Form and your check or money order, if applicable, must be received by the 21 st day of the month for your coverage to be effective on the ñrst day of the following month. I wish to enroll in the DeltaCare USA Individual/Family Dental Program. I acknowledge that I have read the Disclosure Form/Contract and understand that coverage under the Program is subject to the terms as described in the Disclosure Form/Contract. I hereby authorize my medical or dental care institution or proIessional to release to a representative oI Delta Dental, any personal, privileged or medical records inIormation including, but not limited to, my patient records, charts, x-rays, diagnosis histories, billing records, clinical abstracts, or copies oI consultations. The inIormation authorized herein may be used Ior determination oI benefts, quality assessment, utilization review, grievance resolution, or investigation or compliance with the Delta Dental provider agreements or local, state or Iederal laws. This authorization is valid Ior the duration oI coverage. Indicate eIIective date: Month Day Year - 12 - CAA54 EOC - V11 SCHEDULE A Description of Benefits and Copayments The beneIits shown below are perIormed as needed and deemed necessary by the attending Contract Dentist subject to the limitations and exclusions oI the program. Please reIer to Schedule B Ior Iurther clariIication oI beneIits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered. Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT-2011 procedure codes, descriptors or nomenclature which are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal regulations. CODE DESCRIPTION ENROLLEE PAYS D0100-D0999 I. DIAGNOSTIC D0120 Periodic oral evaluation - established patient ........................ No Cost D0140 Limited oral evaluation - problem Iocused ........................... No Cost D0145 Oral evaluation Ior a patient under three years oI age and counseling with primary caregiver .................................... No Cost D0150 Comprehensive oral evaluation - new or established patient ....... No Cost D0160 Detailed and extensive oral evaluation - problem Iocused, by report ....................................................................... No Cost D0170 Re-evaluation - limited, problem Iocused (established patient; not post-operative visit) ...................................................... No Cost D0180 Comprehensive periodontal evaluation - new or established patient ...................................................................... No Cost D0210 Intraoral radiographs - complete series (including bitewings) - limited to 1 series every 24 months ................................... No Cost D0220 Intraoral - periapical Iirst Iilm ......................................... No Cost D0230 Intraoral - periapical each additional Iilm ............................ No Cost D0240 Intraoral - occlusal Iilm ................................................. No Cost D0250 Extraoral - Iirst Iilm ..................................................... No Cost D0260 Extraoral - each additional Iilm ........................................ No Cost D0270 Bitewing radiograph - single Iilm ..................................... No Cost D0272 Bitewings radiographs - two Iilms - limited to 1 series every 6 months ..................................................................... No Cost D0273 Bitewings radiographs - three Iilms - limited to 1 series every 6 months ..................................................................... No Cost - 13 - CAA54 EOC - V11 D0274 Bitewings radiographs - Iour Iilms - limited to 1 series every 6 months ..................................................................... No Cost D0277 Vertical bitewings - 7 to 8 Iilms ....................................... No Cost D0330 Panoramic Iilm - limited to 1 every 24 months ...................... No Cost D0460 Pulp vitality tests ......................................................... No Cost D0470 Diagnostic casts .......................................................... No Cost D0472 Accession oI tissue, gross examination, preparation and transmission oI written report - available only when performed in conjunction with a covered biopsy .................................... No Cost D0473 Accession oI tissue, gross and microscopic examination, preparation and transmission oI written report - available only when performed in conjunction with a covered biopsy ............. No Cost D0474 Accession oI tissue, gross and microscopic examination, including assessment oI surgical margins Ior presence oI disease, preparation and transmission oI written report - available only when performed in conjunction with a covered biopsy ............. No Cost D0999 UnspeciIied diagnostic procedure, by report - includes office visit, per visit (in addition to other services) ............................... $10.00 D1000-D1999 II. PREVENTIVE D1110 Prophylaxis cleaning - adult - 1 per 6 month period ................ $20.00 D1120 Prophylaxis cleaning - child - 1 per 6 month period ................ $20.00 D1203 Topical application oI Iluoride - child - to age 19; 1 per 6 month period ...................................................................... $20.00 D1206 Topical Iluoride varnish; therapeutic application Ior moderate to high caries risk patients - child to age 19; 1 per 6 month period ... $20.00 D1310 Nutritional counseling Ior control oI dental disease ................. No Cost D1320 Tobacco counseling Ior the control and prevention oI oral disease No Cost D1330 Oral hygiene instructions ............................................... No Cost D1351 Sealant - per tooth - limited to permanent molars through age 15 . $22.00 D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth - limited to permanent molars through age 15 ...................................................................... $22.00 D1510 Space maintainer - Iixed - unilateral .................................. $85.00 D1515 Space maintainer - Iixed - bilateral .................................... $85.00 D1520 Space maintainer - removable - unilateral ............................ $85.00 D1525 Space maintainer - removable - bilateral ............................. $85.00 D1550 Re-cementation oI space maintainer ................................... $10.00 D1555 Removal oI Iixed space maintainer .................................... $10.00 - 14 - CAA54 EOC - V11 D2000-D2999 III. RESTORATIVE - Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures. - Replacement of crowns, inlays and onlays requires the existing restoration to be 5+ years old. D2140 Amalgam - one surIace, primary or permanent ...................... $25.00 D2150 Amalgam - two surIaces, primary or permanent ..................... $40.00 D2160 Amalgam - three surIaces, primary or permanent ................... $50.00 D2161 Amalgam - Iour or more surIaces, primary or permanent .......... $55.00 D2330 Resin-based composite - one surIace, anterior ....................... $65.00 D2331 Resin-based composite - two surIaces, anterior ...................... $75.00 D2332 Resin-based composite - three surIaces, anterior .................... $85.00 D2335 Resin-based composite - Iour or more surIaces or involving incisal angle (anterior) .................................................. $115.00 D2390 Resin-based composite crown, anterior ............................... $115.00 D2391 Resin-based composite - one surIace, posterior ...................... $70.00 D2392 Resin-based composite - two surIaces, posterior .................... $80.00 D2393 Resin-based composite - three surIaces, posterior ................... $115.00 D2394 Resin-based composite - Iour or more surIaces, posterior .......... $120.00 D2510 Inlay - metallic - one surIace 1 ......................................... $260.00 D2520 Inlay - metallic - two surIaces 1 ........................................ $270.00 D2530 Inlay - metallic - three or more surIaces 1 ............................ $280.00 D2542 Onlay - metallic - two surIaces 1 ...................................... $270.00 D2543 Onlay - metallic - three surIaces 1 ..................................... $290.00 D2544 Onlay - metallic - Iour or more surIaces 1 ............................ $300.00 D2610 Inlay - porcelain/ceramic - one surIace 2 ............................. $350.00 D2620 Inlay - porcelain/ceramic - two surIaces 2 ............................ $385.00 D2630 Inlay - porcelain/ceramic - three or more surIaces 2 ................. $405.00 D2642 Onlay - porcelain/ceramic - two surIaces 2 ........................... $415.00 D2643 Onlay - porcelain/ceramic - three surIaces 2 .......................... $415.00 D2644 Onlay - porcelain/ceramic - Iour or more surIaces 2 ................. $425.00 D2650 Inlay - resin-based composite - one surIace 2 ........................ $250.00 D2651 Inlay - resin-based composite - two surIaces 2 ....................... $275.00 D2652 Inlay - resin-based composite - three or more surIaces 2 ............ $310.00 D2662 Onlay - resin-based composite - two surIaces 2 ...................... $305.00 D2663 Onlay - resin-based composite - three surIaces 2 .................... $330.00 D2664 Onlay - resin-based composite - Iour or more surIaces 2 ............ $375.00 D2710 Crown - resin-based composite (indirect) 2 ........................... $125.00 D2712 Crown - / resin-based composite (indirect) 2 ........................ $125.00 D2720 Crown - resin with high noble metal 2 ................................ $425.00 D2721 Crown - resin with predominantly base metal 2 ...................... $325.00 D2722 Crown - resin with noble metal 2 ...................................... $425.00 - 15 - CAA54 EOC - V11 D2740 Crown - porcelain/ceramic substrate 2, 3 ............................... $495.00 D2750 Crown - porcelain Iused to high noble metal 2, 3, 4 ................... $425.00 D2751 Crown - porcelain Iused to predominantly base metal 2, 4 ........... $325.00 D2752 Crown - porcelain Iused to noble metal 2, 4 ........................... $425.00 D2780 Crown - / cast high noble metal ...................................... $425.00 D2781 Crown - / cast predominantly base metal ........................... $325.00 D2782 Crown - / cast noble metal ............................................ $425.00 D2783 Crown - / porcelain/ceramic 2, 3 ....................................... $495.00 D2790 Crown - Iull cast high noble metal .................................... $425.00 D2791 Crown - Iull cast predominantly base metal .......................... $325.00 D2792 Crown - Iull cast noble metal .......................................... $425.00 D2794 Crown - titanium ......................................................... $495.00 D2910 Recement inlay, onlay or partial coverage restoration ............... $15.00 D2915 Recement cast or preIabricated post and core ........................ $15.00 D2920 Recement crown .......................................................... $15.00 D2930 PreIabricated stainless steel crown - primary tooth .................. $55.00 D2931 PreIabricated stainless steel crown - permanent tooth ............... $55.00 D2932 PreIabricated resin crown - anterior primary tooth ................. $95.00 D2933 PreIabricated stainless steel crown with resin window - anterior primary tooth ............................................................. $95.00 D2940 Protective restoration .................................................... $10.00 D2950 Core buildup, including any pins ...................................... $85.00 D2951 Pin retention - per tooth, in addition to restoration .................. $30.00 D2952 Post and core in addition to crown, indirectly Iabricated - includes canal preparation 1 ...................................................... $85.00 D2953 Each additional indirectly Iabricated post - same tooth - includes canal preparation 1 ...................................................... $50.00 D2954 PreIabricated post and core in addition to crown - base metal post; includes canal preparation ............................................. $75.00 D2955 Post removal (not in conjunction with endodontic therapy) ........ $40.00 D2957 Each additional preIabricated post - same tooth - base metal post; includes canal preparation ............................................. $45.00 D2970 Temporary crown (Iractured tooth) - palliative treatment only ..... $35.00 D2971 Additional procedures to construct new crown under existing partial denture Iramework .............................................. $65.00 D2980 Crown repair, by report ................................................. $50.00 D3000-D3999 IV. ENDODONTICS - With the exception of pulp caps, pulpotomies, pulpal debridements, and pulpal therapies with resorbable fillings, all endodontic procedures listed below are benefits for permanent teeth only. D3110 Pulp cap - direct (excluding Iinal restoration) ........................ $10.00 D3120 Pulp cap - indirect (excluding Iinal restoration) ..................... $10.00 - 16 - CAA54 EOC - V11 D3220 Therapeutic pulpotomy (excluding Iinal restoration) - removal oI pulp coronal to the dentinocemental junction and application oI medicament ............................................................... $45.00 D3221 Pulpal debridement, primary and permanent teeth ................... $45.00 D3222 Partial pulpotomy Ior apexogenesis - permanent tooth with incomplete root development. .......................................... $45.00 D3230 Pulpal therapy (resorbable Iilling) - anterior, primary tooth (excluding Iinal restoration) ............................................ $45.00 D3240 Pulpal therapy (resorbable Iilling) - posterior, primary tooth (excluding Iinal restoration) ............................................ $45.00 D3310 Root canal - endodontic therapy, anterior tooth (excluding Iinal restoration) ................................................................ $240.00 D3320 Root canal - endodontic therapy, bicuspid tooth (excluding Iinal restoration) ................................................................ $350.00 D3330 Root canal - endodontic therapy, molar (excluding Iinal restoration) ................................................................ $400.00 D3332 Incomplete endodontic therapy; inoperable, unrestorable or Iractured tooth ............................................................ $240.00 D3346 Retreatment oI previous root canal therapy - anterior ............... $500.00 D3347 Retreatment oI previous root canal therapy - bicuspid .............. $600.00 D3348 Retreatment oI previous root canal therapy - molar ................. $725.00 D3410 Apicoectomy/periradicular surgery - anterior ........................ $470.00 D3421 Apicoectomy/periradicular surgery - bicuspid (Iirst root) .......... $535.00 D3425 Apicoectomy/periradicular surgery - molar (Iirst root) ............. $580.00 D3426 Apicoectomy/periradicular surgery (each additional root) .......... $115.00 D3430 Retrograde Iilling - per root ............................................ $65.00 D3450 Root amputation, per root .............................................. $315.00 D3920 Hemisection (including any root removal), not including root canal therapy .............................................................. $95.00 D4000-D4999 V. PERIODONTICS - Includes postoperative evaluations and treatment under a local anesthetic. D4210 Gingivectomy or gingivoplasty - Iour or more contiguous teeth or tooth bounded spaces per quadrant .................................... $260.00 D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant .................................... $150.00 D4240 Gingival Ilap procedure, including root planing - Iour or more contiguous teeth or tooth bounded spaces per quadrant ............. $350.00 D4241 Gingival Ilap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant ............. $280.00 D4249 Clinical crown lengthening - hard tissue .............................. $280.00 D4260 Osseous surgery (including Ilap entry and closure) - Iour or more contiguous teeth or tooth bounded spaces per quadrant ............. $650.00 D4261 Osseous surgery (including Ilap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant ............. $520.00 - 17 - CAA54 EOC - V11 D4270 Pedicle soIt tissue graIt procedure ..................................... $290.00 D4271 Free soIt tissue graIt procedure (including donor site surgery) ..... $300.00 D4274 Distal or proximal wedge procedure (when not perIormed in conjunction with surgical procedures in the same anatomical area) ........................................................................ $95.00 D4341 Periodontal scaling and root planing - Iour or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months ..................................................................... $80.00 D4342 Periodontal scaling and root planing - one to three teeth per quadrant - limited to 4 quadrants during any 12 consecutive months ..................................................................... $64.00 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis - limited to 1 treatment in any 12 consecutive months ... $80.00 D4910 Periodontal maintenance - limited to 1 treatment each 6 month period ...................................................................... $65.00 D5000-D5899 VI. PROSTHODONTICS (removable) - For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement. The Enrollee must continue to be eligible, and the service must be provided at the Contract Dentist's facility where the denture was originally delivered. - Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months. - Replacement of a denture or a partial denture requires the existing denture to be 5+ years old. D5110 Complete denture - maxillary .......................................... $495.00 D5120 Complete denture - mandibular ........................................ $495.00 D5130 Immediate denture - maxillary ......................................... $550.00 D5140 Immediate denture - mandibular ....................................... $550.00 D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) .................................................. $400.00 D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) .................................. $400.00 D5213 Maxillary partial denture - cast metal Iramework with resin denture bases (including any conventional clasps, rests and teeth) ....................................................................... $565.00 D5214 Mandibular partial denture - cast metal Iramework with resin denture bases (including any conventional clasps, rests and teeth) ....................................................................... $565.00 D5225 Maxillary partial denture - Ilexible base (including any clasps, rests and teeth) ........................................................... $700.00 D5226 Mandibular partial denture - Ilexible base (including any clasps, rests and teeth) ........................................................... $700.00 D5410 Adjust complete denture - maxillary .................................. $24.00 D5411 Adjust complete denture - mandibular ................................ $24.00 D5421 Adjust partial denture - maxillary ..................................... $24.00 - 18 - CAA54 EOC - V11 D5422 Adjust partial denture - mandibular ................................... $24.00 D5510 Repair broken complete denture base ................................. $55.00 D5520 Replace missing or broken teeth - complete denture (each tooth) . $40.00 D5610 Repair resin denture base ............................................... $60.00 D5620 Repair cast Iramework .................................................. $60.00 D5630 Repair or replace broken clasp ......................................... $75.00 D5640 Replace broken teeth - per tooth ....................................... $45.00 D5650 Add tooth to existing partial denture .................................. $60.00 D5660 Add clasp to existing partial denture .................................. $75.00 D5710 Rebase complete maxillary denture ................................... $180.00 D5711 Rebase complete mandibular denture ................................. $180.00 D5720 Rebase maxillary partial denture ....................................... $180.00 D5721 Rebase mandibular partial denture .................................... $180.00 D5730 Reline complete maxillary denture (chairside) ....................... $75.00 D5731 Reline complete mandibular denture (chairside) ..................... $75.00 D5740 Reline maxillary partial denture (chairside) .......................... $75.00 D5741 Reline mandibular partial denture (chairside) ........................ $75.00 D5750 Reline complete maxillary denture (laboratory) ..................... $150.00 D5751 Reline complete mandibular denture (laboratory) ................... $150.00 D5760 Reline maxillary partial denture (laboratory) ......................... $150.00 D5761 Reline mandibular partial denture (laboratory) ...................... $150.00 D5820 Interim partial denture (maxillary) - limited to 1 in any 12 consecutive months ...................................................... $175.00 D5821 Interim partial denture (mandibular) - limited to 1 in any 12 consecutive months ...................................................... $175.00 D5850 Tissue conditioning, maxillary ......................................... $40.00 D5851 Tissue conditioning, mandibular ....................................... $40.00 D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS - Not Covered D6000-D6199 VIII. IMPLANT SERVICES - Not Covered D6200-D6999 IX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture ¡bridge]) - Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 5+ years old. D6210 Pontic - cast high noble metal ......................................... $425.00 D6211 Pontic - cast predominantly base metal ............................... $325.00 D6212 Pontic - cast noble metal ................................................ $425.00 D6240 Pontic - porcelain Iused to high noble metal 2, 3 ...................... $425.00 D6241 Pontic - porcelain Iused to predominantly base metal 2 ............. $325.00 D6242 Pontic - porcelain Iused to noble metal 2 ............................. $425.00 D6245 Pontic - porcelain/ceramic 2, 3 .......................................... $495.00 D6250 Pontic - resin with high noble metal 2 ................................. $425.00 - 19 - CAA54 EOC - V11 D6251 Pontic - resin with predominantly base metal 2 ...................... $325.00 D6252 Pontic - resin with noble metal 2 ....................................... $425.00 D6600 Inlay - porcelain/ceramic, two surIaces 2 ............................. $385.00 D6601 Inlay - porcelain/ceramic, three or more surIaces 2 .................. $405.00 D6602 Inlay - cast high noble metal, two surIaces ........................... $370.00 D6603 Inlay - cast high noble metal, three or more surIaces ............... $380.00 D6604 Inlay - cast predominantly base metal, two surIaces ................ $270.00 D6605 Inlay - cast predominantly base metal, three or more surIaces ..... $280.00 D6606 Inlay - cast noble metal, two surIaces ................................. $370.00 D6607 Inlay - cast noble metal, three or more surIaces ..................... $380.00 D6608 Onlay - porcelain/ceramic, two surIaces 2 ............................ $395.00 D6609 Onlay - porcelain/ceramic, three or more surIaces 2 ................. $415.00 D6610 Onlay - cast high noble metal, two surIaces .......................... $370.00 D6611 Onlay - cast high noble metal, three or more surIaces .............. $390.00 D6612 Onlay - cast predominantly base metal, two surIaces ............... $270.00 D6613 Onlay - cast predominantly base metal, three or more surIaces .... $290.00 D6614 Onlay - cast noble metal, two surIaces ................................ $370.00 D6615 Onlay - cast noble metal, three or more surIaces .................... $390.00 D6720 Crown - resin with high noble metal 2 ................................ $425.00 D6721 Crown - resin with predominantly base metal 2 ...................... $325.00 D6722 Crown - resin with noble metal 2 ...................................... $425.00 D6740 Crown - porcelain/ceramic 2, 3 .......................................... $495.00 D6750 Crown - porcelain Iused to high noble metal 2, 3, 4 ................... $425.00 D6751 Crown - porcelain Iused to predominantly base metal 2, 4 ........... $325.00 D6752 Crown - porcelain Iused to noble metal 2, 4 ........................... $425.00 D6780 Crown - / cast high noble metal ...................................... $425.00 D6781 Crown - / cast predominantly base metal ........................... $325.00 D6782 Crown - / cast noble metal ............................................ $425.00 D6783 Crown - / porcelain/ceramic 2, 3 ....................................... $495.00 D6790 Crown - Iull cast high noble metal .................................... $425.00 D6791 Crown - Iull cast predominantly base metal .......................... $325.00 D6792 Crown - Iull cast noble metal .......................................... $425.00 D6930 Recement Iixed partial denture ......................................... $30.00 D6940 Stress breaker ............................................................. $50.00 D6970 Post and core in addition to Iixed partial denture retainer, indirectly Iabricated - includes canal preparation 1 ................. $85.00 D6972 PreIabricated post and core in addition to Iixed partial denture retainer - base metal post; includes canal preparation ............. $75.00 D6973 Core buildup Ior retainer, including any pins ........................ $70.00 D6976 Each additional indirectly Iabricated post - same tooth - includes canal preparation 1 ...................................................... $45.00 - 20 - CAA54 EOC - V11 D6977 Each additional preIabricated post - same tooth - base metal post; includes canal preparation ............................................. $25.00 D6980 Fixed partial denture repair, by report ................................ $75.00 D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY - Includes preoperative and postoperative evaluations and treatment under local anesthetic. D7111 Extraction, coronal remnants - deciduous tooth ...................... $30.00 D7140 Extraction, erupted tooth or exposed root (elevation and/or Iorceps removal) ......................................................... $40.00 D7210 Surgical removal oI erupted tooth requiring removal oI bone and/ or sectioning oI tooth, and including elevation oI mucoperiosteal Ilap iI indicated .......................................................... $70.00 D7220 Removal oI impacted tooth - soIt tissue .............................. $100.00 D7230 Removal oI impacted tooth - partially bony .......................... $190.00 D7240 Removal oI impacted tooth - completely bony ...................... $210.00 D7241 Removal oI impacted tooth - completely bony, with unusual surgical complications ................................................... $230.00 D7250 Surgical removal oI residual tooth roots (cutting procedure) ....... $75.00 D7251 Coronectomy - intentional partial tooth removal .................... $230.00 D7286 Biopsy oI oral tissue - soIt - does not include pathology laboratory procedures ................................................... $100.00 D7310 Alveoloplasty in conjunction with extractions - Iour or more teeth or tooth spaces, per quadrant ........................................... $150.00 D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant ........................................... $150.00 D7320 Alveoloplasty not in conjunction with extractions - Iour or more teeth or tooth spaces, per quadrant .................................... $200.00 D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant .................................... $200.00 D7471 Removal oI lateral exostosis (maxilla or mandible) ................. $150.00 D7472 Removal oI torus palatinus ............................................. $150.00 D7473 Removal oI torus mandibularis ........................................ $150.00 D7510 Incision and drainage oI abscess - intraoral soIt tissue .............. $35.00 D7960 Frenulectomy - also known as Irenectomy or Irenotomy - separate procedure not incidental to another procedure ....................... $160.00 - 21 - CAA54 EOC - V11 D8000-D8999 XI. ORTHODONTICS - The listed Copayment for each phase of orthodontic treatment (limited, interceptive or comprehensive) covers up to 24 months of active treatment. Beyond 24 months, an additional monthly fee, not to exceed $125.00, may apply. - The Retention Copayment includes removal of appliances, construction and placement of removable retainers, and up to 24 months of adjustments and/or office visits. D8010 Limited orthodontic treatment oI the primary dentition .............$1,400.00 D8020 Limited orthodontic treatment oI the transitional dentition - child or adolescent to age 19 ................................................. $1,400.00 D8030 Limited orthodontic treatment oI the adolescent dentition - adolescent to age 19 .....................................................$1,400.00 D8040 Limited orthodontic treatment oI the adult dentition - adults, including covered dependent adult children ......................... $1,600.00 D8050 Interceptive orthodontic treatment oI the primary dentition ........ $1,650.00 D8060 Interceptive orthodontic treatment oI the transitional dentition .... $1,650.00 D8070 Comprehensive orthodontic treatment oI the transitional dentition - child or adolescent to age 19 ........................................ $2,600.00 D8080 Comprehensive orthodontic treatment oI the adolescent dentition - adolescent to age 19 .....................................................$2,600.00 D8090 Comprehensive orthodontic treatment oI the adult dentition - adults, including covered dependent adult children .................$2,800.00 D8660 Pre-orthodontic treatment visit 5 ....................................... No Cost D8670 Periodic orthodontic treatment visit (as part oI contract) ........... No Cost D8680 Orthodontic retention (removal oI appliances, construction and placement oI removable retainers) ..................................... $250.00 D8999 UnspeciIied orthodontic procedure, by report - includes treatment planning session .......................................................... $200.00 D9000-D9999 XII. AD1UNCTIVE GENERAL SERVICES D9110 Palliative (emergency) treatment oI dental pain - minor procedure $35.00 D9211 Regional block anesthesia .............................................. No Cost D9212 Trigeminal division block anesthesia .................................. No Cost D9215 Local anesthesia in conjunction with operative or surgical procedures ................................................................. No Cost D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician ............................ $70.00 D9430 OIIice visit Ior observation (during regularly scheduled hours) - no other services perIormed ............................................ $5.00 D9440 OIIice visit - aIter regularly scheduled hours ........................ $40.00 D9450 Case presentation, detailed and extensive treatment planning ...... No Cost D9951 Occlusal adjustment, limited ........................................... $40.00 D9952 Occlusal adjustment, complete ......................................... $90.00 - 22 - CAA54 EOC - V11 D9972 External bleaching - per arch - limited to one bleaching tray and gel for two weeks of self treatment .................................... $125.00 D9999 UnspeciIied adjunctive procedure, by report - includes failed appointment without 24 hour notice - per 15 minutes of appointment time - up to an overall maximum of $40.00 ........... $10.00 II services Ior a listed procedure are perIormed by the assigned Contract Dentist, the Enrollee pays the speciIied Copayment. Listed procedures which require a Dentist to provide Specialist Services, and are reIerred by the assigned Contract Dentist, must be preauthorized in writing by Delta Dental. The Enrollee pays the Copayment speciIied Ior such services. Procedures not listed above are not covered, however, may be available at the Contract Dentist's "Iiled Iees." "Filed Iees" means the Contract Dentist's Iees on Iile with Delta Dental. Questions regarding these Iees should be directed to the Customer Service department at 800-422-4234. FOOTNOTES Base metal is the benefit. If an inlay, onlay or indirectly fabricated post and core is made of high noble metal or noble metal, an additional fee up to $100.00 per tooth will be charged for the upgrade. Porcelain and other tooth-colored materials on molars are considered a material upgrade with a maximum additional charge to the Enrollee of $150.00. Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are material upgrades. The Contract Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Copayment. Refer to Limitation of Benefits #4 for additional information. For a covered porcelain-fused-to-metal crown, a porcelain margin is considered a material upgrade with a maximum additional charge to the Enrollee of $75.00. In the event orthodontic treatment is not required or is declined by the Enrollee, a fee of $85.00 will apply. The Enrollee is also responsible for any incurred orthodontic diagnostic record fees. - 23 - CAA54 EOC - V11 SCHEDULE B Limitations of Benefits 1. The Irequency oI certain BeneIits is limited. All Irequency limitations are listed in Schedule A, Description of Benefits and Copayments. 2. Fillings (amalgams and composites) are beneIits Ior the removal oI decay, Ior minor repairs oI tooth structure or to replace a lost or Iailing restoration. 3. The placement oI a crown, inlay or onlay is a beneIit when there is insuIIicient tooth structure to support a Iilling. 4. Contract Dentists may oIIer services that utilize brand or trade names at an additional Iee. The Enrollee must be oIIered the plan beneIits oI a high quality laboratory processed crown/pontic that may include: porcelain/ceramic; porcelain with base, noble or high-noble metal. II the Enrollee chooses the alternative oI a material upgrade (name brand, laboratory processed or in- oIIice processed crowns/pontics produced through specialized technique or materials, including but not limited to: Captek, Procera, Lava, Empress and Cerec), the Contract Dentist may charge an additional Iee not to exceed $325.00 in addition to the listed Copayment. Contact the Customer Service department at 800-422-4234 iI you have questions regarding the additional Iee or name brand services. 5. The replacement oI an existing inlay, onlay, crown, Iixed partial denture (bridge) or a removable Iull or partial denture is covered when: a. The existing restoration/bridge/denture is no longer Iunctional and cannot be made Iunctional by repair or adjustment, and b. Either oI the Iollowing: - The existing non-Iunctional restoration/bridge/denture was placed Iive or more years prior to its replacement, or - II an existing partial denture is less than Iive years old, but must be replaced by a new partial denture due to the loss oI a natural tooth, which cannot be replaced by adding another tooth to the existing partial denture. 6. Coverage Ior the placement oI a Iixed partial denture (bridge) requires that: a. No cantilevered posterior pontic (prosthetic tooth) be included; and - The sole tooth to be replaced in the arch is a permanent tooth, which cannot be replaced by adding another tooth to an existing removable partial denture; or - The new bridge would replace an existing, non-Iunctional bridge; or - Each abutment tooth to be crowned meets Limitation #3. - 24 - CAA54 EOC - V11 7. BeneIits Ior retained primary teeth are limited to services applicable to a primary tooth. 8. Excision oI the Irenum is a beneIit only when it causes limited mobility oI the tongue, a large diastema between teeth or it interIeres with a prosthetic appliance. 9. BeneIits provided by a pediatric Dentist are limited to children through age seven Iollowing an attempt by the assigned Contract Dentist to treat the child and upon prior authorization by Delta Dental, less applicable Copayments. The Plan will consider exceptions on an individual basis iI a child has a physical or mental impairment, limitation or condition which substantially interIeres with that child's ability to have BeneIits provided by a Contract Dentist. 10. SoIt tissue management programs are limited to periodontal pocket charting, root planing, scaling, curettage, oral hygiene instruction, periodontal maintenance and/or prophylaxis. II an Enrollee declines non-covered services (including irrigation) within a soIt tissue management program, it does not eliminate or alter other covered services. 11. Three recementations or replacements oI a bracket/band on the same tooth or a total oI Iive rebracketings/rebandings on diIIerent teeth during the covered course oI treatment are BeneIits. II any additional recementations or replacements oI brackets/bands are perIormed, the Enrollee is responsible Ior the cost at the Contract Orthodontist's usual Iee. 12. Comprehensive orthodontic treatment (Phase II) consists oI repositioning all or nearly all oI the permanent teeth in an eIIort to make the Enrollee's occlusion as ideal as possible. This treatment usually requires complete Iixed appliances; however, when the Contract Orthodontist deems it suitable, a European or removable appliance therapy may be substituted at the same Copayment amounts as Ior Iixed appliances. 13. The Copayment is payable to the Contract Orthodontist who initiates banding in a course oI orthodontic treatment. II, aIter banding has been initiated, the Enrollee changes to another Contract Orthodontist to continue orthodontic treatment, the Enrollee: a. will not be entitled to a reIund oI any amounts previously paid; and b. will be responsible Ior all payments, up to and including the Iull Copayment, that are required by the new Contract Orthodontist Ior completion oI the orthodontic treatment. 14. The cost to an Enrollee receiving orthodontic treatment whose coverage is cancelled or terminated Ior any reason will be based on the Contract Orthodontist's usual Iee Ior the treatment plan. The contract Orthodontist will prorate the amount Ior the number oI months remaining to complete treatment. The Enrollee makes payment directly to the Contract Orthodontist as arranged. - 25 - CAA54 EOC - V11 Exclusions of Benefits 1. Any procedure that is not speciIically listed under Schedule A, Description of Benefits and Copayments. 2. All related Iees Ior admission, use, or stays in a hospital, out-patient surgery center, extended care Iacility, or other similar care Iacility. 3. Lost or stolen appliances including, but not limited to, Iull or partial dentures, space maintainers, crowns, Iixed partial dentures (bridges) and orthodontic appliances. 4. Dental expenses incurred in connection with any dental procedure started aIter termination oI eligibility Ior coverage. 5. Dental expenses incurred in connection with any dental procedure started beIore the Enrollee's eligibility with the DeltaCare USA Program. Examples include: teeth prepared Ior crowns, root canals in progress, Iull or partial dentures Ior which an impression has been taken and orthodontics. 6. Prescription and over-the-counter drugs. 7. Any procedure that has poor prognosis Ior a successIul result and reasonable longevity based on the condition oI the tooth or teeth and/or surrounding structures, or is inconsistent with generally accepted standards Ior dentistry. 8. Dental services received Irom any dental Iacility other than the assigned Contract Dentist, or a preauthorized dental specialist (oral surgeon, endodontist, periodontist, pediatric dentist or Contract Orthodontist), except Ior Emergency Services as described in the Disclosure Form/Contract. 9. Consultations or other diagnostic services Ior non-covered beneIits. 10. Duplication oI x-rays. 11. Implant supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated with a dental implant. 12. Porcelain crowns, porcelain Iused to metal or resin with metal type crowns and Iixed partial dentures (bridges) Ior children under 16 years oI age. 13. Services solely Ior cosmetic purposes (except Ior those procedures listed on Schedule A) or Ior conditions that are a result oI hereditary or developmental deIects, such as cleIt palate, upper and lower jaw malIormations, congenitally missing teeth and teeth that are discolored or lacking enamel, except Ior the treatment oI newborn children with congenital deIects or birth abnormalities. 14. Procedures, appliances or restorations iI the purpose is to change vertical dimension, replace or stabilize tooth structure loss by attrition, realignment oI teeth, periodontal splinting, gnathologic recordings, or to diagnose or treat abnormal conditions oI the temporomandibular joint (TMJ), with the exception oI procedures D9951 and D9952 as shown on Schedule A. - 26 - CAA54 EOC - V11 15. An initial treatment plan which involves the removal and reestablishment oI the occlusal contacts oI 10 or more teeth with crowns, onlays, Iixed partial dentures (bridges), or any combination oI these is considered to be Iull mouth reconstruction under the DeltaCare USA program. Crowns, onlays and Iixed partial dentures associated with such a treatment plan are not covered BeneIits. This exclusion does not aIIect any other BeneIits. 16. Precious metal Ior removable appliances, metallic or permanent soIt bases Ior complete dentures, porcelain denture teeth, precision abutments Ior removable partials or Iixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization oI complete and partial dentures. 17. Extraction oI teeth, when teeth are asymptomatic/non-pathologic (no signs or symptoms oI pathology or inIection), including but not limited to the removal oI third molars and orthodontic extractions. 18. Treatment or extraction oI primary teeth when exIoliation (normal shedding and loss) is imminent. 19. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services. 20. Accidental injury. Accidental injury is deIined as damage to the hard and soIt tissue oI the oral cavity resulting Irom Iorces external to the mouth. Damages to the hard and soIt tissues oI the oral cavity Irom normal masticatory (chewing) Iunction will be covered at the normal schedule oI beneIits. 21. MyoIunctional and paraIunctional appliances and/or therapies. 22. Composite or ceramic brackets, lingual adaptation oI orthodontic bands, Invisalign and other specialized or cosmetic alternatives to standard Iixed and removable orthodontic appliances. 23. Pre-, mid- and post-treatment records Ior orthodontia including cephalometric x- rays, tracings, photographs and study models. 24. Changes in orthodontic treatment necessitated by accident oI any kind. Organ and Tissue Donation Donating organs and tissue provides many societal beneIits. Organ and tissue donation allows recipients oI transplants to go on to lead Iuller and more meaningIul lives. Currently, the need Ior organ transplants Iar exceeds availability. II you are interested in organ donation, please speak with your physician. Organ donation begins at the hospital, when a patient is pronounced brain dead and identiIied as a potential organ donor. An organ procurement organization will become involved to coordinate the activities. IMPORTANT: Can you read this document? Ìf not, we can have somebody help you read it. For free help, please call Delta Dental at 1-800-422-4234. You may also be able to receive this document in Spanish or Chinese. IMPORTANTE: ¿Puede leer este documento? Si no, podemos ayudarle. Para obtener ayuda gratis, llame a Delta Dental al 1-800-422-4234. También puede recibir este documento en español o chino. 烉ぐ傥嬨忁ấ㔯ẞ╶烎⤪㚱⓷柴炻ㆹᾹ⎗ 婳ṾṢ⋼≑ぐˤġ⤪暨⃵屣⋼≑炻婳暣ġŅŦŭŵŢġŅŦůŵŢŭġ ĲĮĹııĮĵĳĳĮĵĳĴĵġぐḇ傥⍾⼿忁ấ㔯ẞ䘬大䎕䈁㔯ㆾᷕ 㔯嬗㛔ˤ If you have any questions or need additional information, call or write: Delta Dental Insurance Company P.O. Box 1803 Alpharetta, GA 30023 800-422-4234 In California, DeltaCare USA is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company. EOC¸CAA54¸V11¸06.09.2011

Delta Dental

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