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Provided by:Delta Dental of California17871 Park Plaza Drive, Suite 200Cerritos, CA 90703

Administered by:Delta Dental Insurance CompanyP.O. Box 1803Alpharetta, GA 30023888‑282‑8784

deltadentalins.com

I‑P‑CA‑dc‑REV2020 CAB54-V20

DeltaCare® USA

Delta Dental Individual & Family™

DeltaCare USAIndividual/Family Dental HMO

CAA54

Combined Policy and Disclosure Form (“Policy”)

POLICYThe DeltaCare USA Individual and Family Dental Plan (“Plan”) is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company (collectively referred to as “Delta Den‑tal”). This Policy is issued in exchange for payment of the first install‑ment of Premium and on the basis of the statements made on your application. This Policy will remain in force unless otherwise ter‑minated in accordance with its terms, until the first renewal date and for such further periods for which it is renewed. All periods will begin and end at 12:01 A.M., Standard Time, where you live.

READ THIS POLICY AND ITS ATTACHMENTS CAREFULLYDelta Dental’s enrollment materials advise Enrollees that this Policy is available upon request, prior to enrollment, by contacting Delta Dental’s Customer Care. Enrollees may obtain information about their Benefits under this Plan by calling Delta Dental’s Customer Care at 888-282-8784.

10-DAY RIGHT TO EXAMINE AND RETURN THIS POLICYIf this Policy was solicited by deceptive advertising or negotiated by deceptive, misleading or untrue statements or if you are not satis‑fied, you may return this Policy within 10 days after you receive it. Mail or deliver it to Delta Dental. Any Premium paid will be refunded. This Policy will then be void from its start.

This Policy is issued and delivered in the state of California and is governed by its laws. If you move and no longer reside in the state of California, please contact Customer Care at 888-282-8784.

This Policy is signed for Delta Dental, as of its Effective Date, by:

Delta Dental of California

Michael G. Hankinson, Esq.Executive Vice President, Chief Legal Officer

A STATEMENT DESCRIBING OUR POLICIES AND PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST.

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Information Concerning Benefits Under The DeltaCare USA PlanTHIS MATRIX IS INTENDED TO BE USED TO COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. SCHEDULES A AND B SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF THE PLAN’S BENEFITS, LIMITATIONS AND EXCLUSIONS.

(A) Deductibles None

(B) Lifetime Maximums None

(C) Professional Services

An Enrollee may be required to pay a Copayment amount for each procedure as shown in Schedule A, subject to the limitations and exclusions of this Plan. Copayments range by category of service. Examples are as follows:Diagnostic Services No Cost ‑ $10.00Preventive Services No Cost ‑ $85.00Restorative Services $10.00 ‑ $495.00Endodontic Services $10.00 ‑ $725.00Periodontic Services $64.00 ‑ $650.00Prosthodontic Services, Removable $24.00 ‑ $700.00

Prosthodontic Services, Fixed $25.00 ‑ $495.00

Oral and Maxillofacial Surgery $30.00 ‑ $230.00

Orthodontic Services No Cost ‑ $2800.00Adjunctive General Services No Cost ‑ $125.00

NOTE: Limitations apply to the frequency with which some services may be obtained. For example: cleanings are limited to once in each 6‑month period; replacement of removable and fixed dentures and crowns is limited to once in any 5‑year period.

(D) Outpatient Services Not Covered

(E) Hospitalization Services

Not Covered

(F) Emergency Dental Coverage

The Enrollee may receive a maximum Benefit up to $100.00 per emergency, per Enrollee, for Emergency Dental Services outside of the Delta Dental Service Area.

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Each individual procedure within each category listed above that is covered under this Plan has a specific Copayment that is shown in Schedule A of this Policy.

(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

I‑P‑CA‑dc‑REV2020 ii V20

Table of Contents

INFORMATION CONCERNING BENEFITS UNDER THE DELTACARE USA PLAN ................................................................................. ii

INTRODUCTION ................................................................................................. 1

DEFINITIONS ......................................................................................................2

ELIGIBILITY AND ENROLLMENT ................................................................5

PREMIUM PAYMENT RESPONSIBILITIES ...............................................7

RENEWAL ............................................................................................................8

CANCELLATION, RESCISSION OR NONRENEWAL OF COVERAGE ..........................................................................................................8

CANCELLATION OF ENROLLMENT ..........................................................9

OVERVIEW OF DENTAL BENEFITS .........................................................12

HOW TO USE THE DELTACARE USA PLAN/

CHOICE OF CONTRACT DENTIST ............................................................13

ENROLLEE CLAIMS COMPLAINT PROCEDURE................................. 18

GENERAL PROVISIONS ................................................................................21

SCHEDULE A ....................................................................................................25

SCHEDULE B ................................................................................................... 42

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I-P-CA-dc-REV2020 - 1 - CAB54 EOC - V20

INTRODUCTIONThis Plan provides dental care through a convenient network ofDeltaCare USA Dentists within the Delta Dental Service Area inthe state of California. The DeltaCare USA Individual Network iscomprised of established dental professionals who are screenedto ensure that our standards of quality, access and safety aremaintained. When you visit your assigned Contract Dentist, you payonly the applicable Copayment(s) for Benefits covered under thisPlan. There are no deductibles, lifetime maximums or claim forms.

Using this PolicyThis Policy, including attachments, discloses the terms andconditions of your coverage and is designed to help you make themost of your dental plan. It will help you understand how this Planworks and how to obtain dental care. Keep in mind that "you" and"your" means the individual who is covered under this Plan. "We,""us" and "our" always refer to Delta Dental.

In addition, please read the "Definitions" section of this Policy asit explains any words with special or technical meanings. Personswith special health care needs should read the "Special Health CareNeeds" provision. A matrix describing this Plan's major Benefits,limitations and exclusions is located at the beginning of this Policy.

Contact UsIf you have any questions about your coverage, please call CustomerCare at 888-282-8784 or visit our website at deltadentalins.com tocomplete a customer service form, register for online services orlocate a DeltaCare USA Dentist. If you prefer to write to us with yourquestion(s), please mail it to:


Sacramento, CA 95899-7330

P.O. Box 997330

Identification NumberAn identification ("ID") card containing your ID number is notrequired when visiting your assigned Contract Dentist, however, youmay obtain one on our website at deltadentalins.com.


DEFINITIONSThe following are definitions of words that have special or technicalmeanings under this Policy.

Administrator: Delta Dental Insurance Company or other entitydesignated by Delta Dental of California to perform administrativefunctions described throughout this Policy including, but not limitedto, the collection of Premium and eligibility.

Authorization: the process by which Delta Dental determines if aprocedure or treatment is a referable Benefit to Enrollees coveredunder this Plan.

Benefits: covered dental services provided to Enrollees under theterms of this Policy.

Calendar Year: the 12 months of the year from January 1 throughDecember 31.

Contract Dentist: a DeltaCare USA Dentist who provides servicesin general dentistry and who has agreed to provide Benefits toEnrollees covered under this Plan.

Contract Orthodontist: a DeltaCare USA Dentist who specializesin orthodontics and has agreed to provide Benefits to Enrolleescovered under this Plan.

Contract Specialist: a DeltaCare USA Dentist who providesSpecialist Services and who has agreed to provide Benefits toEnrollees covered under this Plan.

Copayment: the amount listed in Schedule A attached to thisPolicy that is charged to an Enrollee by a DeltaCare USA Dentist forBenefits covered under this Plan. Copayments must be paid at thetime treatment is received.

Delta Dental Service Area: all geographic areas in the state ofCalifornia in which Delta Dental is licensed as a specialized healthcare service plan to offer this Plan.

Dentist: a duly licensed dentist legally entitled to practice dentistryat the time and in the state or jurisdiction in which services areperformed. A dentist also includes a dental partnership, dentalprofessional corporation or dental clinic.


Department of Managed Health Care: a department of the CaliforniaHealth and Human Services Agency who has charge of regulatingspecialized health care service plans. Also referred to as the"Department" or "DMHC."

Effective Date: the original date this Plan starts. We must receiveenrollment materials by the 21st day of the month for coverageto start the first day of the following month. If we receive theenrollment materials after the 21st day of the month, coverage willbegin the first day of the second month.

Eligible Dependent: any dependent of the Policyholder who iseligible for Benefits as described in this Policy.

Emergency Dental Condition: dental symptoms and/or pain thatare so severe that a reasonable person would believe that, withoutimmediate attention by a Dentist, it could reasonably be expected toresult in any of the following:- placing the patient's health in serious jeopardy,- serious impairment to bodily functions,- serious dysfunction of any bodily organ or part, or- death

Emergency Dental Service: dental screening, examination andevaluation by a Dentist, or, to the extent permitted by applicable law,by other appropriate licensed persons under the supervision of aDentist, to determine if an Emergency Dental Condition exists and,if it does, the care, treatment and surgery, if within the scope of thatperson's license, necessary to relieve or eliminate the EmergencyDental Condition, within the capability of the facility.

Enrollee: a person enrolled to receive Benefits under this Plan. Thisincludes the Primary Enrollee and Eligible Dependents.

Grace Period: the period of at least 31 consecutive days beginningthe day the Notice of Start of Grace Period is dated.

Notice of End of Coverage: the notice sent by us notifying you thatyour coverage has been cancelled.

Notice of Start of Grace Period: the notice sent by us that the planwill be terminated unless the Premium amount due is received nolater than the last day of the Grace Period.


Out-of-Network: treatment by a Dentist who has not signed anagreement with Delta Dental to provide Benefits to Enrolleescovered under this Plan.

Policy: this agreement between Delta Dental and the applicantincluding any attached schedules, appendices, endorsements orriders. This policy constitutes the entire agreement between theparties.

Policyholder: the Primary Enrollee who enrolls for coverage underthis Plan.

Policy Term: the one-year period starting on the Effective Dateand each annual renewal period during which this Policy remains ineffect.

Premium: the amount payable by the Policyholder to Delta Dental asstated in the application or renewal notice for coverage under thisPlan.

Procedure Code: the Current Dental Terminology ("CDT") numberassigned to a Single Procedure by the American Dental Association.

Qualifying Status Change:- marital status (marriage, divorce, legal separation, annulment or

death);- number of dependents (a child's birth, adoption of a child,

placement of child for adoption, addition of a step or foster childor death of a child);

- dependent child ceases to satisfy eligibility requirements;- residence (Enrollee moves);- court order requiring dependent coverage; orany other current or future election changes permitted by state

or federal law.

Single Procedure: a dental procedure that is assigned a separateProcedure Code.

Special Health Care Need: a physical or mental impairment,limitation or condition that substantially interferes with an Enrollee'sability to obtain Benefits. Examples of such a special health careneed are: 1) the Enrollee's inability to obtain access to their ContractDentist facility because of a physical disability; and 2) the Enrollee'sinability to comply with their Contract Dentist instructions duringexamination or treatment because of physical disability or mentalincapacity.


Specialist Services: services performed by a DeltaCare USADentist who specializes in the practice of oral surgery, endodontics,orthodontics, pediatric dentistry or periodontics. Specialist Servicesmust be authorized by Delta Dental.

Spouse: a person related to or a domestic partner of the PrimaryEnrollee:- as defined and as may be required to be treated as a spouse by

the laws of the state where this Policy is issued and delivered; or- as defined and as may be required to be treated as a spouse by

the laws of the state where the Primary Enrollee resides.

Treatment in Progress: any Single Procedure as defined by theCDT Code that has been started while the Enrollee was eligibleto receive Benefits and for which multiple appointments arenecessary to complete the Single Procedure(s), whether or notthe Enrollee continues to be eligible for Benefits under this Plan.Examples include: 1) teeth that have been prepared for crowns, 2)root canals where a working length has been established, 3) fullor partial dentures for which an impression has been taken and 4)orthodontics when bands have been placed and tooth movementhas begun.

Urgent Dental Services: medically necessary services for a conditionthat requires prompt dental attention but is not an EmergencyDental Condition.

Usual Fee: the fee that an individual Dentist most frequently chargesfor a given dental service.

We, Us or Our: Delta Dental of California or Delta Dental InsuranceCompany, collectively referred to as "Delta Dental."

ELIGIBILITY AND ENROLLMENTIndividual adults and their eligible dependents who live or work inthe Delta Dental Service Area in California are eligible for coverageunder this Plan.

Eligibility RequirementsPolicyholders electing to enroll Eligible Dependents must enrollthem at the time of initial enrollment, within 90 days of initialenrollment or within 31 days of a Qualifying Status Change.- Dependents are the Policyholder's Spouse and dependent

children from birth to age 26.


- Children include natural children, step-children, foster children,adopted children, children placed for adoption and children of aSpouse.

Over-age dependent children may be eligible if:1) they are incapable of self-sustaining employment by reason of a

physically or mentally disabling injury, illness or condition;2) they are chiefly dependent on the Policyholder and/or Spouse

for support and maintenance; and3) proof of the disability is given to us within 31 days of the over-

age dependent child reaching the limiting age. Such requests willnot be made more than once a year following a 2-year periodafter the dependent child reaches the limiting age.

We will notify the Primary Enrollee at least 90 days prior to thedate the dependent child attains the limiting age that coveragewill terminate unless proof of the disability is given to us withinthe specified time.

Eligibility will continue as long as the dependent child relies onthe Policyholder and/or Spouse for support and maintenanceby reason of a physically or mentally disabling injury, illness orcondition.

Dependents in military service are not eligible.

Enrollment PeriodEnrollees covered under this Plan must enroll for a minimum of 12months.

A Policyholder has the right to terminate coverage under this Planby sending us written notice of cancellation. Coverage for thePolicyholder and Dependent Enrollee(s) will terminate on the lastday of the month that we receive a request to cancel coverage orthe last day of the Policy Term, whichever occurs first. If coverageis voluntarily discontinued, Enrollees are not eligible to be enrolledduring the 12 month period immediately following the voluntarytermination.

A full refund of Premium is available if a written request for a refundis made within the first 10 days of the Effective Date. After that, allrequests for a Premium refund will be pro-rated based upon thenumber of days remaining in the Policy Term if Premium has beenpaid in advance. However, a refund may not be available if Benefitswere received under their plan.


PREMIUM PAYMENT RESPONSIBILITIESThe Policyholder is responsible for making Premium payments andfor paying an application fee when submitting their application forenrollment under this Plan. The application fee is non-refundable.

Prepayment FeesThe Premium, as stated on the application, is to be paid on or beforethe due date. A due date is the day following the last day of theperiod for which the preceding Premium was paid. You may payyour Premium by visiting our website at deltadentalins.com or bymailing it to:

Delta Dental

P.O. Box 660138

Dallas, TX 75266-0138

Rate GuaranteeYour Premium rate is guaranteed for each Policy Term based uponthe new Enrollee rates in force at the time of your enrollment.However, the rate guarantee can be less than a Policy Term if anEnrollee has an Effective Date mid-year due to a Qualifying StatusChange.

Unless there is a change in Premium due to Delta Dental's liabilitybeing changed by law or regulation, no change in Premium willbecome effective within a Policy Term. A change in law or regulationmay include a state and/or federal mandated change or a newor increased tax, assessment or fee imposed on the amountspayable to, or by, Delta Dental under this Policy or any immediatelypreceding policy between Delta Dental and you. Delta Dental wouldprovide written notice to you, and this Policy will be modified on thedate stated in the notice.

Changing Payment OptionsPayment options may be changed at any time. The effective dateof any change is the date of the next scheduled payment basedon your new billing period. You can change your payment optionby visiting our website at deltadentalins.com or by contactingCustomer Care at 888-282-8784.


RENEWALNo change in Benefits or Premium will be made during a PolicyTerm. We will provide 30 days' advance written renewal notice,including any proposed changes in Benefits and/or Premium atleast 30 days before your coverage expires. Your coverage willterminate at the end of the Policy Term unless you renew by payingthe applicable Premium on or before your Policy Term expires.

CANCELLATION, RESCISSION OR NONRENEWAL OFCOVERAGEWe may refuse renewal or terminate coverage due to:- Premiums not paid on or before the last day of the Grace Period.

Please see "Cancellation of Enrollment Due to Non-Payment ofPremiums" provision;

- Enrollee no longer eligible under the terms of this Policy(termination in this case automatically occurs on the last dayof the month in which the Enrollee no longer meets eligibilityrequirements);

- the Policyholder moving out of the state in which this Policywas issued (if you move and no longer reside in the state ofCalifornia, please contact our Customer Care at 888-282-8784);

- fraud or an intentional misrepresentation of material fact whenapplying for this coverage or filing a claim for Benefits;

- the Policyholder failing to comply with material provisions of thisPolicy; or

- Delta Dental ceasing to renew all Policies issued on this form toresidents of the state where you live.

At least 30 days' advance written notice of any non-renewal actionpermitted by this provision will be mailed to the Policyholder atthe last address shown in our records. This notice will includethe reason(s) why coverage is being terminated and the datethat coverage will end. We will not pay for services received aftercoverage is terminated. However, we will pay for the completion ofSingle Procedures started while an Enrollee was eligible if they arecompleted within 31 days of the date coverage ended.

If we fail to issue a 30-day advance written notice of intent toterminate, coverage will remain in effect until 30 days after suchnotice is given or until the effective date of replacement coverage,whichever occurs first. However, no Benefits will be paid forexpenses incurred during any period of time for which Premium hasnot been paid.


In the event of cancellation by either Delta Dental (except in thecase of fraud or deception in the use of services or facilities orknowingly permitting such fraud or deception by another) orthe Policyholder, Delta Dental shall within 30 days return to thePolicyholder the pro rata portion of the money paid to Delta Dentalwhich corresponds to any unexpired period for which payment hadbeen received together with amounts due on claims, if any, less anyamounts due to Delta Dental.

CANCELLATION OF ENROLLMENT

Cancellation Due to Non-Payment of PremiumIf we do not receive your Premium payment by the due date, youraccount will be considered late. We will send you a Notice of Start ofGrace Period advising that a payment delinquency has triggered aGrace Period beginning the day the Notice of Start of Grace Periodis dated and that your coverage will be terminated unless the fullPremium amount due is received by us on or before the last day ofthe Grace Period. This Notice of Start of Grace Period will includeimportant information needed to maintain uninterrupted coveragesuch as: an explanation of the Grace Period, the beginning and enddates of the Grace Period, the dollar amount past due, the dateof the last day of paid coverage and a statement explaining theconsequences of losing coverage.

Coverage will continue during the Grace Period. Coverage willalso continue upon payment of all outstanding Premium amountsreceived any time before the expiration of the Grace Period. Youare financially responsible for any and all Premiums, and anycopayments, coinsurance or deductible amounts, including thoseincurred for services received during the Grace Period.

If, after receiving the Notice of Start of Grace Period, your accountremains delinquent after the Grace Period expires, your coverage willbe terminated. We will then send you a Notice of End of Coveragewithin five (5) calendar days after the date coverage ends statingthe effective date and reason for cancellation of coverage and whomto contact for assistance.

Cancellation of Enrollment for Other Than Non-Payment ofPremiumFor cancellations, rescission and non-renewals for other than fornonpayment of Premium, we will provide you with a Notice ofCancellation, Rescission or Nonrenewal. A Notice of End of Coveragewill be provided to you for all cancellations after the date coverage


has ended, but no later than five (5) calendar days after the datecoverage has ended that includes the reason for cancellation andwhom to contact for assistance.

If coverage is terminated for any cause, we are not required topreauthorize services beyond the termination date or to pay forservices provided after the termination date, except for servicesbegun while the Contract was in effect or if you have a cancellationgrievance pending for reasons other than nonpayment of Premiumsubmitted prior to the effective date of your cancellation, renewal orrescission. Please refer to the following section regarding your rightto submit a grievance.

Right to Submit Grievance Regarding Cancellation, Rescission orNonrenewal of Your Plan Enrollment, Subscription or ContractIf you believe your enrollment has been, or will be, improperlycancelled, rescinded or not renewed you have at least 180 daysfrom the date of the notice you allege to be improper to submit agrievance to us and/or the Department of Managed Health Care("DMHC").

For grievances submitted prior to the effective date of thecancellation, rescission or non-renewal, for reasons other thannonpayment of Premium, we will continue to provide coverage whilethe grievance is pending with us or the DMHC. During the periodof continued coverage, you are responsible for paying Premiumsand any and all copayments, coinsurance, or deductible amounts asrequired under your coverage.

OPTION 1 - YOU MAY SUBMIT A GRIEVANCE TO YOUR PLAN.You may submit online at deltadentalins.com, or call 866-275-7061 orwrite to:


Attn: Correspondence Department

P.O. Box 997330


You may want to submit your grievance to Delta Dental first if youbelieve your cancellation, recession, or nonrenewal is the result of amistake. Grievances should be submitted as soon as possible.

We will resolve your grievance or provide a pending status withinthree (3) calendar days. If you do not receive a response from uswithin three (3) calendar days, or if you are not satisfied in any way


with our response, you may submit a grievance to the DMHC asdetailed under Option 2 below.

OPTION 2 - YOU MAY SUBMIT A GRIEVANCE DIRECTLY TO THEDMHC.You may submit a grievance to the DMHC without first submittingit to Delta Dental or after you have received our decision on yourgrievance. Grievances may be submitted to the DMHC online atwww.Healthhelp.ca.gov or by mailing your written grievance to:

Help Center

Department of Managed Health Care

980 Ninth Street, Suite 500


You may contact the DMHC for more information on filing agrievance at:

Phone: 1-888-466-2219

TDD: 1-877-688-9891

Fax: 1-916-255-5241

ReinstatementIf your coverage is terminated due to nonpayment of Premium andwe accept payment of the proper Premiums after termination ofthis Policy and without requiring a new application, we will reinstatethis Policy as though it had never terminated unless Delta Dental,within 20 business days of receipt of such payment, either: 1) refusethe payment so made; or 2) issue the Policyholder a new Policyaccompanied by written notice stating clearly those respects inwhich the new Policy differs from this terminated Policy in Benefits,coverage or otherwise.

If you submit a grievance for cancellation, rescission or nonrenewal,including a cancellation for nonpayment of Premium, and it isdetermined the cancellation is improper, your coverage may bereinstated retroactive to the date of cancellation, rescission ornonrenewal. You are responsible for paying any and all outstandingPremium payments accrued from the effective date of thecancellation, rescission or nonrenewal before reinstatement. Anyoutstanding Premium must be paid prior to reinstatement.


OVERVIEW OF DENTAL BENEFITSThis section provides information that will give you a betterunderstanding of how this Plan works and how to make it work bestfor you.

Benefits, Limitations and ExclusionsDental plans are designed to help with part of your dental expensesand may not always cover every dental need. The typical planincludes limitations and exclusions, meaning a plan does not coverevery aspect of dental care. This can relate to the type of proceduresor the number of visits. This Plan provides the Benefits, limitationsand exclusions which are detailed in the Schedules that are a part ofthis Policy and you should make yourself familiar with them.

Except for Emergency Dental Services, Urgent Dental Services andauthorized Specialized Services, Benefits are only available withinthe Delta Dental Service Area in the state of California.

Copayments and Other ChargesYou are required to pay any Copayments listed in Schedule Aattached to this Policy. Copayments are paid directly to theDeltaCare USA Dentist who provides treatment. Charges for missedor canceled appointments and visits after normal visiting hours arelisted in Schedule A.

In the event that we fail to pay your DeltaCare USA Dentist, you willnot be liable to that Dentist for any sums owed by us. By statute,every contract between Delta Dental and our DeltaCare USADentists contains a provision prohibiting them from charging anEnrollee for any sums owed by Delta Dental. Except for EmergencyDental Services, Urgent Dental Services and authorized SpecialistServices, if you receive treatment from an Out-of-Network Dentistand we fail to pay that Out-of-Network Dentist, you may be liable tothat Dentist for the cost of services received.

Processing PoliciesClaims will be processed in accordance with our standard processingpolicies. The processing policies may be revised at the beginning ofa Calendar Year to comply with annual CDT Code changes made bythe American Dental Association and to reflect changes in generallyaccepted dental practice standards. We will provide at least 30 days'advance notice to the Policyholder of such changes.

Covered services are performed as deemed appropriate byyour assigned Contract Dentist and are subject to Copayments.


If a Contract Dentist believes that an Enrollee should seektreatment from a specialist, the Contract Dentist contacts us for adetermination of whether the proposed treatment is a Benefit ofyour plan. We will also determine whether the proposed treatmentrequires treatment by a specialist. You may contact Customer Careat 888-282-8784 for more information about this Plan's dental careguidelines.

A covered Benefit appropriately provided through teledentistry iscovered on the same basis and to the same extent that the coveredBenefit is provided through in-person diagnosis, consultation, ortreatment.

Non-Covered ServicesIMPORTANT: If you opt to receive dental services that are notcovered Benefits of this Plan, your assigned Contract Dentist maycharge you their Usual Fee for those services. Prior to providing apatient with treatment that is not a covered Benefit, your Dentistshould provide you with a treatment plan that includes eachanticipated service and estimated cost to be provided for eachservice. Contact Customer Care at 888-282-8784 to learn moreabout your available options. To fully understand your coverage,please carefully review this Policy.

HOW TO USE THE DELTACARE USA PLAN/CHOICE OFCONTRACT DENTISTPLEASE READ THE FOLLOWING INFORMATION SO THAT YOUWILL KNOW HOW TO OBTAIN DENTAL SERVICES. YOU MUSTOBTAIN DENTAL BENEFITS FROM (OR BE REFERRED FORSPECIALIST SERVICES BY) YOUR ASSIGNED CONTRACT DENTIST.

Upon enrollment, we will assign you to a Contract Dentist facility.All Benefits must be performed at the Enrollee's assigned ContractDentist facility. The Policyholder may request changes to theassigned Contract Dentist facility by contacting CustomerCare at 888-282-8784. A list of Contract Dentists is available atdeltadentalins.com. When searching online for a Contract Dentist,select the DeltaCare USA Individual Network to ensure you have thelist of Contract Dentists applicable to your plan. The change must berequested prior to the 15th of the month to become effective on thefirst day of the following month.

We will provide you written notice of assignment to anotherContract Dentist facility near your home if: 1) a requested facility isclosed to further enrollment; 2) a chosen Contract Dentist facility


withdraws from this Plan; or 3) an assigned facility requests, forgood cause, that the Enrollee be re-assigned to another facility.

All Treatment in Progress must be completed before you change toanother Contract Dentist facility. For example, this would include:1) teeth that have been prepared for crowns, 2) root canals wherea working length has been established, 3) full or partial denturesfor which an impression has been taken and 4) orthodontics whenbands have been placed and tooth movement has begun.

All authorized Specialist Services claims will be paid by us, lessany applicable Copayment(s). A Contract Dentist may provideSpecialist Services either personally or through associated Dentistsor technicians or hygienists who may lawfully perform the services.If an Enrollee is assigned to a dental school clinic for SpecialistServices, those services may be provided by a Dentist, a dentalstudent, a clinician or a dental instructor.

If your assigned Contract Dentist facility terminates participation inthis Plan, that Contract Dentist facility will complete all Treatmentin Progress, as described above. If, for any reason, your ContractDentist is unable to complete treatment, we will make reasonableand appropriate provisions for the completion of such treatment byanother Contract Dentist.

We will give you reasonable advance written notice if you willbe materially or adversely affected by the termination, breach ofcontract or inability of a Contract Dentist to perform services.

Continuity of CareIf you are a current Enrollee or newly covered Enrollee, you mayhave the right to obtain completion of care under the contractwith your terminated Contract Dentist for certain specified dentalconditions. If you are a new Enrollee, you may have the right tocompletion of care under the Contract with your Out-of-NetworkDentist for certain specified dental conditions. You must makea specific request for this completion of care Benefit. To make arequest, contact Customer Care at 888-282-8784. You may alsocontact us to request a copy of our Continuity of Care Policy. We arenot required to continue care with the Dentist if you are not eligibleunder the contract or if we cannot reach agreement with the Out-of-Network Dentist or the terminated Contract Dentist on the termsregarding Enrollee care in accordance with California law.


Specialist ServicesSpecialist Services for oral surgery, endodontics or periodonticsmust be: 1) referred by your assigned Contract Dentist, and 2)authorized by Delta Dental. You pay the specified Copayment(s)(Refer to the Schedules attached to this Policy.)

If you require Specialist Services and a Contract Specialist is notwithin 35 miles of your home address to provide these services,your assigned Contract Dentist must obtain prior Authorizationfrom us to refer you to an Out-of-Network specialist to providethese services. Specialist Services performed by an Out-of-Networkspecialist that are not authorized by us will not be covered by thisPlan.

If you are referred to a dental school clinic for Specialist Services,those services may be provided by a Dentist, a dental student, aclinician or a dental instructor.

Emergency Dental ServicesEmergency Dental Services are palliative relief, controlling of dentalpain and/or stabilizing the Enrollee's condition. The Enrollee'sassigned Contract Dentist facility maintains a 24-hour emergencydental services system, 7 days a week. If the Enrollee is experiencingan Emergency Dental Condition, the Enrollee can call 911 (whereavailable) or obtain Emergency Dental Services from any Dentistwithout a referral.

After Emergency Dental Services are provided, further non-emergency treatment is usually needed. Non-emergency treatmentmust be obtained at the Enrollee's assigned Contract Dentist facility.

The Enrollee is responsible for any Copayment(s) for EmergencyDental Services received. Non-covered procedures will be theEnrollee's financial responsibility and will not be paid by this Plan.

Urgent Dental Services

Inside the Delta Dental Service AreaAn Urgent Dental Service requires prompt dental attention but isnot an Emergency Dental Condition. If an Enrollee believes thatthey may need Urgent Dental Services, the Enrollee can call theirassigned Contract Dentist.

Outside the Delta Dental Service AreaIf an Enrollee needs Urgent Dental Services due to an unforeseendental condition or injury, this Plan covers medically necessary


dental services when prompt attention is required from an Out-of-Network Dentist, if all of the following are true:- The Enrollee receives Urgent Dental Services from an Out-of-

Network Dentist while temporarily outside the Delta DentalService Area.

- A reasonable person would have believed that the Enrollee'shealth would seriously deteriorate if they delayed treatment untilthey returned to the Delta Dental Service Area.

Enrollees do not need prior Authorization from us to receive UrgentDental Services outside the Delta Dental Service Area. Any UrgentDental Services an Enrollee receives from an Out-of-Network Dentistoutside the Delta Dental Service Area are covered by this Plan if theBenefits would have been covered if the Enrollee had received themfrom Contract Dentists.

This Plan does not cover follow-up care from an Out-of-NetworkDentist after the Enrollee no longer needs Urgent Dental Services.To obtain follow-up care from a Dentist, the Enrollee can call theirassigned Contract Dentist. The Enrollee is responsible for anyCopayment(s) for Urgent Dental Services received.

Timely Access to CareDeltaCare USA Dentists have agreed waiting times to Enrollees forappointments for care which will never be greater than the followingtimeframes:- for emergency care, 24 hours a day, 7 day days a week;- for any urgent care, 72 hours for appointments consistent with

the Enrollee's individual needs;- for any non-urgent care, 36 business days; andfor any preventive services, 40 business days.

During non-business hours, an Enrollee will have access to theirContract Dentist's answering machine, answering service, cell phoneor pager for guidance on what to do and whom to contact if theyare experiencing an Emergency Dental Condition.

If the Enrollee calls our Customer Care, a representative will answertheir call within 10 minutes during normal business hours.

Language Interpretation ServicesWe offer qualified interpretation services to limited-Englishproficient Enrollees, at no cost to the Enrollee, at all points ofcontact in any modern language, including when an Enrolleeis accompanied by a family member or friend who can providelanguage interpretation services. Should an Enrollee need language


interpretation services with their DeltaCare USA Dentist, they maycall Customer Care at 888-282-8784 for assistance.

Claims for ReimbursementClaims for covered Emergency Dental Services, Urgent DentalServices and authorized Specialist Services should be sent to DeltaDental within 90 days of the end of treatment. Valid claims receivedafter the 90-day period will be reviewed if you can show that itwas not reasonably possible to submit the claim within that time.All claims must be received within one (1) year of the treatmentdate. The address for claims submission is Delta Dental - ClaimsDepartment, P.O. Box 1810, Alpharetta, GA 30023.

Dentist CompensationA Contract Dentist is compensated by Delta Dental throughmonthly capitation (an amount based on the number of enrolleesassigned to the Contract Dentist facility) and by enrollees throughrequired copayments for treatment received. A Contract Specialist iscompensated by Delta Dental through an agreed-upon amount foreach covered procedure, less the applicable copayment paid by theenrollee. In no event does Delta Dental pay a DeltaCare USA Dentistany incentive as an inducement to deny, reduce, limit or delay anyappropriate treatment.

You may obtain further information concerning Dentistcompensation by calling Delta Dental at 888-282-8784.

Second OpinionYou may request a second opinion if you disagree with or questionthe diagnosis and/or treatment plan determination made by yourContract Dentist. Delta Dental may also request that an Enrolleeobtain a second opinion to verify the necessity and appropriatenessof dental treatment or the application of Benefits.

Second opinions will be rendered by a licensed Dentist in a timelymanner, appropriate to the nature of your condition. Requestsinvolving cases of imminent and serious health threat will beexpedited (Authorization approved or denied within 72 hoursof receipt of the request, whenever possible). For assistance oradditional information regarding the procedures and timeframesfor second opinion Authorizations, contact Customer Care at888-282-8784 or write to Delta Dental.

Second opinions will be provided at another Contract Dentistfacility, unless otherwise authorized by us. We will authorize asecond opinion by an Out-of-Network Dentist if an appropriately


qualified Contract Dentist is not available. We will only pay for asecond opinion that we have approved or authorized. You will besent a written notification should we decide not to authorize asecond opinion. If you disagree with this determination, you mayfile a grievance with us or with the DMHC. Refer to the "EnrolleeComplaint Procedure" section for information regarding complaintprocedures.

Special Health Care NeedIf you believe you have a Special Health Care Need, you shouldcontact Customer Care at 888-282-8784. We will confirm thata Special Health Care Need exists and what arrangements canbe made to assist you in obtaining such Benefits. We will not beresponsible for the failure of any Contract Dentist to comply withany law or regulation concerning structural office requirements thatapply to a Dentist treating persons with Special Health Care Needs.

Facility AccessibilityMany dental facilities provide us with information about specialfeatures of their offices, including accessibility information forpatients with mobility impairments. To obtain information regardingdental facility accessibility, contact Customer Care at 888-282-8784.

ENROLLEE CLAIMS COMPLAINT PROCEDUREWe will notify the Enrollee if any dental services or claims aredenied, in whole or in part, stating the specific reason(s) for thedenial. If you have a complaint regarding eligibility, the denial ofdental services or claims, our policies, procedures or operations orthe quality of dental services performed by a Contract Dentist, youmay call Customer Care at 888-282-8784 or the complaint may beaddressed in writing to:

Delta Dental

Quality Management Department

P.O. Box 6050

Artesia, CA 90702-6050

Written communication must include: 1) the patient's name, 2) theEnrollee's name, address, telephone number and ID number and 3)the Contract Dentist's name and facility location.

"Grievance" means a written or oral expression of dissatisfactionregarding the plan and/or provider, including quality of careconcerns, and shall include a complaint, dispute, request forreconsideration or appeal made by the Enrollee or the Enrollee's


representative. Where this Plan is unable to distinguish between agrievance and an inquiry, it will be considered a grievance.

"Complaint" is the same as "grievance".

"Complainant" is the same as "grievant" and means the personwho filed the grievance including the Enrollee, a representativedesignated by the Enrollee or other individual with authority to acton behalf of the Enrollee.

Within five (5) calendar days of the receipt of any complaint, aquality management coordinator will forward to you a writtenacknowledgment of the complaint which will include the dateof receipt and plan contact information. Certain complaints mayrequire that you be referred to a Dentist for clinical evaluation of thedental services provided. We will forward to you a determination, inwriting, within 30 calendar days of receipt of a complaint.

Our grievance system ensures all plan enrollees have access to andcan fully participate in our grievance process by providing assistanceto those with limited English proficiency or with visual or othercommunicative impairments. Such assistance includes, but is notlimited to, translations of grievance procedures, forms and planresponses to grievances as well as access to interpreters, telephonerelay systems and other devices that aid disabled individuals tocommunicate. If you are in need of these services and/or havequestions about our grievance process, please contact CustomerCare at 888-282-8784 and/or visit our website at deltadentalins.comto obtain a grievance form.

Our grievance system allows Enrollees to file grievances for at least180 days following any incident or action that is the subject of theEnrollee's dissatisfaction.

Enrollees may file a complaint with the DMHC after completing ourgrievance process or if they have been involved in our grievanceprocess for more than 30 days. Enrollees may seek assistance orfile a grievance immediately with the DMHC in cases involving animminent and serious threat to their health including, but not limitedto, severe pain, potential loss of life, limb or major bodily function.In such case, we will provide the Enrollee with written statement onthe disposition or pending status of the grievance no later than three(3) days from the date of receipt of the grievance. You may file acomplaint with the DMHC immediately if you are experiencing anEmergency Dental Condition.


Complaints Involving an Adverse Benefit DeterminationIf the review of a denial is based in whole or in part on a lack ofmedical necessity, experimental treatment, or a clinical judgment inapplying the terms of this Policy, we will consult with a Dentist whohas appropriate training and experience. If any consulting Dentistis involved in the review, the identity of such consulting Dentist willbe available upon request. If an Enrollee believes that the decisionwas denied on the grounds that it was not medically necessary,the Enrollee may contact the DMHC to determine if the decisionis eligible for an independent medical review. Enrollees will not bediscriminated against by us in any way for filing a grievance.

California law requires that we provide you with the followinginformation:The CA Department of Managed Health Care is responsible forregulating health care service plans. If you have a grievance againstyour health plan, you should first telephone your health plan at888-282-8784 and use your health plan's grievance process beforecontacting the department. Utilizing this grievance proceduredoes not prohibit any potential legal rights or remedies that maybe available to you. If you need help with a grievance involving anemergency, a grievance that has not been satisfactorily resolved byyour health plan, or a grievance that has remained unresolved formore than 30 days, you may call the department for assistance. Youmay also be eligible for an Independent Medical Review (IMR). If youare eligible for IMR, the IMR process will provide an impartial reviewof medical decisions made by a health plan related to the medicalnecessity of a proposed service or treatment, coverage decisionsfor treatments that are experimental or investigational in nature andpayment disputes for emergency or urgent medical services. Thedepartment also has a toll-free telephone number (1-888-466-2219)and a TDD line (1-877-688-9891) for the hearing and speechimpaired. The department's Internet Web site www.dmhc.ca.gov hascomplaint forms, IMR application forms and instructions online.


GENERAL PROVISIONS

Public Policy Participation by EnrolleesDelta Dental's Board of Directors includes enrollees who participatein establishing Delta Dental's public policy regarding enrolleesthrough periodic review of Delta Dental's Quality AssessmentProgram reports and communications from enrollees. Enrollees maysubmit any suggestions regarding Delta Dental's public policy inwriting to:


P.O. Box 997330


Entire Policy; ChangesThis Policy and any attached schedules, appendices, endorsementsor riders constitute the entire agreement governing this Plan. Noamendment is valid unless approved by an executive officer of DeltaDental and attached to this Policy. No agent or broker has authorityto amend this Plan or waive any of its provisions.

SeverabilityIf any part of this Policy, or an amendment of it, is found by a courtor other authority to be illegal, void or not enforceable, all otherportions of this Policy will remain in full force and effect.

IncontestabilityDelta Dental shall not rescind or limit any provisions of this Policyonce an Enrollee is covered under this Plan unless Delta Dentalcan demonstrate that the Enrollee performed an act or practiceconstituting fraud or made an intentional misrepresentation ofmaterial fact as prohibited by the terms of this Policy. If Delta Dentalcan demonstrate the aforementioned, Delta Dental shall send anotice to the Enrollee at least 30 days prior to the effective dateof rescinding the Enrollee's Plan explaining the reason(s) for theintended rescission and advising the Enrollee of their right to appealthis decision to the director of the DMHC.

After 24 months following the issuance of this Policy, Delta Dentalshall not rescind, cancel or limit any provisions nor raise Premiumsfor any reason due to any omissions, misrepresentations orinaccuracies in the application form, whether willful or not.


Clinical ExaminationBefore approving a claim, we will be entitled to receive, to suchextent as may be lawful, from any attending or examining Dentist orfrom hospitals in which a Dentist's care is provided, such informationand records relating to the attendance to or examination of, ortreatment provided to you as may be required to administer theclaim. Examination may be required by a dental consultant retainedby us in or near your community or residence. We will, in every case,hold such information and records confidential.

Conformity with Applicable LawsAll legal questions about this Policy will be governed by the state ofCalifornia where this Policy was entered into and is to be performed.Any part of this Policy that conflicts with the laws of California,specifically Chapter 2.2 of Division 2 of the California Health andSafety Code and Chapter 1 of Division 1, of Title 28 of the CaliforniaCode of Regulations, or federal law is hereby amended to conformto the minimum requirements of such laws. Any provision requiredto be in this Policy by either of the above shall bind Delta Dentalwhether or not provided in this Policy.

Third Party Administrator ("TPA")Delta Dental may use the services of a TPA, duly registered underapplicable state law, to provide services under this Policy. Any TPAproviding such services or receiving such information shall enter intoa separate business associate agreement with Delta Dental providingthat the TPA shall meet HIPAA and HITECH requirements for thepreservation of protected health information of Enrollees.

Organ and Tissue DonationDonating organ and tissue provides many societal benefits. Organand tissue donation allows recipients of transplants to go on tolead fuller and more meaningful lives. Currently, the need for organtransplants far exceeds availability. If you are interested in organdonation, please speak to your physician. Organ donation begins atthe hospital when a person is pronounced brain dead and identifiedas a potential organ donor. An organ procurement organization willbecome involved to coordinate the activities.

Impossibility of PerformanceNeither party (Policyholder or Delta Dental) shall be liable to theother or be deemed to be in breach of this Policy for any failure ordelay in performance arising out of causes beyond its reasonablecontrol. Such causes are strictly limited to include acts of God or ofa public enemy, explosion, fires or unusually severe weather. Dates


and times of performance shall be extended to the extent of thedelays excused by this paragraph, provided that the party whoseperformance is affected notifies the other promptly of the existenceand nature of the delay.

Non-DiscriminationDelta Dental complies with applicable Federal civil rights laws anddoes not discriminate on the basis of race, color, national origin, age,disability, or sex. Delta Dental does not exclude people or treat themdifferently because of race, color, national origin, age, disability, orsex.Delta Dental:- Provides free aids and services to people with disabilities to

communicate effectively with us, such as:- Qualified sign language interpreters- Written information in other formats (large print, audio,

accessible electronic formats, other formats)- Provides free language services to people whose primary

language is not English, such as:- Qualified interpreters- Information written in other languages

If you need these services, contact Delta Dental's Customer Care at888-282-8784.

If you believe that Delta Dental has failed to provide these servicesor discriminated in another way on the basis of race, color, nationalorigin, age, disability or sex, you can file a grievance electronicallyonline, over the phone with a Customer Care representative or bymail.

Delta Dental

P.O. Box 997330


Telephone Number: 888-282-8784

Website Address: deltadentalins.com


You can also file a civil rights complaint with the U.S. Departmentof Health and Human Services, Office for Civil Rights, electronicallythrough the Office for Civil Rights Complaint Portal, available athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf or mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, S.W

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019

1-800-537-7697 (TDD)

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

I-ScA-CAB54-dc-R19 - 25 - CAB54 EOC - V20

SCHEDULE A

Description of Benefits and Copayments

The Benefits shown below are performed as needed and deemednecessary by the treating Contract Dentist subject to the limitationsand exclusions of the DeltaCare USA Plan (Plan). Please refer toSchedule B, Limitations and Exclusions of Benefits (Schedule B)for further clarification of Benefits. Enrollees should discuss alltreatment options with their Contract Dentist prior to servicesbeing rendered.

Text that appears in italics below is specifically intended to clarifythe delivery of Benefits under the Plan and is not to be interpretedas Current Dental Terminology ("CDT"), CDT-2020 ProcedureCodes, descriptors or nomenclature that are under copyrightby the American Dental Association ("ADA"). The ADA mayperiodically change CDT Procedure Codes or definitions. Suchupdated Procedure Codes, descriptors and nomenclature may beused to describe these covered procedures in compliance withfederal legislation.

CODE

DESCRIPTION

ENROLLEEPAYS

D0100-D0999 I. DIAGNOSTIC- Procedure Codes below with age restrictions are subject toexceptions based on medical necessity.D0120 Periodic oral evaluation - established patient ......... No Cost

D0140 Limited oral evaluation - problem focused ............. No Cost

D0145 Oral evaluation for a patient under three years ofage and counseling with primary caregiver ........... No Cost

D0150 Comprehensive oral evaluation - new orestablished patient .............................................. No Cost

D0160 Detailed and extensive oral evaluation - problemfocused, by report ............................................... No Cost

D0170 Re-evaluation - limited, problem focused(established patient; not post-operative visit) ........ No Cost

D0171 Re-evaluation - post-operative office visit ............. $5.00

D0180 Comprehensive periodontal evaluation - new orestablished patient .............................................. No Cost

D0190 Screening of a patient ......................................... No Cost

D0191 Assessment of a patient ...................................... No Cost


D0210 Intraoral - complete series of radiographic images -limited to 1 series every 24 months ....................... No Cost

D0220 Intraoral - periapical first radiographic image ......... No Cost

D0230 Intraoral - periapical each additional radiographicimage .................................................................. No Cost

D0240 Intraoral - occlusal radiographic image .................. No Cost

D0250 Extraoral - 2D projection radiographic imagecreated using a stationary radiation source, anddetector .............................................................. No Cost

D0251 Extraoral posterior dental radiographic image ....... No Cost

D0270 Bitewing - single radiographic image .................... No Cost

D0272 Bitewings two radiographic images - limited to 1series every 6 months .......................................... No Cost

D0273 Bitewings three radiographic images - limited to 1series every 6 months .......................................... No Cost

D0274 Bitewings - four radiographic images - limited to 1series every 6 months .......................................... No Cost

D0277 Vertical bitewings - 7 to 8 radiographic images ...... No Cost

D0330 Panoramic radiographic image - limited to 1 every24 months ........................................................... No Cost

D0419 Assessment of salivary flow by measurement - 1every 12 months .................................................. No Cost

D0460 Pulp vitality tests ................................................. No Cost

D0470 Diagnostic casts .................................................. No Cost

D0472 Accession of tissue, gross examination, preparationand transmission of written report - available onlywhen performed in conjunction with a coveredbiopsy ................................................................. No Cost

D0473 Accession of tissue, gross and microscopicexamination, preparation and transmission ofwritten report - available only when performed inconjunction with a covered biopsy ........................ No Cost

D0474 Accession of tissue, gross and microscopicexamination, including assessment of surgicalmargins for presence of disease, preparation andtransmission of written report - available only whenperformed in conjunction with a covered biopsy .... No Cost

D0601 Caries risk assessment and documentation, with afinding of low risk ............................................... No Cost

D0602 Caries risk assessment and documentation, with afinding of moderate risk ....................................... No Cost


D0603 Caries risk assessment and documentation, with afinding of high risk .............................................. No Cost

D0999 Unspecified diagnostic procedure, by report -includes office visit, per visit (in addition to otherservices) .............................................................. $5.00

D1000-D1999 II. PREVENTIVE- Procedure Codes below with age restrictions are subject toexceptions based on medical necessity.D1110 Prophylaxis cleaning - adult - 1 D1110, D1120 or

D4346 per 6 month period .................................. $5.00

D1120 Prophylaxis cleaning - child - 1 D1110, D1120 orD4346 per 6 month period .................................. $5.00

D1206 Topical application of fluoride varnish - child to age19; 1 D1206 or D1208 per 6 month period ............... $5.00

D1208 Topical application of fluoride - excluding varnish .. $5.00

D1310 Nutritional counseling for control of dental disease No Cost

D1320 Tobacco counseling for the control and preventionof oral disease ..................................................... No Cost

D1330 Oral hygiene instructions ..................................... No Cost

D1351 Sealant - per tooth - limited to permanent molarsthrough age 15 .................................................... $22.00

D1352 Preventive resin restoration in a moderate to highcaries risk patient - permanent tooth - limited topermanent molars through age 15 ......................... $22.00

D1353 Sealant repair - per tooth ..................................... $22.00

D1354 Interim caries arresting medicament application -per tooth ............................................................ $20.00

D1510 Space maintainer - fixed - unilateral - per quadrant $85.00

D1516 Space maintainer - fixed - bilateral, maxillary ......... $85.00

D1517 Space maintainer - fixed - bilateral, mandibular ...... $85.00

D1520 Space maintainer - removable - unilateral - perquadrant ............................................................. $85.00

D1526 Space maintainer - removable - bilateral, maxillary . $85.00

D1527 Space maintainer - removable - bilateral,mandibular .......................................................... $85.00

D1551 Re-cement or re-bond bilateral space maintainer -maxillary ............................................................. $10.00

D1552 Re-cement or re-bond bilateral space maintainer -mandibular .......................................................... $10.00


D1553 Re-cement or re-bond unilateral space maintainer -per quadrant ....................................................... $10.00

D1556 Removal of fixed unilateral space maintainer - perquadrant ............................................................. $10.00

D1557 Removal of fixed bilateral space maintainer -maxillary ............................................................. $10.00

D1558 Removal of fixed bilateral space maintainer -mandibular .......................................................... $10.00

D1575 Distal shoe space maintainer - fixed, unilateral - perquadrant ............................................................. $85.00

D2000-D2999 III. RESTORATIVE- Includes polishing, all adhesives and bonding agents, indirect pulpcapping, bases, liners and acid etch procedures.- Replacement of crowns, inlays and onlays requires the existingrestoration to be 5+ years old.D2140 Amalgam - one surface, primary or permanent ...... $15.00

D2150 Amalgam - two surfaces, primary or permanent .... $20.00

D2160 Amalgam - three surfaces, primary or permanent .. $25.00

D2161 Amalgam - four or more surfaces, primary orpermanent .......................................................... $30.00

D2330 Resin-based composite - one surface, anterior ....... $35.00

D2331 Resin-based composite - two surfaces, anterior ..... $40.00

D2332 Resin-based composite - three surfaces, anterior ... $45.00

D2335 Resin-based composite - four or more surfaces orinvolving incisal angle (anterior) ........................... $60.00

D2390 Resin-based composite crown, anterior ................. $60.00

D2391 Resin-based composite - one surface, posterior ..... $35.00

D2392 Resin-based composite - two surfaces, posterior ... $40.00

D2393 Resin-based composite - three surfaces, posterior . $60.00

D2394 Resin-based composite - four or more surfaces,posterior ............................................................. $60.00

D2510 Inlay - metallic - one surface 4 .............................. $260.00

D2520 Inlay - metallic - two surfaces 4 ............................ $270.00

D2530 Inlay - metallic - three or more surfaces 4 .............. $280.00

D2542 Onlay - metallic - two surfaces 4 ........................... $270.00

D2543 Onlay - metallic - three surfaces 4 ......................... $290.00

D2544 Onlay - metallic - four or more surfaces 4 .............. $300.00

D2610 Inlay - porcelain/ceramic - one surface .................. $350.00


D2620 Inlay - porcelain/ceramic - two surfaces 2 .............. $385.00

D2630 Inlay - porcelain/ceramic - three or more surfaces 2 $405.00

D2642 Onlay - porcelain/ceramic - two surfaces 2 ............. $415.00

D2643 Onlay - porcelain/ceramic - three surfaces 2 ........... $415.00

D2644 Onlay - porcelain/ceramic - four or more surfaces 2 $425.00

D2650 Inlay - resin-based composite - one surface 2 ......... $250.00

D2651 Inlay - resin-based composite - two surfaces 2 ....... $275.00

D2652 Inlay - resin-based composite - three or moresurfaces 2 ............................................................ $310.00

D2662 Onlay - resin-based composite - two surfaces 2 ...... $305.00

D2663 Onlay - resin-based composite - three surfaces 2 .... $330.00

D2664 Onlay - resin-based composite - four or moresurfaces 2 ............................................................ $375.00

D2710 Crown - resin-based composite (indirect) 2 ............ $125.00

D2712 Crown - 3/4 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

D2740 Crown - porcelain/ceramic 2, 5 ............................... $375.00

D2750 Crown - porcelain fused to high noble metal 1, 2, 5 .... $300.00

D2751 Crown - porcelain fused to predominantly basemetal 1, 2 .............................................................. $250.00

D2752 Crown - porcelain fused to noble metal 1, 2 ............. $300.00

D2753 Crown - porcelain fused to titanium and titaniumalloys .................................................................. $300.00

D2780 Crown - 3/4 cast high noble metal ........................ $425.00

D2781 Crown - 3/4 cast predominantly base metal .......... $325.00

D2782 Crown - 3/4 cast noble metal ............................... $425.00

D2783 Crown - 3/4 porcelain/ceramic 2, 5 ......................... $495.00

D2790 Crown - full cast high noble metal ........................ $425.00

D2791 Crown - full cast predominantly base metal ........... $325.00

D2792 Crown - full cast noble metal ............................... $425.00

D2794 Crown - titanium and titanium alloys ..................... $495.00

D2910 Re-cement or re-bond inlay, onlay, veneer or partialcoverage restoration ............................................ $15.00


D2915 Re-cement or re-bond indirectly fabricated orprefabricated post and core ................................. $15.00

D2920 Re-cement or re-bond crown ............................... $15.00

D2921 Reattachment of tooth fragment, incisal edge orcusp (anterior) .................................................... $115.00

D2929 Prefabricated porcelain/ceramic crown - primarytooth - anterior ................................................... $95.00

D2930 Prefabricated stainless steel crown - primary tooth $55.00

D2931 Prefabricated stainless steel crown - permanenttooth ................................................................... $55.00

D2932 Prefabricated resin crown - anterior primary tooth . $95.00

D2933 Prefabricated stainless steel crown with resinwindow - anterior primary tooth ........................... $95.00

D2940 Protective restoration .......................................... $10.00

D2941 Interim therapeutic restoration - primary dentition . $10.00

D2949 Restorative foundation for an indirect restoration .. $85.00

D2950 Core buildup, including any pins when required ..... $85.00

D2951 Pin retention - per tooth, in addition to restoration . $30.00

D2952 Post and core in addition to crown, indirectlyfabricated - includes canal preparation 4 ............... $85.00

D2953 Each additional indirectly fabricated post - sametooth - includes canal preparation 4 ...................... $50.00

D2954 Prefabricated post and core in addition to crown -base metal post; includes canal preparation .......... $75.00

D2955 Post removal ....................................................... $40.00

D2957 Each additional prefabricated post - same tooth -base metal post; includes canal preparation .......... $45.00

D2971 Additional procedures to construct new crownunder existing partial denture framework .............. $65.00

D2980 Crown repair necessitated by restorative materialfailure .................................................................. $50.00

D2981 Inlay repair necessitated by restorative materialfailure .................................................................. $50.00

D2982 Onlay repair necessitated by restorative materialfailure .................................................................. $50.00

D2983 Veneer repair necessitated by restorative materialfailure .................................................................. $50.00

D2990 Resin infiltration of incipient smooth surface lesions............................................................................ $22.00


D3000-D3999 IV. ENDODONTICS- With the exception of pulp caps, pulpotomies, pulpaldebridements, and pulpal therapies with resorbable fillings, allendodontic procedures listed below are Benefits for permanentteeth only.D3110 Pulp cap - direct (excluding final restoration) ........ $10.00

D3120 Pulp cap - indirect (excluding final restoration) ...... $10.00

D3220 Therapeutic pulpotomy (excluding finalrestoration) - removal of pulp coronal to thedentinocemental junction and application ofmedicament ........................................................ $45.00

D3221 Pulpal debridement, primary and permanent teeth $45.00

D3222 Partial pulpotomy for apexogenesis - permanenttooth with incomplete root development .............. $45.00

D3230 Pulpal therapy (resorbable filling) - anterior,primary tooth (excluding final restoration) ............ $45.00

D3240 Pulpal therapy (resorbable filling) - posterior,primary tooth (excluding final restoration) ............ $45.00

D3310 Root canal - endodontic therapy, anterior tooth(excluding final restoration) .................................. $230.00

D3320 Root canal - endodontic therapy, premolar tooth(excluding final restoration) .................................. $300.00

D3330 Root canal - endodontic therapy, molar tooth(excluding final restoration) .................................. $340.00

D3331 Treatment of root canal obstruction; non-surgicalaccess ................................................................. $230.00

D3332 Incomplete endodontic therapy; inoperable,unrestorable or fractured tooth ............................ $240.00

D3346 Retreatment of previous root canal therapy -anterior ............................................................... $500.00

D3347 Retreatment of previous root canal therapy -premolar ............................................................. $600.00

D3348 Retreatment of previous root canal therapy - molar............................................................................ $725.00

D3410 Apicoectomy - anterior ........................................ $470.00

D3421 Apicoectomy - premolar (first root) ...................... $535.00

D3425 Apicoectomy - molar (first root) ........................... $580.00

D3426 Apicoectomy (each additional root) ..................... $115.00

D3427 Periradicular surgery without apicoectomy ............ $470.00

D3430 Retrograde filling - per root ................................. $65.00


D3450 Root amputation - per root .................................. $315.00

D3920 Hemisection (including any root removal), notincluding root canal therapy ................................. $95.00

D4000-D4999 V. PERIODONTICS- Includes postoperative evaluations and treatment under a localanesthetic.D4210 Gingivectomy or gingivoplasty - four or more

contiguous teeth or tooth bounded spaces perquadrant ............................................................. $260.00

D4211 Gingivectomy or gingivoplasty - one to threecontiguous teeth or tooth bounded spaces perquadrant ............................................................. $150.00

D4212 Gingivectomy or gingivoplasty to allow access forrestorative procedure, per tooth ........................... $150.00

D4240 Gingival flap procedure, including root planing -four or more contiguous teeth or tooth boundedspaces per quadrant ............................................ $350.00

D4241 Gingival flap procedure, including root planing -one to three contiguous teeth or tooth boundedspaces per quadrant ............................................ $280.00

D4249 Clinical crown lengthening - hard tissue ................ $280.00

D4260 Osseous surgery (including elevation of a fullthickness flap and closure) - four or morecontiguous teeth or tooth bounded spaces perquadrant ............................................................. $650.00

D4261 Osseous surgery (including elevation of a fullthickness flap and closure) - one to threecontiguous teeth or tooth bounded spaces perquadrant ............................................................. $520.00

D4270 Pedicle soft tissue graft procedure ....................... $290.00

D4274 Mesial/distal wedge procedure, single tooth (whennot performed in conjunction with surgicalprocedures in the same anatomical area) .............. $95.00

D4277 Free soft tissue graft procedure (includingrecipient and donor surgical sites) first tooth,implant, or edentulous tooth position in graft ........ $300.00

D4278 Free soft tissue graft procedure (includingrecipient and donor surgical sites) each additionalcontiguous tooth, implant, or edentulous toothposition in same graft site .................................... $300.00

D4341 Periodontal scaling and root planing - four or moreteeth per quadrant - limited to 4 quadrants duringany 12 consecutive months ................................... $50.00


D4342 Periodontal scaling and root planing - one to threeteeth per quadrant - limited to 4 quadrants duringany 12 consecutive months ................................... $40.00

D4346 Scaling in presence of generalized moderate orsevere gingival inflammation - full mouth, after oralevaluation - 1 D1110, D1120 or D4346 per 6 monthperiod ................................................................. $20.00

D4355 Full mouth debridement to enable acomprehensive oral evaluation and diagnosis on asubsequent visit - limited to 1 treatment in any 12consecutive months ............................................. $50.00

D4910 Periodontal maintenance - limited to 1 treatmenteach 6 month period ........................................... $40.00

D4921 Gingival irrigation - per quadrant .......................... No Cost

D5000-D5899 VI. PROSTHODONTICS (removable)- For all listed dentures and partial dentures, Copayment includesafter delivery adjustments and tissue conditioning, if needed, for thefirst six months after placement. The Enrollee must continue to beeligible, and the service must be provided at the Contract Dentist'sfacility where the denture was originally delivered.- Rebases, relines and tissue conditioning are limited to 1 per dentureduring any 12 consecutive months.- Replacement of a denture or a partial denture requires the existingdenture 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 (includingretentive/clasping materials, rests, and teeth) ........ $400.00

D5212 Mandibular partial denture - resin base (includingretentive/clasping materials, rests, and teeth) ........ $400.00

D5213 Maxillary partial denture - cast metal frameworkwith resin denture bases (including retentive/clasping materials, rests and teeth) ....................... $565.00

D5214 Mandibular partial denture - cast metal frameworkwith resin denture bases (including retentive/clasping materials, rests and teeth) ....................... $565.00

D5221 Immediate maxillary partial denture - resin base(including retentive/clasping materials, rests andteeth) .................................................................. $400.00


D5222 Immediate mandibular partial denture - resin base(including retentive/clasping materials, rests andteeth) .................................................................. $400.00

D5223 Immediate maxillary partial denture - cast metalframework with resin denture bases (includingretentive/clasping materials, rests and teeth) ......... $565.00

D5224 Immediate mandibular partial denture - cast metalframework with resin denture bases (includingretentive/clasping materials, rests and teeth) ......... $565.00

D5225 Maxillary partial denture - flexible base (includingany clasps, rests and teeth) .................................. $700.00

D5226 Mandibular partial denture - flexible 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

D5422 Adjust partial denture - mandibular ...................... $24.00

D5511 Repair broken complete denture base, mandibular . $55.00

D5512 Repair broken complete denture base, maxillary .... $55.00

D5520 Replace missing or broken teeth - completedenture (each tooth) ........................................... $40.00

D5611 Repair resin partial denture base, mandibular ........ $60.00

D5612 Repair resin partial denture base, maxillary ........... $60.00

D5621 Repair cast partial framework, mandibular ............. $60.00

D5622 Repair cast partial framework, maxillary ................ $60.00

D5630 Repair or replace broken retentive/claspingmaterials - per tooth ............................................ $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 - per tooth .... $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 inany 12 consecutive months ................................... $175.00

D5821 Interim partial denture (mandibular) - limited to 1 inany 12 consecutive months ................................... $175.00

D5850 Tissue conditioning, maxillary ............................... $40.00

D5851 Tissue conditioning, mandibular ........................... $40.00

D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS - NotCovered

D6000-D6199 VIII. IMPLANT SERVICES - Not Covered

D6200-D6999 IX. PROSTHODONTICS, fixed (each retainerand each pontic constitutes a unit in a fixedpartial denture [bridge])

- Replacement of a crown, pontic, inlay, onlay or stress breakerrequires 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 fused to high noble metal 2, 5 ...... $425.00

D6241 Pontic - porcelain fused to predominantly basemetal 2 ................................................................ $325.00

D6242 Pontic - porcelain fused to noble metal 2 ............... $425.00

D6243 Pontic - porcelain fused to titanium and titaniumalloys .................................................................. $425.00

D6245 Pontic - porcelain/ceramic 2, 5 ............................... $495.00

D6250 Pontic - resin with high noble metal 2 .................... $425.00

D6251 Pontic - resin with predominantly base metal 2 ...... $325.00

D6252 Pontic - resin with noble metal 2 ........................... $425.00

D6600 Retainer inlay - porcelain/ceramic, two surfaces 2 ... $385.00

D6601 Retainer inlay - porcelain/ceramic, three or moresurfaces 2 ............................................................ $405.00

D6602 Retainer inlay - cast high noble metal, two surfaces............................................................................ $370.00

D6603 Retainer inlay - cast high noble metal, three ormore surfaces ...................................................... $380.00


D6604 Retainer inlay - cast predominantly base metal, twosurfaces .............................................................. $270.00

D6605 Retainer inlay - cast predominantly base metal,three or more surfaces ......................................... $280.00

D6606 Retainer inlay - cast noble metal, two surfaces ....... $370.00

D6607 Retainer inlay - cast noble metal, three or moresurfaces .............................................................. $380.00

D6608 Retainer onlay - porcelain/ceramic, two surfaces 2 .. $395.00

D6609 Retainer onlay - porcelain/ceramic, three or moresurfaces 2 ............................................................ $415.00

D6610 Retainer onlay - cast high noble metal, twosurfaces .............................................................. $370.00

D6611 Retainer onlay - cast high noble metal, three ormore surfaces ...................................................... $390.00

D6612 Retainer onlay - cast predominantly base metal,two surfaces ........................................................ $270.00

D6613 Retainer onlay - cast predominantly base metal,three or more surfaces ......................................... $290.00

D6614 Retainer onlay - cast noble metal, two surfaces ..... $370.00

D6615 Retainer onlay - cast noble metal, three or moresurfaces .............................................................. $390.00

D6720 Retainer crown - resin with high noble metal 2 ....... $425.00

D6721 Retainer crown - resin with predominantly basemetal 2 ................................................................ $325.00

D6722 Retainer crown - resin with noble metal 2 .............. $425.00

D6740 Retainer crown - porcelain/ceramic 2, 5 .................. $495.00

D6750 Retainer crown - porcelain fused to high noblemetal 1, 2, 5 ............................................................ $425.00

D6751 Retainer crown - porcelain fused to predominantlybase metal 1, 2 ...................................................... $325.00

D6752 Retainer crown - porcelain fused to noble metal 1, 2 . $425.00

D6753 Retainer crown - porcelain fused to titanium andtitanium alloys ..................................................... $425.00

D6780 Retainer crown - 3/4 cast high noble metal ........... $425.00

D6781 Retainer crown - 3/4 cast predominantly basemetal .................................................................. $325.00

D6782 Retainer crown - 3/4 cast noble metal .................. $425.00

D6783 Retainer crown - 3/4 porcelain/ceramic 2, 5 ............. $495.00

D6784 Retainer crown 3/4 - titanium and titanium alloys .. $425.00


D6790 Retainer crown - full cast high noble metal ............ $425.00

D6791 Retainer crown - full cast predominantly basemetal .................................................................. $325.00

D6792 Retainer crown - full cast noble metal ................... $425.00

D6930 Re-cement or re-bond fixed partial denture ........... $30.00

D6940 Stress breaker ..................................................... $50.00

D6980 Fixed partial denture repair necessitated byrestorative material failure .................................... $75.00

D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY- Includes preoperative and postoperative evaluations and treatmentunder local anesthetic.D7111 Extraction, coronal remnants - primary tooth ......... $30.00

D7140 Extraction, erupted tooth or exposed root(elevation and/or forceps removal) ....................... $40.00

D7210 Extraction, erupted tooth requiring removal ofbone and/or sectioning of tooth, and includingelevation of mucoperiosteal flap if indicated .......... $70.00

D7220 Removal of impacted tooth - soft tissue ................ $100.00

D7230 Removal of impacted tooth - partially bony ........... $190.00

D7240 Removal of impacted tooth - completely bony ...... $210.00

D7241 Removal of impacted tooth - completely bony, withunusual surgical complications ............................. $230.00

D7250 Removal of residual tooth roots (cuttingprocedure) .......................................................... $75.00

D7251 Coronectomy - intentional partial tooth removal .... $230.00

D7286 Incisional biopsy of oral tissue - soft - does notinclude pathology laboratory procedures .............. $100.00

D7310 Alveoloplasty in conjunction with extractions - fouror more teeth or tooth spaces, per quadrant ......... $150.00

D7311 Alveoloplasty in conjunction with extractions - oneto three teeth or tooth spaces, per quadrant ......... $150.00

D7320 Alveoloplasty not in conjunction with extractions -four 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 of lateral exostosis (maxilla or mandible) . $150.00

D7472 Removal of torus palatinus ................................... $150.00

D7473 Removal of torus mandibularis ............................. $150.00

D7510 Incision and drainage of abscess - intraoral softtissue .................................................................. $35.00


D7511 Incision and drainage of abscess - intraoral softtissue - complicated (includes drainage of multiplefascial spaces) ..................................................... $55.00

D7922 Placement of intra-socket biological dressing to aidin hemostasis or clot stabilization, per site ............ No Cost

D7960 Frenulectomy - also known as frenectomy orfrenotomy - separate procedure not incidental toanother procedure ............................................... $160.00

D8000-D8999 XI. ORTHODONTICS- The listed Copayment for each phase of orthodontic treatment(limited, interceptive or comprehensive) covers up to 24 months ofactive treatment. Beyond 24 months, an additional monthly fee, notto exceed $125.00, may apply.- The retention Copayment includes removal of appliances,construction and placement of removable retainers, and up to 24months of adjustments and/or office visits.- In the event orthodontic treatment is not required or is declinedby the Enrollee, a fee of $85.00 will apply. The Enrollee is alsoresponsible for any incurred orthodontic diagnostic record fees.- Procedure Codes below with age restrictions are subject toexceptions based on medical necessity.D8010 Limited orthodontic treatment of the primary

dentition .............................................................$1,400.00

D8020 Limited orthodontic treatment of the transitionaldentition - child or adolescent to age 19 ................$1,400.00

D8030 Limited orthodontic treatment of the adolescentdentition - adolescent to age 19 ...........................$1,400.00

D8040 Limited orthodontic treatment of the adultdentition - adults, including covered dependentadult children ......................................................$1,600.00

D8050 Interceptive orthodontic treatment of the primarydentition .............................................................$1,650.00

D8060 Interceptive orthodontic treatment of thetransitional dentition ............................................$1,650.00

D8070 Comprehensive orthodontic treatment of thetransitional dentition - child or adolescent to age 19............................................................................$2,600.00

D8080 Comprehensive orthodontic treatment of theadolescent dentition - adolescent to age 19 ...........$2,600.00

D8090 Comprehensive orthodontic treatment of the adultdentition - adults, including covered dependentadult children ......................................................$2,800.00


D8660 Pre-orthodontic treatment examination to monitorgrowth and development 3 ................................... No Cost

D8670 Periodic orthodontic treatment visit (as part ofcontract) ............................................................. No Cost

D8680 Orthodontic retention (removal of appliances,construction and placement of removableretainers) ............................................................ $250.00

D8681 Removable orthodontic retainer adjustment .......... No Cost

D8999 Unspecified orthodontic procedure, by report -includes treatment planning session ..................... $200.00

D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICES

D9110 Palliative (emergency) treatment of dental pain -minor procedure .................................................. $35.00

D9210 Local anesthesia not in conjunction with operativeor surgical procedures ......................................... No Cost

D9211 Regional block anesthesia .................................... No Cost

D9212 Trigeminal division block anesthesia ..................... No Cost

D9215 Local anesthesia in conjunction with operative orsurgical procedures ............................................. No Cost

D9219 Evaluation for moderate sedation, deep sedation orgeneral anesthesia ............................................... No Cost

D9310 Consultation - diagnostic service provided bydentist or physician other than requesting dentistor physician ......................................................... $70.00

D9311 Consultation with medical health care professional No Cost

D9430 Office visit for observation (during regularlyscheduled hours) - no other services performed .... $5.00

D9440 Office visit - after regularly scheduled hours .......... $40.00

D9450 Case presentation, detailed and extensivetreatment planning .............................................. No Cost

D9932 Cleaning and inspection of removable completedenture, maxillary ................................................ No Cost

D9933 Cleaning and inspection of removable completedenture, mandibular ............................................. No Cost

D9934 Cleaning and inspection of removable partialdenture, maxillary ................................................ No Cost

D9935 Cleaning and inspection of removable partialdenture, mandibular ............................................. No Cost

D9951 Occlusal adjustment, limited ................................. $40.00

D9952 Occlusal adjustment, complete ............................. $90.00


D9975 External bleaching for home application, per arch;includes materials and fabrication of custom trays . $125.00

D9986 Missed appointment - without 24 hour notice - per15 minutes of appointment time - up to an overallmaximum of $40.00 ............................................ $10.00

D9987 Canceled appointment - without 24 hour notice -per 15 minutes of appointment time - up to anoverall maximum of $40.00 ................................. $10.00

D9990 Certified translation or sign-language services - pervisit ..................................................................... No Cost

D9991 Dental case management - addressingappointment compliance barriers ......................... No Cost

D9992 Dental case management - care coordination ........ No Cost

D9995 Teledentistry - synchronous; real-time encounter ... No Cost

D9996 Teledentistry - asynchronous; information storedand forwarded to dentist for subsequent review .... No Cost

D9997 Dental case management - Patients with specialHealth Care Needs ............................................... No Cost

If services for a listed procedure are performed by the assignedContract Dentist, the Enrollee pays the specified Copayment. Listedprocedures which require a DeltaCare USA Dentist to providespecialized services and are referred by the Enrollee's assignedContract Dentist, must be preauthorized in writing by Delta Dental.The Enrollee pays the Copayment specified for such services.

FOOTNOTES

1 For a covered porcelain-fused-to-metal crown, a porcelain margin isconsidered a material upgrade with a maximum additional charge tothe Enrollee of $75.00.

2 Porcelain and other tooth-colored materials on molars areconsidered a material upgrade with a maximum additional charge tothe Enrollee of $150.00.

3 In the event orthodontic treatment is not required or is declinedby the Enrollee, a fee of $85.00 will apply. The Enrollee is alsoresponsible for any incurred orthodontic diagnostic record fees.


4 Base metal is the benefit. If an inlay, onlay or indirectly fabricatedpost and core is made of high noble metal or noble metal, anadditional fee up to $100.00 per tooth will be charged for theupgrade.

5 Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials arematerial upgrades. The Contract Dentist may charge an additionalfee not to exceed $325.00 in addition to the listed Copayment. Referto Limitation of Benefits #4 for additional information.

I-ScB-CAB54-dc-R19 - 42 - CAB54 EOC - V20

SCHEDULE B

Limitations of Benefits

Limitations below with age restrictions are subject to exceptionsbased on medical necessity.

1. The frequency of certain Benefits is limited. All frequencylimitations are listed in Schedule A, Description of Benefits andCopayments. ("Schedule A").

2. Fillings (amalgams and composites) are Benefits for the removalof decay, for minor repairs of tooth structure or to replace a lostor failing restoration.

3. The placement of a crown, inlay or onlay is a Benefit when thereis insufficient tooth structure to support a filling.

4. Contract Dentists may offer services that utilize brand or tradenames at an additional fee. The Enrollee must be offered theplan Benefits of a high quality laboratory processed crown/pontic that may include: porcelain/ceramic; porcelain with base,noble or high-noble metal. If the Enrollee chooses the alternativeof a material upgrade (name brand, laboratory processed or in-office processed crowns/pontics produced through specializedtechnique or materials, including but not limited to: Captek,Procera, Lava, Empress and Cerec), the Contract Dentist maycharge an additional fee not to exceed $325.00 in addition tothe listed Copayment. Contact Customer Care at 888-282-8784if you have questions regarding the additional fee or name brandservices.

5. The replacement of an existing inlay, onlay, crown, fixed partialdenture (bridge) or a removable full or partial denture is coveredwhen:

a. The existing restoration/bridge/denture is no longer functionaland cannot be made functional by repair or adjustment, and

b. Either of the following:

- The existing non-functional restoration/bridge/denture

was placed five or more years prior to its replacement, or

- If an existing partial denture is less than five years old, but

must be replaced by a new partial denture due to the loss

of a natural tooth, which cannot be replaced by adding

another tooth to the existing partial denture.


6. Coverage for the placement of a fixed 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-functional

bridge; or

- Each abutment tooth to be crowned meets Limitation #3.

7. Benefits for retained primary teeth are limited to servicesapplicable to a primary tooth.

8. Excision of the frenum is a Benefit only when it causes limitedmobility of the tongue, a large diastema between teeth or itinterferes with a prosthetic appliance.

9. Benefits provided by a pediatric Dentist are limited to childrenthrough age seven following an attempt by the assignedContract Dentist to treat the child and upon prior Authorizationby Delta Dental, less applicable Copayments. The Plan willconsider exceptions on an individual basis if a child has aphysical or mental impairment, limitation or condition whichsubstantially interferes with that child's ability to have Benefitsprovided by a Contract Dentist.

10. Benefits for a soft tissue management program are limited tothose parts which are listed covered services listed in ScheduleA. If an Enrollee declines non-covered services (includingirrigation) within a soft tissue management program, it does noteliminate or alter other covered Benefits.

11. Three recementations or replacements of a bracket/band onthe same tooth or a total of five rebracketings/rebandings ondifferent teeth during the covered course of treatment areBenefits. If any additional recementations or replacements ofbrackets/bands are performed, the Enrollee is responsible forthe cost at the Contract Orthodontist's Usual Fee.

12. Comprehensive orthodontic treatment (Phase II) consists ofrepositioning all or nearly all of the permanent teeth in aneffort to make the Enrollee's occlusion as ideal as possible. Thistreatment usually requires complete fixed appliances; however,when the Contract Orthodontist deems it suitable, a Europeanor removable appliance therapy may be substituted at the sameCopayment amounts as for fixed appliances.


13. The Copayment is payable to the Contract Orthodontist whoinitiates banding in a course of orthodontic treatment. If, afterbanding has been initiated, the Enrollee changes to anotherContract Orthodontist to continue orthodontic treatment, theEnrollee:

a. will not be entitled to a refund of any amounts previously paid;and

b. will be responsible for all payments, up to and including the fullCopayment, that are required by the new Contract Orthodontistfor completion of the orthodontic treatment.

14. The cost to an Enrollee receiving orthodontic treatment whosecoverage is cancelled or terminated for any reason will be basedon the Contract Orthodontist's Usual Fee for the treatmentplan. The Contract Orthodontist will prorate the amount forthe number of months remaining to complete treatment. TheEnrollee makes payment directly to the Contract Orthodontist asarranged.


Exclusions of Benefits

Exclusions below with age restrictions are subject to exceptionsbased on medical necessity.

1. Any procedure that is not specifically listed under Schedule A,Description of Benefits and Copayments.

2. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similarcare facility.

3. Lost or stolen appliances including, but not limited to, fullor partial dentures, space maintainers, crowns, fixed partialdentures (bridges) and orthodontic appliances.

4. Dental expenses incurred in connection with any dentalprocedures started after termination of eligibility for coverage.

5. Dental expenses incurred in connection with any dentalprocedure started before the Enrollee's eligibility with theDeltaCare USA Plan. Examples include: teeth prepared forcrowns, root canals in progress, full or partial dentures for whichan impression has been taken and orthodontics.

6. Prescription and over-the-counter drugs.

7. Any procedure that has poor prognosis for a successful resultand reasonable longevity based on the condition of the toothor teeth and/or surrounding structures, or is inconsistent withgenerally accepted standards for dentistry.

8. Dental services received from any dental facility other than theassigned Contract Dentist, or a preauthorized Contract Specialist(oral surgeon, endodontist, periodontist, pediatric Dentist orContract Orthodontist), except for Emergency Dental Servicesand Urgent Dental Services as described in the Policy.

9. Consultations or other diagnostic services for non-coveredBenefits.

10. Duplication of x-rays.

11. Implant supported dental appliances and attachments, implantplacement, maintenance, removal and all other servicesassociated with a dental implant.

12. Porcelain crowns, porcelain fused to metal or resin with metaltype crowns and fixed partial dentures (bridges) for childrenunder 16 years of age.


13. Services solely for cosmetic purposes, with the exception ofProcedure Code D9975 (external bleaching for home application,per arch), or for conditions that are a result of hereditary ordevelopmental defects, such as cleft palate, upper and lowerjaw malformations, congenitally missing teeth and teeth thatare discolored or lacking enamel, except for the treatment ofnewborn children with congenital defects or birth abnormalities.

14. Procedures, appliances or restorations if the purpose is tochange vertical dimension, replace or stabilize tooth structureloss by attrition, realignment of teeth, periodontal splinting,gnathologic recordings, or to diagnose or treat abnormalconditions of the temporomandibular joint (TMJ), with theexception of Procedure Codes D9951 and D9952, as shown onSchedule A.

15. An initial treatment plan which involves the removal andreestablishment of the occlusal contacts of 10 or more teethwith crowns, onlays, fixed partial dentures (bridges), orany combination of these is considered to be full mouthreconstruction under the DeltaCare USA Plan. Crowns, onlaysand fixed partial dentures associated with such a treatment planare not covered Benefits. This exclusion does not affect anyother Benefits.

16. Precious metal for removable appliances, metallic or permanentsoft bases for complete dentures, porcelain denture teeth,precision abutments for removable partials or fixed partialdentures (overlays, implants, and appliances associatedtherewith) and personalization and characterization of completeand partial dentures.

17. Extraction of teeth, when teeth are asymptomatic/non-pathologic (no signs or symptoms of pathology or infection),including but not limited to the removal of third molars andorthodontic extractions.

18. Treatment or extraction of primary teeth when exfoliation(normal shedding and loss) is imminent.

19. Treatment or appliances that are provided by a Dentist whosepractice specializes in prosthodontic services;

20. Accidental injury. Accidental injury is defined as damage tothe hard and soft tissue of the oral cavity resulting from forcesexternal to the mouth. Damages to the hard and soft tissues ofthe oral cavity from normal masticatory (chewing) function willbe covered at the normal schedule of Benefits.

21. Myofunctional and parafunctional appliances and/or therapies.


22. Composite or ceramic brackets, lingual adaptation oforthodontic bands, Invisalign and other specialized or cosmeticalternatives to standard fixed and removable orthodonticappliances.

23. Pre-, mid- and post-treatment records for orthodontia includingcephalometric x-rays, tracings, photographs and study models.

24. Changes in orthodontic treatment necessitated by accident ofany kind.

25. Orthodontic treatment must be provided by a licensed Dentist.Self-administered orthodontics is not a covered Benefit.

26. The removal of fixed orthodontic appliances for reasons otherthan completion of treatment is not a covered Benefit.

In California, DeltaCare USA is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company.

I‑P‑CA‑dc‑REV2020 128191_EOC_CAB54_V20_03.09.2020

If you have any questions or need additional information, call or write:

Delta Dental Insurance CompanyP.O. Box 1803Alpharetta, GA 30023888‑282‑8784

IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For free help, please call right away at the Member/Cus‑tomer Service telephone number on the back of your Delta Dental ID card, or 888‑282‑8784.

IMPORTANTE: ¿Puede leer esta carta? Si no, podem‑os hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Delta Den‑tal o al 888‑282‑8784.

重要通知：您能讀懂這封信嗎？如果不能，我們可以請人幫您閲讀。這封信也可以用您所講的語言書寫。如需幫助，請立即撥打登列在您的Delta Dental ID卡背面上的會員/客戶服務部的電話，或者撥打電話 888‑282‑8784。

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