nebo school district 2020 bg · 2. be a smart shopper. if you were buying a car or purchasing a...

EmployeeBenefits Guide

20202021

This guide provides highlights of our benefits program. A complete description of your benefit plans can be found in the plan documents, Summary Plan

Descriptions (SPD) and contracts. While every effort has been made to provide an accurate summary of the plans, the information contained in this guide does not replace or change the meaning of our employer-sponsored benefit(s) plan

documents; SPDs and contracts; the plan documents and contracts are controlling in the event of any discrepancy. We reserve the right to terminate or amend these employer-sponsored plans at any time, in whole or in part, for any

reason. Any such amendment or termination may apply to current and future participants, covered spouses, beneficiaries, and dependents.

Contacts

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MedicalSelectHealth(800) 538-5038selecthealth.org

Nebo Health & Wellness Center(877) 423-1330CareHere.comCode: NSD2start135 West 300 SouthSpanish Fork

Health Savings AccountHealthEquity(866) 346-5800healthequity.com

DentalEMI Health(800) 662-5851emihealth.com

VisionVSP(800) 363-0950vsp.com

EyeMed(866) 939-3633eyemedvisioncare.com

Flexible Spending AccountAxisPlus(877) 872-2125myaxisplus.com

Basic Life & AD&DThe Hartford(888) 563-1124thehartford.com

DisabilityThe Hartford(888) 563-1124thehartford.com

Critical IllnessAccidentHospital IndemnityMetLife(800) GET-MET8https://portal.metlink.com/MetLinkPortal/jsp/index.jsp

Employee Assistance ProgramBlomquist Hale(800) 926-9619blomquisthale.com

Human ResourcesRyan Kay, Human Resources(801) [email protected]

Nebo School DistrictSeptember 1, 2020 – August 31, 2021

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This Guide is designed to highlight your benefit options so that you can make the best possible decisions for you and your family. Use this guide

as your go-to-resource when you’re enrolling for benefits and throughout the plan year. The choices you make will remain in effect during the plan

year, unless you have a qualifying major life event.

We are committed to providing our employees with quality benefits programs that are comprehensive, flexible and affordable. Giving our employees the best in benefit plans is one way we can show you that as an employee, YOU are our most important

asset. Eligible employees have many benefit plans to choose from, so we ask that you read this benefits guide carefully to help you make the benefit elections that are the

best fit for you and your family.

Table of Contents

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6 Important Information

11 Online Benefits Enrollment InstructionsInfinityHR

12 MedicalSelectHealth

18 Nebo Health & Wellness Center

20 Health Savings AccountHealthEquity

23 DentalEMI Health

35 VisionEyeMed & VSP

38 Life and AD&DThe Hartford

40 DisabilityThe Hartford

42 VoluntaryMet Life

47 Employee Assistance ProgramBlomquist Hale

49 WellnessNebo School District & Intermountain LiVe Well

53 Premiums

Important InformationNebo School District

Benefits Overview

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Making wise decisions about your benefits requires planning. By selecting benefits thatprovide the best care and coverage, you can optimize their value and minimize the impact toyour budget. The best thing you can do is “shop” for benefits carefully, using the same typeof decision-making process you use for other major purchases.

1. Take advantage of the tools available to you. That includes this guide, access to planinformation, provider directories, and enrollment materials.

2. Be a smart shopper. If you were buying a car or purchasing a home, you would do a lot ofresearch beforehand. You should do the same for benefits because the wrong decisioncould be costly.

3. Don’t miss the deadline and keep record of your enrollment! Pay attention to theenrollment deadline and be sure to provide Human Resources with your benefit electionsin a timely manner. It is important to review your paycheck to ensure the accuracy ofpayroll deductions. Notify HR immediately if there are any discrepancies.

Who Is Eligible?Please see the eligibility guidelines on the following page.

How We Define Medical Benefits EligibilityWe are a large employer according to the Employer Shared Responsibility provisions of theACA. The enrollment guidelines listed in this guide may vary if you are hired to work less than30 hours per week (130 hours per month) or your hours worked drop below the threshold.Please contact us for our complete policy on Measurement Methods to determine full-timebenefits eligibility status under the Employer Shared Responsibility.

When Do I Enroll?You can enroll for coverage within 30 days of your date of hire, or during the annual openenrollment period. Outside of your open enrollment period, the only time you can changeyour coverage is within 30 days after you experience a qualifying event.

Benefits Overview

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You are eligible for benefits if you fall into one of the following classes:

Medical Plan• Active CERTIFIED employees working 20 or more hours per week• Active CLASSIFIED employees hired prior to July 1, 2013 and working 30 or more hours per

week• Active CLASSIFIED employees hired July 1, 2013 through February 7, 2018 and working 30 or

more hours per week• Active CLASSIFIED employees hired February 8, 2018 or later and working 30 or more hours

per week are eligible for a family base medical plan under ACA. Plan premium is proratedbased on hours and capped at $90 per month for a single plan.

• Active CLASSIFIED BUS DRIVERS hired July 1, 2013 or later and working 30 or more hoursper week

Long-Term Disability Plan• Active CERTIFIED employees working 20 or more hours per week• Active CLASSIFIED employees hired prior to July 1, 2013 and working 20 or more hours per



per week• Active CLASSIFIED BUS DRIVERS hired July 1, 2013 or later and working 30 or more hours

per week

The Hartford Life Insurance• Active CERTIFIED employees working 20 or more hours per week• Active CLASSIFIED employees hired prior to July 1, 2013 and working 20 or more hours per



per week• Active CLASSIFIED BUS DRIVERS hired July 1, 2013 or later and working 30 or more hours

per week

Coverage will begin on the first of the month following date of hire. Eligible dependentsinclude your legal spouse and your natural, adopted or step-child(ren). The dependent agelimit for children on your plan is age 26.

Benefits Overview

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Making Changes During The YearThe IRS provides strict regulations about the changes to pre-tax elections during the planyear. Once you enroll in benefits, you will not be able to make any changes to your electionsuntil the next annual open enrollment period, unless you experience a qualified life event.

Qualified life events include, but are not limited to:• Change in your legal marital status• Change in number of dependents• A dependent no longer meets the eligibility requirements• You and/or your dependent becomes eligible or loses eligibility for Medicare, Medicaid or

the Children’s Health Insurance Program (CHIP)• Employee or dependents change in employment status resulting in loss or gain of

eligibility for employer sponsored benefits• A court or administrative order

It is your responsibility to notify Human Resources within 30 days after a qualified life event.Any benefit changes must be directly related to the qualified life event.

When Coverage EndsFor most benefits, coverage will end on the last day of the month in which:• Your regular work schedule is reduced to fewer than 30 hours per week• Your employment with Nebo School District ends

Your dependent(s) coverage ends:• When your coverage ends, or• The last day of the month in which the dependent is no longer eligible

Important Information

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GoodRx Comparison ToolStop paying too much for your prescriptions! With the GoodRx Comparison Tool, you cancompare drug prices at over 70,000 pharmacies, and discover free coupons and savings tips.

Isn’t health insurance all I need? Your health insurance provides valuable prescription andother health benefits, but a smart consumer can save much more, especially for drugs thatare not covered by health insurance (weight-loss medications, some antihistamines, etc.),drugs that have limited quantities, drugs that can be found for less than your copay, or drugswith a lower priced generic.

How can I find these savings? The GoodRx Comparison Tool provides you with instant accessto current prices on more than 6,000 drugs at virtually every pharmacy in America.

1. On the web: https://www.goodrx.com/ Instantly look up current drug prices at CVS,Walgreens, Walmart, Costco, and other local pharmacies.

2. On your phone: Available in the App Store or Google Play. Or, simply visit m.goodrx.comfrom your phone.

Please Note:• Prescription drug pricing displayed on the GoodRx Comparison Tool may be more or

less than your insurance drug card.• Please be sure to compare all discount pricing options before you purchase.• Check your insurance carrier’s pharmacy benefit before purchasing a 90 day supply.

Health Care Reform And YouFor the most up-to-date information regarding the ACA, please visit www.healthcare.gov.

Summary of Benefits and Coverage (SBC) and Uniform GlossaryIn addition to the plan information in this Benefits Guide, you can also review a Summary ofBenefits and Coverage for each medical plan. This requirement of the ACA standardizeshealth plan information so that you can better understand and compare plan features. Wewill automatically provide you a copy of the SBC and Uniform Glossary annually during openenrollment. Please contact HR should you need an additional copy.

Please follow the simple steps below to elect or waive coverage for the current plan year. Beforeyou begin, you will need to have the following information: You/your dependent(s) names, socialsecurity number(s), dates(s) of birth and home address.

Step 1 – Getting Started• In your web browser type www.infinityhr.com in the address bar.• Click “First time user? Forgot or want to Reset your password?”• Validate your identity by entering your Date of Birth and SSN then click “Find my Record.”• Enter a new password and make note of it for your records, then click create new password.• Enter your User ID and Password then click log in.

• Your User ID is: [lower case last name][Employee ID]• For Example: Name John Doe, Employee ID 9999, User ID = d9999

• On the home screen look for Change Events.• Select the event available, which should be “Open Enrollment,” then click “Begin Event.”

o If enrolling outside of Open Enrollment, select the options that are appropriate such as, New Hire or Marriage.

Step 2 – Verify Your Personal and Dependent Information• Verify your Personal Information• If you need to add or make a change click on “edit personal information” and make updates,

then click “Save Information”• Once you have verified that everything is correct click “Save & Continue”.• If you need to add a dependent click “Add Dependent” or if you need to change a dependent’s

information click “Edit” then add/update the information and click “Save Information”.• Once all of your dependents have been added/updated, click “Save & Continue”.

o If your spouse will be enrolled in coverage they are considered a dependent forinsurance purposes.

o Please Note: If you plan on enrolling in Spouse Life Insurance or Child Life Insurance,you need to add your spouse and children as dependents on this screen.

Step 3 – Make Your Open Enrollment Elections• Follow the enrollment wizard through each step of the enrollment process and elect or decline

each benefit. • Please Note: As you elect plans, your dependents will appear at the bottom of the screen.

Please remove the check mark from the box if you do not want a dependent covered on that specific plan.

• Click “Save & Continue” to continue navigating through the system.

Step 4 – Confirm Your Elections• After you have made all of your elections you will be at the Review Tab. • Review the benefit elections for yourself and your dependents to ensure accuracy. • Click “Save & Confirm”. • The Enrollment Confirmation Statement will be emailed to you.

Online Benefits Enrollment

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MedicalSelectHealth

Base Plan Option Plan

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MedicalSelectHealth

Plan Features Share Base Plan Share Option Plan

In-Network Only In-Network Only

Deductible $2,700/person$5,400/family

$1,600/single$3,200/family

Out-of-Pocket Maximum $3,700/person$7,400/family

$3,250/single$6,500/family

Preventive Care Covered in Full Covered in Full

Office VisitsPrimary CareSpecialistUrgent CareIntermountain Connect Care

20% AD20% AD20% AD20% AD

20% AD20% AD20% AD20% AD

Hospital ServicesInpatientOutpatient

20% AD20% AD

20% AD20% AD

Emergency Room 20% AD 20% AD

Mental Health ServicesOffice VisitInpatientOutpatient

20% AD20% AD20% AD

20% AD20% AD20% AD

Pharmacy Retail 30 day supply

Mail Order 90 day supply

Retail 30 day supply


Tier 1Tier 2Tier 3Tier 4

$10 AD$25 AD$50 AD$100 AD

$10 AD$50 AD$150 AD

N/A

$10 AD$25 AD$50 AD$100 AD

$10 AD$50 AD$150 AD

N/APreventive MaintenanceTier 1Tier 2Tier 3Tier 4

$10$25$50$100

$10$50$100N/A

$10$25$50$100

$10$50$150N/A

AD = After Deductible

MedicalSelectHealth

Dual Employee Base Plan Dual Employee Option Plan

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MedicalSelectHealth

Plan Features Dual Employee Share Base Plan

Dual Employee Share Option Plan

In-Network Only In-Network Only

Deductible $2,700/person$5,400/family $3,200/family

Out-of-Pocket Maximum $2,700/person$5,400/family $3,200/family

Preventive Care Covered in Full Covered in Full

Office VisitsPrimary CareSpecialistUrgent CareIntermountain Connect Care

Covered in Full ADCovered in Full ADCovered in Full ADCovered in Full AD

Covered in Full ADCovered in Full ADCovered in Full ADCovered in Full AD

Hospital ServicesInpatientOutpatient

Covered in Full ADCovered in Full AD

Covered in Full ADCovered in Full AD

Emergency Room Covered in Full AD Covered in Full AD

Mental Health ServicesOffice VisitInpatientOutpatient

Covered in Full ADCovered in Full ADCovered in Full AD

Covered in Full ADCovered in Full ADCovered in Full AD

Pharmacy Retail 30 day supply


Retail 30 day supply


Tier 1Tier 2Tier 3Tier 4

Covered in Full AD

for all tiers

Covered in Full AD

for all tiers

Covered in Full AD

for all tiers

Covered in Full AD

for all tiers

Preventive MaintenanceTier 1Tier 2Tier 3Tier 4

Covered in Full for all tiers




AD = After Deductible

SelectHealth Share

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Welcome to SelectHealth Share, let’s get started on your journey to better healthcare!As part of SelectHealth Share, there are several, what we call, engagements that are required.You’re going to hear this word a lot now that you’re part of team Share. There are twodifferent time frames in which you must complete your engagements. The first 90 days andthe first nine months of your plan year.

Now, we don’t expect you to remember everything you have to do. That’s why we’ve created achecklist. Keep it handy and check things off as you complete them. And you know what? Asyou complete each of these, you will be on your way to living your healthiest life possible. Andthat’s the whole point! So, let’s dig in. Read about each of the engagements, and rememberto complete them on time!

SelectHealth Share Network Service AreaSelectHealth Share members have access to 5,100+ participating providers, including manyIntermountain Medical Group physicians and thousands more affiliated providers.Additionally, you can use 20 Intermountain Healthcare hospitals in Utah, including:

• Cedar City Hospital• Heber Valley Hospital• Logan Regional Hospital• Park City Hospital• Primary Children’s

Hospital• Intermountain Medical

Center

• The Orthopedic Specialty Hospital (TOSH)

• Utah Valley Hospital• McKay-Dee Hospital• Dixie Regional Medical

Center• Mountain West Medical

CenterDon’t see your hospital? Visit selecthealth.org/providers to see all the

hospitals included on SelectHealth Share.

SelectHealth also includes: Intermountain Health Answers – a 24/7 nurse line that allows you to speak to a registered

nurse who will listen to your concerns, answer your medical questions, and help you decidewhat course of action to take. All you need is your phone.

Intermountain Connect Care – use your computer, tablet, or phone to video connect with adoctor or nurse practitioner anytime (24/7 access). Visit intermountainconnectcare.org ordownload the ConnectCare app. It’s a great option for colds, sore throats, earaches, andmore.

Intermountain InstaCare/KidsCare – They’re open late – and are a great choice for sorethroats, broken bones, sprains, and other urgent medical conditions. With nearly 40locations, there’s a site near you. Use our app to reserve your spot in line!

SelectHealth Share

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Your First Ninety DaysCreate an online My Health account. This is key to accessingyour Healthy Living tools and tracking your engagements.It’s your health hub.

Pick your Primary Care Provider (PCP). Once you chooseyour doctor, make sure to tell us via My Health or by callingMember Services at 800-538-5038. Establishing a PCP iscritical. From getting care quickly when you need it toreferrals, your PCP is your #1.

Attend a work-site health screening event or obtain thescreening from a physician. This is how we establish yourhealth baseline and figure out the best plan for you.

Complete the annual online health assessment on theHealthy Living website (via your My Health account). Yourassessment can identify health risks so you can addressthose risks sooner rather than later.

Establish and contribute to a Health Savings Account(HSA). This is for those of you who have a high-deductiblehealth plan and contribute at least 25 percent of yourannual deductible. Consider this your health bucks account –a real lifesaver if you need it.

Your First Nine MonthsComplete at least one digital coaching program. Receivetips and resources on improving any health issues – and hey,we all have at least one. Go to My Health, then find “DigitalCoaching” in the Healthy Living section of your dashboard.

Get moving with Virgin Pulse. This is a two-partengagement. First, create a Virgin Pulse account. This iswhere we track your activity. Then, complete at least two ofthe wellness/activity campaigns. Keep in mind, companyteam challenges, 7,000 steps in 20 days, or Healthy HabitsChallenges all count as activity campaigns.

A Few ExtrasFor employees who have a condition, or are of a specific age and/or gender, there are a few special engagements that will help you feel your best. And because we care, these are also required.

Complete age and gender based screenings.

• Women age 42 – 69 – one mammogram every two years

• Women age 24 – 64 – one pap test every three years

• Men & women age 51 – 80 – one colonoscopy every 5 years, or other colorectal cancer screening every 1 – 5 years

Complete prediabetes education.

If your health screening/assessment indicates you have prediabetes, you will need to complete prediabetes education and health coaching. Plus, we’ll reward you for improving your health with Healthy Rewards Visa cash cards.

Participate in Disease Management

If you have asthma, diabetes, Chronic Obstructive Pulmonary Disease (COPD), or heart failure, you need to work with a SelectHealth care manager. Plus, we’ll reward you for improving your health with Healthy Rewards Visa cash cards.

Health Savings AccountHealthEquity

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A Health Savings Account (HSA) paired with our qualified high deductible health plan helpsyou and your family plan, save and pay for qualified health care expenses. An HSA empowersyou to build savings for health care expenses in a tax advantaged account.

About Health Savings AccountsA Health Savings Account (HSA) is a tax advantaged savings account that you own andcontrol. HSAs are similar to retirement accounts in that they rollover year-to-year, they areportable when you move jobs or retire, the balance can be invested in mutual funds, andthere are survivor benefits.

Who Is Eligible?You must be enrolled in our qualified high deductible health plan and meet the followingrequirements:

• Have no other health insurance coverage except what’s permitted by the IRS• Not be enrolled in Medicare• Not be claimed as a dependent on someone else’s tax return

What Is A Qualified Health Care Expense?You can use money in your HSA to pay for any qualified health care expenses for you, yourspouse and your tax dependents, even if they are not covered on your plan. Examples ofqualified health care expenses include: your insurance plan deductibles, copayments, andcoinsurance; doctor’s office visits; prescriptions; dental treatments and x-rays; andeyeglasses and vision exams.

How Much Can I Contribute To A HSA?Each year the IRS establishes the maximum contribution limit. The chart below representsthe limits for 2020. These limits are for the total funds contributed, including companycontributions, your contributions and any other contributions. Please keep in mind you canchange your HSA allocation at any time during the plan year.

HSA Contribution Limits

IRS HSA Contribution Limits for 2020

Employee Only $3,550Employee + One $7,100Family $7,100

At age 55, an additional $1,000 contribution is allowed annually

Health Savings AccountHealthEquity

Qualified Health Care ExpensesYou can use money in your HSA to pay for any qualified health care expenses you, your legalspouse and your tax dependents incur, even if they are not covered on your plan. Qualifiedhealth care expenses are designated by the IRS (Publication 502). They include medical,dental, vision and prescription expenses not covered by the insurance carrier.

Qualified expenses include, but are not limited to:• Acupuncture• Alcoholism (rehab)• Ambulance• Amounts not covered under

another health plan• Annual physical

examination• Artificial limbs• Birth control

pills/prescription contraceptives

• Body scans• Post-mastectomy breast

reconstruction surgery

• Chiropractor• Contact lenses• Crutches• Dental treatments• Eyeglasses/eye surgery• Hearing aids• Long-term care expenses• Medicines (prescribed)• Nursing home medical care• Nursing services• Optometrist• Lasik surgery• Orthodontia

• Oxygen• Stop-smoking programs• Surgery, other than

unnecessary cosmetic surgery

• Telephone equipment for the hearing-impaired

• Therapy• Transplants• Weight-loss program

(prescribed)• Wheelchairs• Wigs (prescribed)

Non-qualified expenses include any expenses incurred before you establish your HSA. Other non-qualified expenses include, but are not limited to:• Concierge services• Dancing lessons• Diaper service• Elective cosmetic surgery• Electrolysis or hair removal

• Funeral Expenses• Future medical care• Hair transplants• Health club dues• Insurance premiums*

• Medicines and drugs from other countries

• Non-prescription drugs (other than insulin)

• Teeth whiteningThe following insurance premiums may be reimbursed from your HSA:• COBRA premiums• Health insurance premiums while receiving unemployment benefits• Qualified long-term care premiums• Medicare premiums (Parts A, B, C, etc.)

Documentation is KeyAn HSA can be used for a wide range of health care services within the limits established by law.Be sure you understand what expenses are HSA qualified, and be able to produce receipts forthose items or services that you purchase with your HSA. You must keep records sufficient toshow that:

• The distributions were exclusively to pay or reimburse qualified medical expenses,• The qualified expenses had not been previously paid or reimbursed from another source,

and• The qualified expense had not been taken as an itemized deduction in any year.

Do not send these records with your tax return. Keep them with your tax records.

Health Savings Account

› ImportantAny funds you withdraw for non-qualified expenses will be taxed at your income tax rate plus a20% tax penalty if you're under age 65. After age 65, you pay taxes but no penalty.

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DentalEMI Health

2 4

DentalEMI Health

Advantage Plus PPO Plan

Plan Features In-Network Out-of-Network

Deductiblewaived for Preventive Services and Orthodontics

No Deductible

Annual Maximum No Annual Maximum

Type 1 – Preventive Servicesx-rays, cleanings, exams

100% No Coverage

Type 2 – Basic Servicesfillings, extractions, root canals

See Member Schedule Discount Only No Coverage

Type 3 – Major Servicesdentures, crowns, bridges

See Member Schedule Discount Only No Coverage

Type 4 – Orthodonticsfor adults and children

25% Discount Only No Coverage

Orthodontic Lifetime Maximum No Maximum

Advantage Plus 100 (Utah)Schedule of Member Fees

Effective 1/1/2019Corporate (801)262-7475 Customer Service (800)662-5851

emihealth.com

CDT CDT Name Member Fee

D0120 PERIODIC ORAL EVALUATION - EST PATIENT 0D0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED 0D0145 ORAL EVAL PT UND 3 YR AGE CNSL W/PRIM CAREGIVER 0D0150 COMP ORAL EVALUATION - NEW OR EST PATIENT 0D0160 DTL&EXT ORAL EVALUATION - PROBLEM FOCUSED REPORT 0D0170 RE-EVALUATION - LIMITED PROBLEM FOCUSED 0D0180 COMP PERIODONTAL EVALUATION - NEW OR EST PATIENT 0D0210 INTRAORAL-COMPLETE SERIES OF RADIOGRAPHIC IMAGES (Including bitewings) 0D0220 INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE 0D0230 INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM 0D0240 INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE 0D0250 EXTRAORAL - 2D PROJECTION RADIOGRAPHIC IMAGE 0D0251 EXTRA-ORAL POSTERIOR DENTAL RADIOGRAPHIC IMAGE 0D0270 BITEWING - SINGLE RADIOGRAPHIC IMAGE 0D0272 BITEWINGS - TWO RADIOGRAPHIC IMAGES 0D0273 BITEWINGS - THREE RADIOGRAPHIC IMAGES 0D0274 BITEWINGS - FOUR RADIOGRAPHIC IMAGES 0D0277 VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGES 0D0330 PANORAMIC RADIOGRAPHIC IMAGE 0D0340 2D CEPHALOMETRIC RADIOGRAPHIC IMAGE - ACQUISITION MEASUREMENT AND ANALYSIS 50D0460 PULP VITALITY TESTS 25D1110 PROPHYLAXIS - ADULT 0D1120 PROPHYLAXIS - CHILD 0D1206 TOPICAL APPLICATION OF FLUORIDE VARNISH (*Only allowed if patient is under age 16) 0D1208 TOPICAL APPLICATION OF FLUORIDE EXCL VARNISH (*Only allowed if patient is under age 16) 0D1351 SEALANT - PER TOOTH (*Only allowed if patient is under age 16) 19D1352 PREV RSN REST MOD HIGH CARIES RISK PT-PERM TOOTH (*Only allowed if patient is under age 16) 26D1353 SEALANT REPAIR PER TOOTH (*Only allowed if patient is under age 16) 26D1510 SPACE MAINTAINER - FIXED - UNILATERAL (*Only allowed if patient is under age 16) 98D1516 SPACE MAINTAINER - FIXED - BILATERAL, MAXILLARY (*Only allowed if patient is under age 16) 137D1517 SPACE MAINTAINER - FIXED - BILATERAL, MANDIBULAR (*Only allowed if patient is under age 16) 137D1520 SPACE MAINTAINER - REMOVABLE - UNILATERAL (*Only allowed if patient is under age 16) 108D1526 SPACE MAINTAINER - REMOVABLE - BILATERAL, MAXILLARY (*Only allowed if patient is under age 16) 166D1527 SPACE MAINTAINER - REMOVABLE - BILATERAL, MANDIBULAR (*Only allowed if patient is under age 16) 166D1550 RECMNT/REBND OF SPACE MAINTAINER (*Only allowed if patient is under age 16) 21D1555 REMOVAL OF FIXED SPACE MAINTAINER (*Only allowed if patient is under age 16) 25D1575 DISTAL SHOE SPACE MAINTAINER - FIXED UNILATERAL (*Only allowed if patient is under age 16) 98D2140 AMALGAM - ONE SURFACE PRIMARY OR PERMANENT 45D2150 AMALGAM - TWO SURFACES PRIMARY OR PERMANENT 59D2160 AMALGAM - THREE SURFACES PRIMARY OR PERMANENT 70D2161 AMALGAM-FOUR/MORE SURFACES PRIMARY/PERMANENT 80D2330 RESIN-BASED COMPOSITE - ONE SURFACE ANTERIOR 71D2331 RESIN-BASED COMPOSITE - TWO SURFACES ANTERIOR 81D2332 RESIN-BASED COMPOSITE - THREE SURFACES ANTERIOR 96D2335 RESIN-BASED COMPOSITE 4/> SURFACES INCISAL ANGLE 107D2390 RESIN-BASED COMPOSITE CROWN ANTERIOR 110D2391 RESIN-BASED COMPOSITE - ONE SURFACE POSTERIOR 69D2392 RESIN-BASED COMPOSITE - TWO SURFACES POSTERIOR 91D2393 RESIN-BASED COMPOSITE - THREE SURFACES POSTERIOR 111D2394 RESIN COMPOS - FOUR OR MORE SURFACES POSTERIOR 120D2542 ONLAY - METALLIC - TWO SURFACES 309D2543 ONLAY - METALLIC - THREE SURFACES 323D2544 ONLAY - METALLIC - FOUR OR MORE SURFACES 336D2610 INLAY - PORCELAIN/CERAMIC - ONE SURFACE 391D2620 INLAY - PORCELAIN/CERAMIC - TWO SURFACES 412D2630 INLAY - PORCELAIN/CERAMIC - THREE/MORE SURFACES 439D2642 ONLAY - PORCELAIN/CERAMIC - TWO SURFACES 310D2643 ONLAY - PORCELAIN/CERAMIC - THREE SURFACES 360D2644 ONLAY - PORCELAIN/CERAMIC - 4 OR MORE SURFACES 390D2650 INLAY - RESIN-BASED COMPOSITE - ONE SURFACE 257D2651 INLAY - RESIN-BASED COMPOSITE - TWO SURFACES 306D2652 INLAY RESIN BASED COMPOSITE 3 OR MORE SURFACES 321D2662 ONLAY - RESIN-BASED COMPOSITE - TWO SURFACES 279D2663 ONLAY - RESIN-BASED COMPOSITE - THREE SURFACES 335D2664 ONLAY RESIN BASED COMPOSIT FOUR OR MORE SURFACES 340D2710 CROWN - RESIN-BASED COMPOSITE (INDIRECT) 141D2712 CROWN 3/4 RESIN-BASED COMPOSITE (INDIRECT) 189D2720 CROWN - RESIN WITH HIGH NOBLE METAL 500D2721 CROWN - RESIN WITH PREDOMINANTLY BASE METAL 500D2722 CROWN - RESIN WITH NOBLE METAL 500D2740 CROWN - PORCELAIN/CERAMIC 610D2750 CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL 555D2751 CROWN - PORCELAIN FUSED PREDOMINANTLY BASE METAL 510D2752 CROWN - PORCELAIN FUSED TO NOBLE METAL 510D2780 CROWN - 3/4 CAST HIGH NOBLE METAL 510D2781 CROWN - 3/4 CAST PREDOMINANTLY BASE METAL 475D2782 CROWN - 3/4 CAST NOBLE METAL 475D2783 CROWN - 3/4 PORCELAIN/CERAMIC 500D2790 CROWN - FULL CAST HIGH NOBLE METAL 518D2791 CROWN - FULL CAST PREDOMINANTLY BASE METAL 475D2792 CROWN - FULL CAST NOBLE METAL 475D2910 RECMNT/REBND INLAY ONLAY/PART CVRGE RESTORATION 38D2915 RECMNT/REBND CAST OR PREFABRICATED POST AND CORE 27D2920 RE-CEMENT OR RE-BOND CROWN 32


D2929 PREFABR STAINLESS PORC CROWN - PRIMARY TOOTH 159D2930 PREFABR STAINLESS STEEL CROWN - PRIMARY TOOTH 93D2931 PREFABR STAINLESS STEEL CROWN - PERMANENT TOOTH 100D2932 PREFABRICATED RESIN CROWN 104D2933 PREFABR STAINLESS STEEL CROWN W/RESIN WINDOW 120D2934 PREFAB ESTHETIC COAT STNLESS STEEL CROWN PRIM 120D2940 PROTECTIVE RESTORATION 33D2950 CORE BUILDUP INCLUDING ANY PINS WHEN REQUIRED 101D2951 PIN RETENTION - PER TOOTH ADDITION RESTORATION 20D2952 POST AND CORE ADDITION TO CROWN INDIRECTLY FAB 112D2953 EACH ADDITIONAL INDIRECTLY FAB POST SAME TOOTH 56D2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN 104D2955 POST REMOVAL 85D2957 EACH ADDITIONAL PREFABRICATED POST - SAME TOOTH 45D2960 LABIAL VENEER (RESIN LAMINATE) - CHAIRSIDE 20% DiscountD2961 LABIAL VENEER (RESIN LAMINATE) - LABORATORY 20% DiscountD2962 LABIAL VENEER (PORCELAIN LAMINATE) - LABORATORY 20% DiscountD2980 CROWN REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 52D2981 INLAY REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 76D2982 ONLAY REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 76D2983 VENEER REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 20% DiscountD3110 PULP CAP - DIRECT (Excluding final restoration) 30D3120 PULP CAP - INDIRECT (Excluding final restoration) 26D3220 TX PULP-REMV PULP CORONAL DENTINOCEMENTL JUNC 62D3221 PULPAL DEBRIDEMENT PRIMARY AND PERMANENT TEETH 62D3230 PULPAL THERAPY - ANTERIOR PRIMARY TOOTH (Excluding final restoration) 60D3240 PULPAL THERAPY - POSTERIOR PRIMARY TOOTH (Excluding final restoration) 62D3310 ENDODONTIC THERAPY ANTERIOR TOOTH (Excluding final restoration) 295D3320 ENDODONTIC THERAPY PREMOLAR TOOTH (Excluding final restoration) 365D3330 ENODODONTIC THERAPY MOLAR TOOTH (Excluding final restoration) 450D3331 TREATMENT RC OBSTRUCTION; NON-SURGICAL ACCESS 90D3332 INCOMPLETE ENDO TX; INOP UNRESTORABLE/FX TOOTH 171D3333 INTERNAL ROOT REPAIR OF PERFORATION DEFECTS 109D3346 RETREATMENT PREVIOUS RC THERAPY - ANTERIOR 321D3347 RETREATMENT PREVIOUS RC THERAPY - PREMOLAR 378D3348 RETREATMENT PREVIOUS ROOT CANAL THERAPY - MOLAR 468D3351 APEXIFICATION/RECALCIFICAT INIT VST 172D3352 APEXIFICAT/RECALCIFICAT INT MED REPL 60D3353 APEXIFICATION/RECALCIFICATION - FINAL VISIT 237D3410 APICOECTOMY - ANTERIOR 386D3421 APICOECTOMY - PREMOLAR (FIRST ROOT) 383D3425 APICOECTOMY - MOLAR (FIRST ROOT) 388D3426 APICOECTOMY (EACH ADDITIONAL ROOT) 135D3430 RETROGRADE FILLING - PER ROOT 95D3450 ROOT AMPUTATION - PER ROOT 163D3920 HEMISECTION NOT INCLUDING ROOT CANAL THERAPY 140D3950 CANAL PREPARATION&FITTING PREFORMED DOWEL/POST 88D4210 GINGIVECT/PLSTY 4/>CNTIG/TOOTH BOUND SPACES-QUAD 238D4211 GINGIVECT/PLSTY 1-3 CNTIG/TOOTH BOUND SPACE-QUAD 90D4212 GINGIVECT/PLSTY TO ALLOW ACCESS FOR RESTORATIVE PROCEDURE PER TOOTH 106D4240 GINGL FLP PROC 4/> CONTIG/TOOTH BOUND SPACE-QUAD 256D4241 GINGL FLP PROC 1-3 CONTIG/TOOTH BOUND SPACE-QUAD 177D4245 APICALLY POSITIONED FLAP 254D4249 CLINICAL CROWN LENGTHENING - HARD TISSUE 280D4260 OSSEOUS SURG 4/> CNTIG TEETH QUAD 426D4261 OSSEOUS SURG 1-3 CNTIG TEETH QUAD 273D4263 BONE REPLACEMENT GRAFT - FIRST SITE IN QUADRANT 211D4264 BONE REPLACEMENT GRAFT - EA ADD SITE QUADRANT 130D4265 BIOLOGIC MATERIALS AID SOFT&OSSEOUS TISSUE REGEN 275D4266 GUID TISSUE REGEN - RESORBABLE BARRIER PER SITE 208D4267 GUID TISSUE REGEN - NONRESORB BARRIER PER SITE 202D4268 SURGICAL REVISION PROCEDURE PER TOOTH 243D4270 PEDICLE SOFT TISSUE GRAFT PROCEDURE 303D4273 AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE (INCLUDING DONOR AND RECIPIENT SURGICAL SITE 440D4274 MESIAL/DISTAL WEDGE PROCEDURE SINGLE TOOTH 180D4275 NON-AUTOGENOUS CONNECTIVE TISSUE GRAFT (INCLUDING RECIPIENT SURGICAL SITE AND DONOR MATER 310D4276 COMB CNCTIVE TISSUE&DBL PEDICLE GRAFT PER TOOTH 415D4277 SOFT TISSUE GRAFT PROCEDURE FIRST TOOTH 334D4278 SOFT TISSUE GRAFT PROCEDURE EACH ADD TOOTH 200D4283 AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE (INCLUDING DONOR AND RECIPIENT SURGICAL SITE 397D4285 NON-AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE (INCLUDING RECIPIENT SURGICAL SITE AND DO 298D4320 PROVISIONAL SPLINTING - INTRACORONAL 141D4321 PROVISIONAL SPLINTING - EXTRACORONAL 128D4341 PRDONTAL SCALING&ROOT PLANING 4/MORE TEETH-QUAD 106D4342 PRDONTAL SCALING&ROOT PLANING 1-3 TEETH-QUAD 71D4346 SCALING IN PRESENCE OF GENERALIZED MODERATE OR SEVERE GINGIVAL INFLAMMATION 106D4355 FULL MOUTH DEBRID ENABLE COMP ORAL EVALUATION&DX ON A SUBSEQUENT VISIT 72D4381 LOC DEL ANTIMICROBL AGTS CREVICULR TISS TOOTH BR 20% DiscountD4910 PERIODONTAL MAINTENANCE 74D5110 COMPLETE DENTURE - MAXILLARY 690D5120 COMPLETE DENTURE - MANDIBULAR 675D5130 IMMEDIATE DENTURE - MAXILLARY 675D5140 IMMEDIATE DENTURE - MANDIBULAR 675D5211 MAXILLARY PARTIAL DENTURE - RESIN BASE (Including retentive/clasping materials, rests and teeth) 525D5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE (Including retentive/clasping materials, rests and teeth) 525D5213 MAX PART DENTUR-CAST METL FRMEWRK W/RSN BASE 699D5214 MAND PART DENTUR- CAST METL FRMEWRK W/RSN BASE 699D5225 MAXILLARY PARTIAL DENTRUE FLEXIBLE BASE (Including any clasps, rests and teeth) 518D5226 MANDIBULAR PARTIAL DENTURE FLEXIBLE BASE (Including any clasps, rests and teeth) 511D5282 REMV UNILAT PART DENTUR - 1 PIECE CAST METAL, MAXILLARY (Including any clasps, rests and teeth) 400


D5283 REMV UNILAT PART DENTUR - 1 PIECE CAST METAL, MANDIBULAR (Including any clasps, rests and teeth) 400D5410 ADJUST COMPLETE DENTURE - MAXILLARY 35D5411 ADJUST COMPLETE DENTURE - MANDIBULAR 35D5421 ADJUST PARTIAL DENTURE - MAXILLARY 35D5422 ADJUST PARTIAL DENTURE - MANDIBULAR 35D5511 REPAIR BROKEN COMPLETE DENTURE BASE, MANDIBULAR 75D5512 REPAIR BROKEN COMPLETE DENTURE BASE, MAXILLARY 75D5520 REPLACE MISSING/BROKEN TEETH - COMPLETE DENTURE (Each tooth) 65D5611 REPAIR RESIN PARTIAL DENTURE BASE, MANDIBULAR 53D5612 REPAIR RESIN PARTIAL DENTURE BASE, MAXILLARY 53D5621 REPAIR CAST PARTIAL FRAMEWORK, MANDIBULAR 57D5622 REPAIR CAST PARTIAL FRAMEWORK, MAXILLARY 57D5630 REPAIR OR REPLACE BROKEN RETENTIVE/CLASPING MATERIALS - PER TOOTH 69D5640 REPLACE BROKEN TEETH - PER TOOTH 52D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE 61D5660 ADD CLASP TO EXISTING PARTIAL DENTURE 100D5710 REBASE COMPLETE MAXILLARY DENTURE 294D5711 REBASE COMPLETE MANDIBULAR DENTURE 294D5720 REBASE MAXILLARY PARTIAL DENTURE 250D5721 REBASE MANDIBULAR PARTIAL DENTURE 280D5750 RELINE COMPLETE MAXILLARY DENTURE (LABORATORY) 160D5751 RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY) 160D5760 RELINE MAXILLARY PARTIAL DENTURE (LABORATORY) 157D5761 RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY) 157D5810 INTERIM COMPLETE DENTURE (MAXILLARY) 295D5811 INTERIM COMPLETE DENTURE (MANDIBULAR) 295D5820 INTERIM PARTIAL DENTURE (MAXILLARY) 223D5821 INTERIM PARTIAL DENTURE (MANDIBULAR) 223D5850 TISSUE CONDITIONING MAXILLARY 50D5851 TISSUE CONDITIONING MANDIBULAR 50D5863 OVERDENTURE - COMPLETE MAXILLARY 20% DiscountD5864 OVERDENTURE - PARTIAL MAXILLARY 20% DiscountD5876 ADD METAL SUBSTRUCTURE TO ACRYLIC FULL DENTURE (PER ARCH) 50D5899 UNS REMOVABLE PROSTHODONTIC PROCEDURE REPORT 150D6010 SURG PLACEMENT IMPLANT BODY: ENDOSTEAL IMPLANT 1186D6012 SURG PLCMT INTERIM IMPL TRNSITIONL PROS: ENDOS 1083D6040 SURGICAL PLACEMENT: EPOSTEAL IMPLANT 2567D6050 SURGICAL PLACEMENT: TRANSOSTEAL IMPLANT 1915D6055 CONNECTING BAR IMPLANT OR ABUTMENT SUPPORTED 291D6056 PREFABRICATED ABUTMENT INCLUDES PLACEMENT 220D6057 CUSTOM FABRICATED ABUTMENT INCLUDES PLACEMENT 350D6058 ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN 634D6059 ABUT SUPP PORCELAIN TO METL CROWN HI NOBLE METL 610D6060 ABUT SUPP PORCELAIN TO MTL CROWN PREDOM BASE MTL 527D6061 ABUT SUPP PORCELAIN TO METAL CROWN NOBLE METAL 538D6062 ABUTMENT SUPP CAST METAL CROWN HIGH NOBLE METAL 491D6063 ABUTMENT SUPP CAST METAL CROWN PREDOM BASE METAL 499D6064 ABUTMENT SUPP CAST METAL CROWN NOBLE METAL 488D6065 IMPL SUPP PORCELAIN/CERAMIC CROWN 556D6066 IMPL SUPP PORCLN FUSED METL CRWN TITNM/HIGH NOBL 542D6067 IMPL SUPP METAL CROWN TITIANM/HIGH NOBLE METL 526D6068 ABUT SUPP RETAINER PORCELAIN/CERAMIC FPD 660D6069 ABUT RETAINR PORCELN TO METL FPD HI NOBL METL 651D6070 ABUT RETN PORCELN TO METL FPD PREDOM BASE METL 615D6071 ABUT SUPP RETN PORCELN FUSD METAL FPD NOBLE METL 628D6072 ABUT SUPP RETN CAST METL FPD HIGH NOBLE METL 641D6073 ABUT RTNR CAST METL FPD PREDOM BASE METL 580D6074 ABUTMENT RTNR CAST METAL FPD NOBLE METAL 625D6075 IMPLANT SUPPORTED RETAINER FOR CERAMIC FPD 649D6076 IMPL SUPP RTNR PORCLN FUSED METL FPD TITNM/HIGH 542D6077 IMPL SUPP RTNR CST METL FPD TITNM/HIGH NOBLE 613D6080 IMPL MAINT PROC REMV CLEAN PROSTH & ABUT REINSRT 41D6091 REPL ATTACHMNT IMPL/ABUT SUPP PROS PER ATTACHMNT 260D6092 RECEMENT / REBOND IMPLANT/ABUTMENT SUPP CROWN 39D6093 RECMNT/REBOND IMPL/ABUTMNT SUPP FIX PART DENTURE 79D6094 ABUTMENT SUPPORTED CROWN TITANIUM 516D6101 DBRDMNT OF PERI-IMPLANT DEFECT 167D6102 DBRDMNT AND OSSEUS CONTOUR OF PERI-IMPLANT DEFECT 274D6103 BONE GRAFT REPAIR OF PERI-IMPLANT 162D6104 BONE GRAFT AT TIME OF IMPLANT PLACEMENT 139D6110 IMPL/ABUTMENT SUPPORTED RD - MAXILLARY 766D6111 IMPL/ABUTMENT SUPPORTED RD - MANDIBULAR 766D6112 IMPL/ABUTMENT SUPPORTED RPD - MAXILLARY 766D6113 IMPLANT / ABUTMENT SUPPORTED RPD - MANDIBULAR 766D6114 IMPLANT / ABUTMENT SUPPORTED FD - MAXILLARY 1342D6115 IMPLANT/ABUTMENT SUPPORTED FD - MANDIBULAR 1342D6116 IMPL/ABUTMENT SUPPORTED FD - MAXILLARY - PARTIAL 1029D6117 IMPL/ABUT SUPPORTED FD - MANDIBULAR - PARTIAL 1029D6190 RADIOGRAPHIC/SURGICAL IMPLANT INDEX BY REPORT 116D6194 ABUTMENT SUPPORTED RETAINER CROWN FOR FPD 532D6205 PONTIC - INDIRECT RESIN BASED COMPOSITE 233D6210 PONTIC - CAST HIGH NOBLE METAL 405D6211 PONTIC - CAST PREDOMINANTLY BASE METAL 350D6212 PONTIC - CAST NOBLE METAL 375D6240 PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL 435D6241 PONTIC - PORCELN FUSED PREDOMINANTLY BASE METAL 430D6242 PONTIC - PORCELAIN FUSED TO NOBLE METAL 420D6245 PONTIC - PORCELAIN/CERAMIC 430D6250 PONTIC - RESIN WITH HIGH NOBLE METAL 415D6251 PONTIC - RESIN WITH PREDOMINANTLY BASE METAL 400


D6252 PONTIC - RESIN WITH NOBLE METAL 385D6600 RETAINER INLAY - PORCELAIN/CERAMIC, TWO SURFACES 321D6601 INLAY - PORCELAIN/CERAMIC THREE OR MORE SURFACES 330D6602 INLAY - CAST HIGH NOBLE METAL TWO SURFACES 336D6603 RETAINER INLAY - CAST HIGH NOBLE METAL, THREE OR MORE SURFACES 360D6604 INLAY - CAST PREDOMINANTLY BASE METAL 2 SURFACES 330D6605 INLAY - CAST PREDOM BASE METAL 3/MORE SURFACES 349D6606 INLAY - CAST NOBLE METAL TWO SURFACES 324D6607 INLAY - CAST NOBLE METAL THREE OR MORE SURFACES 360D6608 ONLAY - PORCELAIN/CERAMIC TWO SURFACES 286D6609 ONLAY - PORCELAIN/CERAMIC THREE OR MORE SURFACES 345D6610 ONLAY - CAST HIGH NOBLE METAL TWO SURFACES 257D6611 ONLAY - CAST HIGH NOBLE METAL 3/MORE SURFACES 282D6612 ONLAY - CAST PREDOMINANTLY BASE METAL 2 SURFACES 256D6613 ONLAY - CAST PREDOM BASE METAL 3/MORE SURFACES 268D6614 ONLAY - CAST NOBLE METAL TWO SURFACES 251D6615 ONLAY - CAST NOBLE METAL THREE OR MORE SURFACES 260D6624 INLAY - TITANIUM 336D6634 ONLAY - TITANIUM 353D6710 RETAINER CROWN - INDIRECT RESIN BASED COMPOSITE 470D6720 CROWN - RESIN WITH HIGH NOBLE METAL 500D6721 CROWN - RESIN WITH PREDOMINANTLY BASE METAL 500D6722 CROWN - RESIN WITH NOBLE METAL 500D6740 CROWN - PORCELAIN/CERAMIC 615D6750 CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL 555D6751 CROWN - PORCELAIN FUSED PREDOMINANTLY BASE METAL 510D6752 CROWN - PORCELAIN FUSED TO NOBLE METAL 510D6780 CROWN - 3/4 CAST HIGH NOBLE METAL 510D6781 CROWN - 3/4 CAST PREDOMINANTLY BASE METAL 475D6782 CROWN - 3/4 CAST NOBLE METAL 475D6783 CROWN - 3/4 PORCELAIN/CERAMIC 500D6790 CROWN - FULL CAST HIGH NOBLE METAL 500D6791 CROWN - FULL CAST PREDOMINANTLY BASE METAL 475D6792 CROWN - FULL CAST NOBLE METAL 475D6930 RECEMENT / REBOND FIXED PARTIAL DENTURE 48D7111 EXTRACTION CORONAL REMNANTS - DECIDUOUS TOOTH 47D7140 EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT (Elevation and/or forceps removal) 66D7210 SURG REMOVAL ERUPTED TOOTH REMV BONE ELEV FLAP 101D7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE 116D7230 REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY 150D7240 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY 176D7241 REMV IMP TOOTH - CMPL BONY W/UNUSUAL SURG COMPS 195D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS 85D7270 TOOTH REIMPL &OR STBL ACC EVULSED/DISPLCD TOOTH 175D7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH 148D7283 PLCMT DEVICE FACILITATE ERUPTION IMPACTED TOOTH 66D7285 BIOPSY OF ORAL TISSUE HARD 200D7286 BIOPSY OF ORAL TISSUE SOFT 155D7287 EXFOLIATIVE CYTOLOGICAL SAMPLE COLLECTION 56D7288 BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION 56D7290 SURGICAL REPOSITIONING OF TEETH 150D7310 ALVEOLOPLASTY W/EXTRACTION 4/> TEETH/SPACE QUAD 98D7311 ALVEOLOPLSTY CONJNC XTRACT 1-3 TEETH/SPACES QUAD 67D7320 ALVEOLOPLASTY NOT W/EXTRACTIONS 4/> TEETH/SPACE 160D7321 ALVEOLOPLSTY NOT CNJNC XTRCT 1-3 TEETH/SPCE QUAD 100D7410 EXCISION OF BENIGN LESION UP TO 1.25 CM 253D7411 EXCISION OF BENIGN LESION GREATER THAN 1.25 CM 400D7471 REMOVAL OF LATERAL EXOSTOSIS 313D7510 INCISION & DRAINAGE ABSCESS-INTRAORAL SOFT TISS 91D7511 I & D ABSCESS INTRAORAL SOFT TISSUE COMPLICATED 137

D7810-D7899 TMD THERAPY 20% DiscountD7952 SINUS AUGMENTATION VIA A VERTICAL APPROACH 297D7960 FRENULECTOMY SEP PROC NOT INCIDENTL ANOTHER PROC 135D7971 EXCISION OF PERICORONAL GINGIVA 74

D8010-D8999 ORTHODONTIC SERVICES 25% DiscountD9110 PALLIATIVE EMERGENCY TX DENTAL PAIN MINOR PROC 40D9120 FIXED PARTIAL DENTURE SECTIONING 20% DiscountD9210 LOCAL ANES-NOT CONJUNCTION W/OP/SURGICAL PROC 15D9215 LOCAL ANESTHESIA CONJUCTION OPERATIVE/SURG PROC 11D9222 DEEP SEDATION/GENERAL ANESTHESIA - FIRST 15 MINUTES 96D9223 DEEP SEDATION/GENERAL ANESTHESIA - EACH SUBSEQUENT 15 MINUTE INCREMENT 72D9230 INHALATION OF NITROUS OXIDE/ANXIOLYSIS ANALGESIA 21D9239 INTRAVENOUS MODERATE (CONSCIOUS) SEDATION/ANESTHESIA - FIRST 15 MINUTES 79D9243 INTRAVENOUS MODERATE (CONSCIOUS) SEDATION/ANESTHESIA - EACH SUBSEQUENT 15 MINUTE INCREMEN 61D9248 NON-INTRAVENOUS CONSCIOUS SEDATION 110D9310 CONSULT DX SERV DENT/PHY NOT REQUESTING DENT/PHY 0D9430 OFFICE VISIT OBSERVATION NO OTHER SRVC PERFORMED 0D9440 OFFICE VISIT - AFTER REGULARLY SCHEDULED HOURS 0D9610 THERAPEUTIC PARENTERAL DRUG SINGL ADMINISTRATION 20% DiscountD9612 TX PARENTERAL DRUGS 2/> ADMINISTRATIONS DIFF MED 20% DiscountD9944 OCCLUSAL GUARD - HARD APPLIANCE, FULL ARCH 155D9945 OCCLUSAL GUARD - SOFT APPLIANCE, FULL ARCH 155D9946 OCCLUSAL GUARD - HARD APPLIANCE, PARTIAL ARCH 155D9951 OCCLUSAL ADJUSTMENT - LIMITED 32D9972 EXTERNAL BLEACHING - PER ARCH 20% DiscountD9973 EXTERNAL BLEACHING - PER TOOTH 20% Discount

2 9

DentalEMI Health

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No Deductible

Annual Maximum No Annual Maximum

Type 1 – Preventive Servicesx-rays, cleanings, exams

100% See Co-Pay Schedule


See Co-Pay Schedule See Co-Pay Schedule


See Co-Pay Schedule See Co-Pay Schedule

Type 4 – Orthodonticsfor adults and children

25% Discount Only No Coverage

Orthodontic Lifetime Maximum No Maximum

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Effective 1/1/2020Corporate (801)262-7475 Customer Service (800)662-5851

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CDT CDT NamePatient Co-Pay (General & Pediatric providers)

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Out-of-Network Claim Payment

D0120 PERIODIC ORAL EVALUATION - EST PATIENT 0 20% Discount 21D0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED 0 20% Discount 18D0145 ORAL EVAL PT UND 3 YR AGE CNSL W/PRIM CAREGIVER 0 20% Discount 19D0150 COMP ORAL EVALUATION - NEW OR EST PATIENT 0 20% Discount 21D0160 DTL&EXT ORAL EVALUATION - PROBLEM FOCUSED REPORT 0 20% Discount 26D0170 RE-EVALUATION - LIMITED PROBLEM FOCUSED 0 20% Discount 19D0180 COMP PERIODONTAL EVALUATION - NEW OR EST PATIENT 0 20% Discount 26D0210 INTRAORAL-COMPLETE SERIES OF RADIOGRAPHIC IMAGES (Including bitewings) 0 20% Discount 38D0220 INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE 0 20% Discount 9D0230 INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM 0 20% Discount 8D0240 INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE 0 20% Discount 12D0250 EXTRAORAL - 2D PROJECTION RADIOGRAPHIC IMAGE 0 20% Discount 14D0251 EXTRA-ORAL POSTERIOR DENTAL RADIOGRAPHIC IMAGE 0 20% Discount 13D0270 BITEWING - SINGLE RADIOGRAPHIC IMAGE 0 20% Discount 10D0272 BITEWINGS - TWO RADIOGRAPHIC IMAGES 0 20% Discount 14D0273 BITEWINGS - THREE RADIOGRAPHIC IMAGES 0 20% Discount 18D0274 BITEWINGS - FOUR RADIOGRAPHIC IMAGES 0 20% Discount 19D0277 VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGES 0 20% Discount 26D0330 PANORAMIC RADIOGRAPHIC IMAGE 0 20% Discount 41D0340 2D CEPHALOMETRIC RADIOGRAPHIC IMAGE - ACQUISITION MEASUREMENT AND ANALYSIS 50 20% Discount 0D0460 PULP VITALITY TESTS 25 20% Discount 0D1110 PROPHYLAXIS - ADULT 0 20% Discount 38D1120 PROPHYLAXIS - CHILD 0 20% Discount 26D1206 TOPICAL APPLICATION OF FLUORIDE VARNISH (*Verify age limits of the plan) 0 20% Discount 14D1208 TOPICAL APPLICATION OF FLUORIDE EXCL VARNISH (*Verify age limits of the plan) 0 20% Discount 9D1351 SEALANT - PER TOOTH (*Verify age limits of the plan) 14 20% Discount 5D1352 PREV RSN REST MOD HIGH CARIES RISK PT-PERM TOOTH (*Verify age limits of the plan) 26 20% Discount 0D1353 SEALANT REPAIR PER TOOTH (*Verify age limits of the plan) 26 20% Discount 0D1510 SPACE MAINTAINER - FIXED - UNILATERAL - PER QUADRANT (*Verify age limits of the plan) 98 20% Discount 0D1516 SPACE MAINTAINER - FIXED - BILATERAL, MAXILLARY (*Verify age limits of the plan) 137 20% Discount 0D1517 SPACE MAINTAINER - FIXED - BILATERAL, MANDIBULAR (*Verify age limits of the plan) 137 20% Discount 0D1520 SPACE MAINTAINER - REMOVABLE - UNILATERAL - PER QUADRANT (*Verify age limits of the plan) 108 20% Discount 0D1526 SPACE MAINTAINER - REMOVABLE - BILATERAL, MAXILLARY (*Verify age limits of the plan) 166 20% Discount 0D1527 SPACE MAINTAINER - REMOVABLE - BILATERAL, MANDIBULAR (*Verify age limits of the plan) 166 20% Discount 0D1551 RECMNT/REBND OF BILATERAL SPACE MAINTAINER - MAXILLARY (*Verify age limits of the plan) 21 20% Discount 0D1552 RECMNT/REBND OF BILATERAL SPACE MAINTAINER - MANDIBULAR (*Verify age limits of the plan) 21 20% Discount 0D1553 RECMNT/REBND OF UNILATERAL SPACE MAINTAINER - PER QUADRANT (*Verify age limits of the plan) 21 20% Discount 0D1556 REMOVAL OF FIXED UNILATERAL SPACE MAINTAINER - PER QUADRANT (*Verify age limits of the plan) 25 20% Discount 0D1557 REMOVAL OF FIXED BILATERAL SPACE MAINTAINER - MAXILLARY (*Verify age limits of the plan) 25 20% Discount 0D1558 REMOVAL OF FIXED BILATERAL SPACE MAINTAINER - MANDIBULAR (*Verify age limits of the plan) 25 20% Discount 0D1575 DISTAL SHOE SPACE MAINTAINER - FIXED UNILATERAL - PER QUADRANT (*Verify age limits of the plan) 98 20% Discount 0D2140 AMALGAM - ONE SURFACE PRIMARY OR PERMANENT 20 20% Discount 25D2150 AMALGAM - TWO SURFACES PRIMARY OR PERMANENT 26 20% Discount 33D2160 AMALGAM - THREE SURFACES PRIMARY OR PERMANENT 36 20% Discount 34D2161 AMALGAM-FOUR/MORE SURFACES PRIMARY/PERMANENT 40 20% Discount 40D2330 RESIN-BASED COMPOSITE - ONE SURFACE ANTERIOR 41 20% Discount 30D2331 RESIN-BASED COMPOSITE - TWO SURFACES ANTERIOR 46 20% Discount 35D2332 RESIN-BASED COMPOSITE - THREE SURFACES ANTERIOR 51 20% Discount 45D2335 RESIN-BASED COMPOSITE 4/> SURFACES INCISAL ANGLE (ANTERIOR) 56 20% Discount 51D2390 RESIN-BASED COMPOSITE CROWN ANTERIOR 110 20% Discount 0D2391 RESIN-BASED COMPOSITE - ONE SURFACE POSTERIOR 41 20% Discount 28D2392 RESIN-BASED COMPOSITE - TWO SURFACES POSTERIOR 56 20% Discount 35D2393 RESIN-BASED COMPOSITE - THREE SURFACES POSTERIOR 66 20% Discount 45D2394 RESIN COMPOS - FOUR OR MORE SURFACES POSTERIOR 80 20% Discount 40D2542 ONLAY - METALLIC - TWO SURFACES 181 20% Discount 128D2543 ONLAY - METALLIC - THREE SURFACES 194 20% Discount 129D2544 ONLAY - METALLIC - FOUR OR MORE SURFACES 204 20% Discount 132D2610 INLAY - PORCELAIN/CERAMIC - ONE SURFACE 274 20% Discount 117D2620 INLAY - PORCELAIN/CERAMIC - TWO SURFACES 288 20% Discount 124D2630 INLAY - PORCELAIN/CERAMIC - THREE/MORE SURFACES 307 20% Discount 132D2642 ONLAY - PORCELAIN/CERAMIC - TWO SURFACES 217 20% Discount 93D2643 ONLAY - PORCELAIN/CERAMIC - THREE SURFACES 260 20% Discount 100D2644 ONLAY - PORCELAIN/CERAMIC - 4 OR MORE SURFACES 280 20% Discount 110D2650 INLAY - RESIN-BASED COMPOSITE - ONE SURFACE 180 20% Discount 77D2651 INLAY - RESIN-BASED COMPOSITE - TWO SURFACES 214 20% Discount 92D2652 INLAY RESIN BASED COMPOSITE 3 OR MORE SURFACES 225 20% Discount 96D2662 ONLAY - RESIN-BASED COMPOSITE - TWO SURFACES 195 20% Discount 84D2663 ONLAY - RESIN-BASED COMPOSITE - THREE SURFACES 220 20% Discount 115D2664 ONLAY RESIN BASED COMPOSIT FOUR OR MORE SURFACES 220 20% Discount 120D2710 CROWN - RESIN-BASED COMPOSITE (INDIRECT) 131 20% Discount 10D2712 CROWN 3/4 RESIN-BASED COMPOSITE (INDIRECT) 132 20% Discount 57D2720 CROWN - RESIN WITH HIGH NOBLE METAL 325 20% Discount 175D2721 CROWN - RESIN WITH PREDOMINANTLY BASE METAL 305 20% Discount 195D2722 CROWN - RESIN WITH NOBLE METAL 305 20% Discount 195D2740 CROWN - PORCELAIN/CERAMIC 355 20% Discount 255D2750 CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL 355 20% Discount 200D2751 CROWN - PORCELAIN FUSED PREDOMINANTLY BASE METAL 320 20% Discount 190D2752 CROWN - PORCELAIN FUSED TO NOBLE METAL 320 20% Discount 190D2753 CROWN - PORCELAIN FUSED TO TITANIUM AND TITANIUM ALLOYS 320 20% Discount 190D2780 CROWN - 3/4 CAST HIGH NOBLE METAL 310 20% Discount 200D2781 CROWN - 3/4 CAST PREDOMINANTLY BASE METAL 290 20% Discount 185D2782 CROWN - 3/4 CAST NOBLE METAL 290 20% Discount 185D2783 CROWN - 3/4 PORCELAIN/CERAMIC 300 20% Discount 200D2790 CROWN - FULL CAST HIGH NOBLE METAL 306 20% Discount 212D2791 CROWN - FULL CAST PREDOMINANTLY BASE METAL 290 20% Discount 185D2792 CROWN - FULL CAST NOBLE METAL 290 20% Discount 185D2910 RECMNT/REBND INLAY ONLAY/PART CVRGE RESTORATION 38 20% Discount 0D2915 RECMNT/REBND CAST OR PREFABRICATED POST AND CORE 27 20% Discount 0D2920 RE-CEMENT OR RE-BOND CROWN 32 20% Discount 0D2929 PREFABR STAINLESS PORC CROWN - PRIMARY TOOTH 159 20% Discount 0D2930 PREFABR STAINLESS STEEL CROWN - PRIMARY TOOTH 93 20% Discount 0D2931 PREFABR STAINLESS STEEL CROWN - PERMANENT TOOTH 100 20% Discount 0D2932 PREFABRICATED RESIN CROWN 104 20% Discount 0




D2933 PREFABR STAINLESS STEEL CROWN W/RESIN WINDOW 120 20% Discount 0D2934 PREFAB ESTHETIC COAT STNLESS STEEL CROWN PRIM 120 20% Discount 0D2940 PROTECTIVE RESTORATION 33 20% Discount 0D2950 CORE BUILDUP INCLUDING ANY PINS WHEN REQUIRED 101 20% Discount 0D2951 PIN RETENTION - PER TOOTH ADDITION RESTORATION 20 20% Discount 0D2952 POST AND CORE ADDITION TO CROWN INDIRECTLY FAB 112 20% Discount 0D2953 EACH ADDITIONAL INDIRECTLY FAB POST SAME TOOTH 56 20% Discount 0D2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN 104 20% Discount 0D2955 POST REMOVAL 85 20% Discount 0D2957 EACH ADDITIONAL PREFABRICATED POST - SAME TOOTH 45 20% Discount 0D2960 LABIAL VENEER (RESIN LAMINATE) - CHAIRSIDE 20% Discount 20% Discount 0D2961 LABIAL VENEER (RESIN LAMINATE) - LABORATORY 20% Discount 20% Discount 0D2962 LABIAL VENEER (PORCELAIN LAMINATE) - LABORATORY 20% Discount 20% Discount 0D2980 CROWN REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 52 20% Discount 0D2981 INLAY REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 76 20% Discount 0D2982 ONLAY REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 76 20% Discount 0D2983 VENEER REPAIR NECESSITATED BY RESTORATIVE MATERIAL FAILURE 20% Discount 20% Discount 0D3110 PULP CAP - DIRECT (Excluding final restoration) 30 20% Discount 0D3120 PULP CAP - INDIRECT (Excluding final restoration) 26 20% Discount 0D3220 TX PULP-REMV PULP CORONAL DENTINOCEMENTL JUNC 62 20% Discount 0D3221 PULPAL DEBRIDEMENT PRIMARY AND PERMANENT TEETH 62 20% Discount 0D3230 PULPAL THERAPY - ANTERIOR PRIMARY TOOTH (Excluding final restoration) 60 20% Discount 0D3240 PULPAL THERAPY - POSTERIOR PRIMARY TOOTH (Excluding final restoration) 62 20% Discount 0D3310 ENDODONTIC THERAPY ANTERIOR TOOTH (Excluding final restoration) 209 20% Discount 86D3320 ENDODONTIC THERAPY PREMOLAR TOOTH (Excluding final restoration) 269 20% Discount 96D3330 ENODODONTIC THERAPY MOLAR TOOTH (Excluding final restoration) 345 20% Discount 105D3331 TREATMENT RC OBSTRUCTION; NON-SURGICAL ACCESS 90 20% Discount 0D3332 INCOMPLETE ENDO TX; INOP UNRESTORABLE/FX TOOTH 171 20% Discount 0D3333 INTERNAL ROOT REPAIR OF PERFORATION DEFECTS 77 20% Discount 32D3346 RETREATMENT PREVIOUS RC THERAPY - ANTERIOR 233 20% Discount 88D3347 RETREATMENT PREVIOUS RC THERAPY - PREMOLAR 300 20% Discount 78D3348 RETREATMENT PREVIOUS ROOT CANAL THERAPY - MOLAR 373 20% Discount 95D3351 APEXIFICATION/RECALCIFICAT INIT VST 120 20% Discount 52D3352 APEXIFICAT/RECALCIFICAT INT MED REPL 60 20% Discount 0D3353 APEXIFICATION/RECALCIFICATION - FINAL VISIT 165 20% Discount 72D3410 APICOECTOMY - ANTERIOR 386 20% Discount 0D3421 APICOECTOMY - PREMOLAR (FIRST ROOT) 383 20% Discount 0D3425 APICOECTOMY - MOLAR (FIRST ROOT) 388 20% Discount 0D3426 APICOECTOMY (EACH ADDITIONAL ROOT) 135 20% Discount 0D3430 RETROGRADE FILLING - PER ROOT 95 20% Discount 0D3450 ROOT AMPUTATION - PER ROOT 163 20% Discount 0D3920 HEMISECTION NOT INCLUDING ROOT CANAL THERAPY 140 20% Discount 0D3950 CANAL PREPARATION&FITTING PREFORMED DOWEL/POST 88 20% Discount 0D4210 GINGIVECT/PLSTY 4/>CNTIG/TOOTH BOUND SPACES-QUAD 238 20% Discount 0D4211 GINGIVECT/PLSTY 1-3 CNTIG/TOOTH BOUND SPACE-QUAD 90 20% Discount 0D4212 GINGIVECT/PLSTY TO ALLOW ACCESS FOR RESTORATIVE PROCEDURE PER TOOTH 106 20% Discount 0D4240 GINGL FLP PROC 4/> CONTIG/TOOTH BOUND SPACE-QUAD 256 20% Discount 0D4241 GINGL FLP PROC 1-3 CONTIG/TOOTH BOUND SPACE-QUAD 177 20% Discount 0D4245 APICALLY POSITIONED FLAP 254 20% Discount 0D4249 CLINICAL CROWN LENGTHENING - HARD TISSUE 280 20% Discount 0D4260 OSSEOUS SURG 4/> CNTIG TEETH QUAD 426 20% Discount 0D4261 OSSEOUS SURG 1-3 CNTIG TEETH QUAD 273 20% Discount 0D4263 BONE REPLACEMENT GRAFT - FIRST SITE IN QUADRANT 211 20% Discount 0D4264 BONE REPLACEMENT GRAFT - EA ADD SITE QUADRANT 130 20% Discount 0D4265 BIOLOGIC MATERIALS AID SOFT&OSSEOUS TISSUE REGEN 275 20% Discount 0D4266 GUID TISSUE REGEN - RESORBABLE BARRIER PER SITE 208 20% Discount 0D4267 GUID TISSUE REGEN - NONRESORB BARRIER PER SITE 202 20% Discount 0D4268 SURGICAL REVISION PROCEDURE PER TOOTH 243 20% Discount 0D4270 PEDICLE SOFT TISSUE GRAFT PROCEDURE 303 20% Discount 0D4273 AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE (INCLUDING DONOR AND RECIPIENT SURGICA 440 20% Discount 0D4274 MESIAL/DISTAL WEDGE PROCEDURE SINGLE TOOTH 180 20% Discount 0D4275 NON-AUTOGENOUS CONNECTIVE TISSUE GRAFT (INCLUDING RECIPIENT SURGICAL SITE AND DONOR M 310 20% Discount 0D4276 COMB CNCTIVE TISSUE&DBL PEDICLE GRAFT PER TOOTH 415 20% Discount 0D4277 SOFT TISSUE GRAFT PROCEDURE FIRST TOOTH 334 20% Discount 0D4278 SOFT TISSUE GRAFT PROCEDURE EACH ADD TOOTH 200 20% Discount 0D4283 AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE (INCLUDING DONOR AND RECIPIENT SURGICA 397 20% Discount 0D4285 NON-AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE (INCLUDING RECIPIENT SURGICAL SITE 298 20% Discount 0D4320 PROVISIONAL SPLINTING - INTRACORONAL 141 20% Discount 0D4321 PROVISIONAL SPLINTING - EXTRACORONAL 128 20% Discount 0D4341 PRDONTAL SCALING&ROOT PLANING 4/MORE TEETH-QUAD 91 20% Discount 15D4342 PRDONTAL SCALING&ROOT PLANING 1-3 TEETH-QUAD 61 20% Discount 10D4346 SCALING IN PRESENCE OF GENERALIZED MODERATE OR SEVERE GINGIVAL INFLAMMATION 106 20% Discount 0D4355 FULL MOUTH DEBRID ENABLE COMP ORAL EVALUATION&DX ON A SUBSEQUENT VISIT 62 20% Discount 10D4381 LOC DEL ANTIMICROBL AGTS CREVICULR TISS TOOTH BR 20% Discount 20% Discount 0D4910 PERIODONTAL MAINTENANCE 61 20% Discount 13D5110 COMPLETE DENTURE - MAXILLARY 429 20% Discount 261D5120 COMPLETE DENTURE - MANDIBULAR 420 20% Discount 255D5130 IMMEDIATE DENTURE - MAXILLARY 440 20% Discount 235D5140 IMMEDIATE DENTURE - MANDIBULAR 440 20% Discount 235D5211 MAXILLARY PARTIAL DENTURE - RESIN BASE (Including retentive/clasping materials, rests and teeth) 375 20% Discount 150D5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE (Including retentive/clasping materials, rests and teeth) 375 20% Discount 150D5213 MAX PART DENTUR-CAST METL FRMEWRK W/RSN BASE (Including retentive/clasping materials, rests and tee 466 20% Discount 233D5214 MAND PART DENTUR- CAST METL FRMEWRK W/RSN BASE (Including retentive/clasping materials, rests and 440 20% Discount 259D5225 MAXILLARY PARTIAL DENTRUE FLEXIBLE BASE (Including any clasps, rests and teeth) 414 20% Discount 104D5226 MANDIBULAR PARTIAL DENTURE FLEXIBLE BASE (Including any clasps, rests and teeth) 409 20% Discount 102D5282 REMV UNILAT PART DENTUR - 1 PIECE CAST METAL, MAXILLARY (Including any clasps, rests and teeth) 295 20% Discount 105D5283 REMV UNILAT PART DENTUR - 1 PIECE CAST METAL, MANDIBULAR (Including any clasps, rests and teeth) 295 20% Discount 105D5284 REMV UNILAT PART DENTUR - 1 PIECE FLEXIBLE BASE (Including any clasps, rests and teeth) - PER QUADR 295 20% Discount 105D5286 REMV UNILAT PART DENTUR - 1 PIECE RESIN (Including any clasps, rests and teeth) - PER QUADRANT 295 20% Discount 105D5410 ADJUST COMPLETE DENTURE - MAXILLARY 35 20% Discount 0D5411 ADJUST COMPLETE DENTURE - MANDIBULAR 35 20% Discount 0D5421 ADJUST PARTIAL DENTURE - MAXILLARY 35 20% Discount 0D5422 ADJUST PARTIAL DENTURE - MANDIBULAR 35 20% Discount 0D5511 REPAIR BROKEN COMPLETE DENTURE BASE, MANDIBULAR 75 20% Discount 0D5512 REPAIR BROKEN COMPLETE DENTURE BASE, MAXILLARY 75 20% Discount 0D5520 REPLACE MISSING/BROKEN TEETH - COMPLETE DENTURE (Each tooth) 65 20% Discount 0D5611 REPAIR RESIN PARTIAL DENTURE BASE, MANDIBULAR 53 20% Discount 0D5612 REPAIR RESIN PARTIAL DENTURE BASE, MAXILLARY 53 20% Discount 0D5621 REPAIR CAST PARTIAL FRAMEWORK, MANDIBULAR 57 20% Discount 0




D5622 REPAIR CAST PARTIAL FRAMEWORK, MAXILLARY 57 20% Discount 0D5630 REPAIR OR REPLACE BROKEN RETENTIVE/CLASPING MATERIALS - PER TOOTH 69 20% Discount 0D5640 REPLACE BROKEN TEETH - PER TOOTH 52 20% Discount 0D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE 61 20% Discount 0D5660 ADD CLASP TO EXISTING PARTIAL DENTURE 100 20% Discount 0D5710 REBASE COMPLETE MAXILLARY DENTURE 294 20% Discount 0D5711 REBASE COMPLETE MANDIBULAR DENTURE 294 20% Discount 0D5720 REBASE MAXILLARY PARTIAL DENTURE 250 20% Discount 0D5721 REBASE MANDIBULAR PARTIAL DENTURE 280 20% Discount 0D5750 RELINE COMPLETE MAXILLARY DENTURE (LABORATORY) 160 20% Discount 0D5751 RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY) 160 20% Discount 0D5760 RELINE MAXILLARY PARTIAL DENTURE (LABORATORY) 157 20% Discount 0D5761 RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY) 157 20% Discount 0D5810 INTERIM COMPLETE DENTURE (MAXILLARY) 295 20% Discount 0D5811 INTERIM COMPLETE DENTURE (MANDIBULAR) 295 20% Discount 0D5820 INTERIM PARTIAL DENTURE (MAXILLARY) 223 20% Discount 0D5821 INTERIM PARTIAL DENTURE (MANDIBULAR) 223 20% Discount 0D5850 TISSUE CONDITIONING MAXILLARY 50 20% Discount 0D5851 TISSUE CONDITIONING MANDIBULAR 50 20% Discount 0D5863 OVERDENTURE - COMPLETE MAXILLARY 20% Discount 20% Discount 0D5864 OVERDENTURE - PARTIAL MAXILLARY 20% Discount 20% Discount 0D5876 ADD METAL SUBSTRUCTURE TO ACRYLIC FULL DENTURE (PER ARCH) 50 20% Discount 0D5899 UNS REMOVABLE PROSTHODONTIC PROCEDURE REPORT 150 20% Discount 0D6010 SURG PLACEMENT IMPLANT BODY: ENDOSTEAL IMPLANT 1186 20% Discount 0D6012 SURG PLCMT INTERIM IMPL TRNSITIONL PROS: ENDOS 1083 20% Discount 0D6040 SURGICAL PLACEMENT: EPOSTEAL IMPLANT 2567 20% Discount 0D6050 SURGICAL PLACEMENT: TRANSOSTEAL IMPLANT 1915 20% Discount 0D6055 CONNECTING BAR IMPLANT OR ABUTMENT SUPPORTED 291 20% Discount 0D6056 PREFABRICATED ABUTMENT INCLUDES PLACEMENT 220 20% Discount 0D6057 CUSTOM FABRICATED ABUTMENT INCLUDES PLACEMENT 350 20% Discount 0D6058 ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN 634 20% Discount 0D6059 ABUT SUPP PORCELAIN TO METL CROWN HI NOBLE METL 610 20% Discount 0D6060 ABUT SUPP PORCELAIN TO MTL CROWN PREDOM BASE MTL 527 20% Discount 0D6061 ABUT SUPP PORCELAIN TO METAL CROWN NOBLE METAL 538 20% Discount 0D6062 ABUTMENT SUPP CAST METAL CROWN HIGH NOBLE METAL 491 20% Discount 0D6063 ABUTMENT SUPP CAST METAL CROWN PREDOM BASE METAL 499 20% Discount 0D6064 ABUTMENT SUPP CAST METAL CROWN NOBLE METAL 488 20% Discount 0D6065 IMPL SUPP PORCELAIN/CERAMIC CROWN 556 20% Discount 0D6066 IMPL SUPP CROWN PORCLN FUSED HIGH NOBL ALLOYS 542 20% Discount 0D6067 IMPL SUPP CROWN HIGH NOBLE ALLOYS 526 20% Discount 0D6068 ABUT SUPP RETAINER PORCELAIN/CERAMIC FPD 660 20% Discount 0D6069 ABUT RETAINR PORCELN TO METL FPD HI NOBL METL 651 20% Discount 0D6070 ABUT RETN PORCELN TO METL FPD PREDOM BASE METL 615 20% Discount 0D6071 ABUT SUPP RETN PORCELN FUSD METAL FPD NOBLE METL 628 20% Discount 0D6072 ABUT SUPP RETN CAST METL FPD HIGH NOBLE METL 641 20% Discount 0D6073 ABUT RTNR CAST METL FPD PREDOM BASE METL 580 20% Discount 0D6074 ABUTMENT RTNR CAST METAL FPD NOBLE METAL 625 20% Discount 0D6075 IMPLANT SUPPORTED RETAINER FOR CERAMIC FPD 649 20% Discount 0D6076 IMPL SUPP RTNR FPD PORCLN FUSED HIGH NOBL ALLOYS 542 20% Discount 0D6077 IMPL SUPP RTNR METL FPD HIGH NOBLE ALLOYS 613 20% Discount 0D6080 IMPL MAINT PROC REMV CLEAN PROSTH & ABUT REINSRT 41 20% Discount 0D6082 IMPL SUPP CROWN PORCLN FUSED PREDOMINANTLY BASE ALLOYS 527 20% Discount 0D6083 IMPL SUPP CROWN PORCLN FUSED NOBLE ALLOYS 538 20% Discount 0D6084 IMPL SUPP CROWN PORCLN FUSED TITANIUM AND TITANIUM ALLOYS 491 20% Discount 0D6086 IMPL SUPP CROWN PREDOMINANTLY BASE ALLOYS 608 20% Discount 0D6087 IMPL SUPP CROWN NOBLE ALLOYS 637 20% Discount 0D6088 IMPL SUPP CROWN TITANIUM AND TITANIUM ALLOYS 679 20% Discount 0D6091 REPL ATTACHMNT IMPL/ABUT SUPP PROS PER ATTACHMNT 260 20% Discount 0D6092 RECEMENT / REBOND IMPLANT/ABUTMENT SUPP CROWN 39 20% Discount 0D6093 RECMNT/REBOND IMPL/ABUTMNT SUPP FIX PART DENTURE 79 20% Discount 0D6094 ABUTMENT SUPPORTED CROWN TITANIUM AND TITANIUM ALLOYS 516 20% Discount 0D6097 ABUTMENT SUPPORTED CROWN PORCLN FUSED TITANIUM AND TITANIUM ALLOYS 647 20% Discount 0D6098 IMPL SUPP RTNR PORCLN FUSED PREDOMINANTLY BASE ALLOYS 545 20% Discount 0D6099 IMPL SUPP RTNR FPD PORCLN FUSED NOBLE ALLOYS 556 20% Discount 0D6101 DBRDMNT OF PERI-IMPLANT DEFECT 167 20% Discount 0D6102 DBRDMNT AND OSSEUS CONTOUR OF PERI-IMPLANT DEFECT 274 20% Discount 0D6103 BONE GRAFT REPAIR OF PERI-IMPLANT 162 20% Discount 0D6104 BONE GRAFT AT TIME OF IMPLANT PLACEMENT 139 20% Discount 0D6110 IMPL/ABUTMENT SUPPORTED RD - MAXILLARY 766 20% Discount 0D6111 IMPL/ABUTMENT SUPPORTED RD - MANDIBULAR 766 20% Discount 0D6112 IMPL/ABUTMENT SUPPORTED RPD - MAXILLARY 766 20% Discount 0D6113 IMPLANT / ABUTMENT SUPPORTED RPD - MANDIBULAR 766 20% Discount 0D6114 IMPLANT / ABUTMENT SUPPORTED FD - MAXILLARY 1342 20% Discount 0D6115 IMPLANT/ABUTMENT SUPPORTED FD - MANDIBULAR 1342 20% Discount 0D6116 IMPL/ABUTMENT SUPPORTED FD - MAXILLARY - PARTIAL 1029 20% Discount 0D6117 IMPL/ABUT SUPPORTED FD - MANDIBULAR - PARTIAL 1029 20% Discount 0D6120 IMPL SUPP RTNR PORCLN FUSED TITANIUM AND TITANIUM ALLOYS 565 20% Discount 0D6121 IMPL SUPP RTNR METAL FPD PREDOMINANTLY BASE ALLOYS 518 20% Discount 0D6122 IMPL SUPP RTNR METAL FPD NOBLE ALLOYS 554 20% Discount 0D6123 IMPL SUPP RTNR METAL FPD TITANIUM AND TITANIUM ALLOYS 548 20% Discount 0D6190 RADIOGRAPHIC/SURGICAL IMPLANT INDEX BY REPORT 116 20% Discount 0D6194 ABUTMENT SUPPORTED RETAINER CROWN FOR FPD TITANIUM AND TITANIUM ALLOYS 532 20% Discount 0D6195 ABUTMENT SUPPORTED RETAINER PORCLN FUSED TITANIUM AND TITANIUM ALLOYS 631 20% Discount 0D6205 PONTIC - INDIRECT RESIN BASED COMPOSITE 129 20% Discount 104D6210 PONTIC - CAST HIGH NOBLE METAL 250 20% Discount 155D6211 PONTIC - CAST PREDOMINANTLY BASE METAL 210 20% Discount 140D6212 PONTIC - CAST NOBLE METAL 215 20% Discount 160D6240 PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL 293 20% Discount 142D6241 PONTIC - PORCELN FUSED PREDOMINANTLY BASE METAL 287 20% Discount 143D6242 PONTIC - PORCELAIN FUSED TO NOBLE METAL 280 20% Discount 140D6243 PONTIC - PORCELAIN FUSED TO TITANIUM AND TITANIUM ALLOYS 287 20% Discount 143D6245 PONTIC - PORCELAIN/CERAMIC 280 20% Discount 150D6250 PONTIC - RESIN WITH HIGH NOBLE METAL 270 20% Discount 145D6251 PONTIC - RESIN WITH PREDOMINANTLY BASE METAL 245 20% Discount 155D6252 PONTIC - RESIN WITH NOBLE METAL 255 20% Discount 130D6600 RETAINER INLAY - PORCELAIN/CERAMIC, TWO SURFACES 321 20% Discount 0D6601 RETAINER INLAY - PORCELAIN/CERAMIC THREE OR MORE SURFACES 330 20% Discount 0D6602 RETAINER INLAY - CAST HIGH NOBLE METAL TWO SURFACES 336 20% Discount 0D6603 RETAINER INLAY - CAST HIGH NOBLE METAL, THREE OR MORE SURFACES 360 20% Discount 0




D6604 RETAINER INLAY - CAST PREDOMINANTLY BASE METAL 2 SURFACES 330 20% Discount 0D6605 RETAINER INLAY - CAST PREDOM BASE METAL 3/MORE SURFACES 349 20% Discount 0D6606 RETAINER INLAY - CAST NOBLE METAL TWO SURFACES 324 20% Discount 0D6607 RETAINER INLAY - CAST NOBLE METAL THREE OR MORE SURFACES 360 20% Discount 0D6608 RETAINER ONLAY - PORCELAIN/CERAMIC TWO SURFACES 195 20% Discount 91D6609 RETAINER ONLAY - PORCELAIN/CERAMIC THREE OR MORE SURFACES 225 20% Discount 120D6610 RETAINER ONLAY - CAST HIGH NOBLE METAL TWO SURFACES 159 20% Discount 98D6611 RETAINER ONLAY - CAST HIGH NOBLE METAL 3/MORE SURFACES 174 20% Discount 108D6612 RETAINER ONLAY - CAST PREDOMINANTLY BASE METAL 2 SURFACES 164 20% Discount 92D6613 RETAINER ONLAY - CAST PREDOM BASE METAL 3/MORE SURFACES 172 20% Discount 96D6614 RETAINER ONLAY - CAST NOBLE METAL TWO SURFACES 161 20% Discount 90D6615 RETAINER ONLAY - CAST NOBLE METAL THREE OR MORE SURFACES 166 20% Discount 94D6624 RETAINER INLAY - TITANIUM 336 20% Discount 0D6634 RETAINER ONLAY - TITANIUM 353 20% Discount 0D6710 RETAINER CROWN - INDIRECT RESIN BASED COMPOSITE 287 20% Discount 183D6720 RETAINER CROWN - RESIN WITH HIGH NOBLE METAL 320 20% Discount 180D6721 RETAINER CROWN - RESIN WITH PREDOMINANTLY BASE METAL 305 20% Discount 195D6722 RETAINER CROWN - RESIN WITH NOBLE METAL 305 20% Discount 195D6740 RETAINER CROWN - PORCELAIN/CERAMIC 355 20% Discount 260D6750 RETAINER CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL 355 20% Discount 200D6751 RETAINER CROWN - PORCELAIN FUSED PREDOMINANTLY BASE METAL 320 20% Discount 190D6752 RETAINER CROWN - PORCELAIN FUSED TO NOBLE METAL 320 20% Discount 190D6753 RETAINER CROWN - PORCELAIN FUSED TO TITANIUM AND TITANIUM ALLOYS 320 20% Discount 190D6780 RETAINER CROWN - 3/4 CAST HIGH NOBLE METAL 310 20% Discount 200D6781 RETAINER CROWN - 3/4 CAST PREDOMINANTLY BASE METAL 290 20% Discount 185D6782 RETAINER CROWN - 3/4 CAST NOBLE METAL 290 20% Discount 185D6783 RETAINER CROWN - 3/4 PORCELAIN/CERAMIC 300 20% Discount 200D6784 RETAINER CROWN - 3/4 TITANIUM AND TITANIUM ALLOYS 292 20% Discount 195D6790 RETAINER CROWN - FULL CAST HIGH NOBLE METAL 295 20% Discount 205D6791 RETAINER CROWN - FULL CAST PREDOMINANTLY BASE METAL 290 20% Discount 185D6792 RETAINER CROWN - FULL CAST NOBLE METAL 290 20% Discount 185D6930 RECEMENT / REBOND FIXED PARTIAL DENTURE 48 20% Discount 0D7111 EXTRACTION CORONAL REMNANTS - DECIDUOUS TOOTH 31 20% Discount 16D7140 EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT (Elevation and/or forceps removal) 46 20% Discount 20D7210 SURG REMOVAL ERUPTED TOOTH REMV BONE ELEV FLAP 76 20% Discount 25D7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE 96 20% Discount 20D7230 REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY 120 20% Discount 30D7240 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY 151 20% Discount 25D7241 REMV IMP TOOTH - CMPL BONY W/UNUSUAL SURG COMPS 154 20% Discount 41D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS 85 20% Discount 0D7270 TOOTH REIMPL &OR STBL ACC EVULSED/DISPLCD TOOTH 175 20% Discount 0D7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH 148 20% Discount 0D7283 PLCMT DEVICE FACILITATE ERUPTION IMPACTED TOOTH 66 20% Discount 0D7285 BIOPSY OF ORAL TISSUE HARD 200 20% Discount 0D7286 BIOPSY OF ORAL TISSUE SOFT 155 20% Discount 0D7287 EXFOLIATIVE CYTOLOGICAL SAMPLE COLLECTION 56 20% Discount 0D7288 BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION 56 20% Discount 0D7290 SURGICAL REPOSITIONING OF TEETH 150 20% Discount 0D7310 ALVEOLOPLASTY W/EXTRACTION 4/> TEETH/SPACE QUAD 98 20% Discount 0D7311 ALVEOLOPLSTY CONJNC XTRACT 1-3 TEETH/SPACES QUAD 67 20% Discount 0D7320 ALVEOLOPLASTY NOT W/EXTRACTIONS 4/> TEETH/SPACE 160 20% Discount 0D7321 ALVEOLOPLSTY NOT CNJNC XTRCT 1-3 TEETH/SPCE QUAD 100 20% Discount 0D7410 EXCISION OF BENIGN LESION UP TO 1.25 CM 253 20% Discount 0D7411 EXCISION OF BENIGN LESION GREATER THAN 1.25 CM 400 20% Discount 0D7471 REMOVAL OF LATERAL EXOSTOSIS 313 20% Discount 0D7510 INCISION & DRAINAGE ABSCESS-INTRAORAL SOFT TISS 91 20% Discount 0D7511 I & D ABSCESS INTRAORAL SOFT TISSUE COMPLICATED 137 20% Discount 0

D7810-D7899 TMD THERAPY 20% Discount 20% Discount 0D7952 SINUS AUGMENTATION VIA A VERTICAL APPROACH 297 20% Discount 0D7960 FRENULECTOMY SEP PROC NOT INCIDENTL ANOTHER PROC 135 20% Discount 0D7971 EXCISION OF PERICORONAL GINGIVA 74 20% Discount 0

D8010-D8999 ORTHODONTIC SERVICES 25% Discount 25% Discount 0D9110 PALLIATIVE EMERGENCY TX DENTAL PAIN MINOR PROC 40 20% Discount 0D9120 FIXED PARTIAL DENTURE SECTIONING 20% Discount 20% Discount 0D9210 LOCAL ANES-NOT CONJUNCTION W/OP/SURGICAL PROC 15 20% Discount 0D9215 LOCAL ANESTHESIA CONJUCTION OPERATIVE/SURG PROC 11 20% Discount 0D9222 DEEP SEDATION/GENERAL ANESTHESIA - FIRST 15 MINUTES 96 20% Discount 0D9223 DEEP SEDATION/GENERAL ANESTHESIA - EACH SUBSEQUENT 15 MINUTE INCREMENT 72 20% Discount 0D9230 INHALATION OF NITROUS OXIDE/ANXIOLYSIS ANALGESIA 21 20% Discount 0D9239 INTRAVENOUS MODERATE (CONSCIOUS) SEDATION/ANESTHESIA - FIRST 15 MINUTES 79 20% Discount 0D9243 INTRAVENOUS MODERATE (CONSCIOUS) SEDATION/ANESTHESIA - EACH SUBSEQUENT 15 MINUTE INC 61 20% Discount 0D9248 NON-INTRAVENOUS CONSCIOUS SEDATION 110 20% Discount 0D9310 CONSULT DX SERV DENT/PHY NOT REQUESTING DENT/PHY 61 20% Discount 0D9430 OFFICE VISIT OBSERVATION NO OTHER SRVC PERFORMED 25 20% Discount 0D9440 OFFICE VISIT - AFTER REGULARLY SCHEDULED HOURS 44 20% Discount 0D9610 THERAPEUTIC PARENTERAL DRUG SINGL ADMINISTRATION 20% Discount 20% Discount 0D9612 TX PARENTERAL DRUGS 2/> ADMINISTRATIONS DIFF MED 20% Discount 20% Discount 0D9944 OCCLUSAL GUARD - HARD APPLIANCE, FULL ARCH 155 20% Discount 0D9945 OCCLUSAL GUARD - SOFT APPLIANCE, FULL ARCH 155 20% Discount 0D9946 OCCLUSAL GUARD - HARD APPLIANCE, PARTIAL ARCH 155 20% Discount 0D9951 OCCLUSAL ADJUSTMENT - LIMITED 32 20% Discount 0D9972 EXTERNAL BLEACHING - PER ARCH 20% Discount 20% Discount 0D9973 EXTERNAL BLEACHING - PER TOOTH 20% Discount 20% Discount 0

3 4

DentalEMI Health

Choice PPO Plan

Plan FeaturesIn-Network

Advantage Plus Network

In-NetworkPremier Network

Out-of-Network


$50/person$150/family



Annual Maximum $1,500/person $1,200/person $1,200/person

Type 1 – PreventiveServicesx-rays, cleanings, exams

100% 100% 100% up to TOA


80% AD 80% AD 80% AD up to TOA


50% AD 50% AD 50% AD up to TOA

Type 4 – Orthodonticsfor dependent children ages 7 – 18

50% 50% 50%

Orthodontic Discountfor all members

Up to 25% Up to 25% No Discount

Orthodontic Lifetime Maximum $1,000 per person

AD = After DeductibleTOA = Table of Allowances. When using a non-participating provider, the insured is responsible for all fees in excess of the Table of Allowances.

VisionEyeMed

VSP

3 6

Access Network


You Pay Plan Reimburses You

Exam once every 12 months $20 Up to $35

Frames once every 24 months$130 allowance + 20% off

balance over $130 Up to $65

Lenses once every 12 months

Single Vision BifocalTrifocalStandard ProgressivePremium Progressive

$20$20$20$85

$85 + 80% of charge less $120 allowance

Up to $25Up to $40Up to $55Up to $40Up to $40

Contact Lenses once every 12 months

Elective

Medically Necessary

$120 allowance + 15% off balance over $120

Covered in Full

Up to $96

Up to $200

VisionEyeMed

Laser Vision Correction 15% off retail price5% off promotional price No Benefit

3 7

VSP Choice Network


You Pay Plan Reimburses You

Exam once every 12 months $20 Up to $45

Frames once every 24 months

$120 allowance$140 allowance for featured

frame brands$70 Costco frame allowance20% discount on remaining

balance over allowed amount

Up to $70

Lenses once every 12 months

Single Vision BifocalTrifocalStandard ProgressivePremium Progressive

$0$0$0$0

Cost varies by option chosen

Up to $30Up to $50Up to $65Up to $50Up to $50

Contact Lenses once every 12 months

Elective $120 allowance Up to $105

VisionVSP

Laser Vision Correction 15% off retail price5% off promotional price No Benefit

Life and AD&DThe Hartford

3 9

Life and AD&DThe Hartford

Plan Features Basic Life And AD&D Voluntary Life And AD&D

Life Benefit AmountEmployee: $29,000

Spouse: $5,000Child(ren): $3,000

Employee, Spouse & Child(ren): Elect in increments of $5,000

AD&D Benefit Amount Equal to life benefit (employee only) N/A

Maximum Life / AD&D Benefit

Employee: $29,000Spouse: $5,000

Child(ren): $3,000

Employee: $300,000Spouse: $250,000 not to exceed 100% of the employee’s amount

Child(ren): $10,000

Voluntary Life Guaranteed Issuenew employees only

Employee: $250,000Spouse: $40,000

Child(ren): $5,000 or $10,000

Increasing coverage at Open Enrollmentall eligible employees

For both employees and their spouses, if you were previously eligible and are electing coverage for the first time or electing to

increase your current coverage, you will need to provide evidence of insurability (EOI) before coverage can become effective.

Child(ren) insurance is guaranteed issue coverage – it is available without having to provide EOI.

Life Insurance and Accidental Death & Dismemberment (AD&D) benefits provide you andyour loved ones financial protection in the event of an illness, accident, or death.

Basic Life Insurance and Accidental Death and Dismemberment (AD&D)Nebo School District provides all eligible employees with a basic group life insurance andaccidental death and dismemberment coverage at no cost to you (see page 7).

Voluntary Life Insurance and AD&DYou also have the option to purchase additional life insurance coverage for yourself, yourspouse and your dependent children to age 26. However, you may only elect coverage foryour dependents if you elected additional coverage for yourself. You pay for the cost ofadditional coverage through payroll deductions on a post-tax basis.

Beneficiary DesignationWe recommend you designate a beneficiary for your life insurance policy(ies). A beneficiaryis the person (or people, estate, trust, etc.) to whom benefits will be paid to in the event ofyour death. You may change your beneficiary at any time during the plan year.

Disability

The Hartford

4 1

Plan Features Long-Term Disability

Benefit Amount 60% of monthly earnings

Maximum Benefit $5,000 monthly

Benefit Waiting Period 120 days

Maximum Benefit Duration Social Security Normal Retirement Age

Own Occupation 24 months

Disability insurance benefits replace a portion of your income if you are unable towork for a period of time due to a qualified off-the-job injury or illness.

Long-term DisabilityLong-term disability provides an ongoing source of income if your disability is prolonged.

EligibilityYou are eligible for Long-Term Disability if you meet one of the following criteria:• All active, certified employees working 20 or more hours per week• active classified employees hired prior to July 1, 2013 through February 7, 2018 and working

30 hours or more per week• Active classified employees hired February 8, 2018 or later and working 40 hours or more

per week• Active classified bus drivers hired July 1, 2013 or later and working 30 hours or more per

week

Definition Of DisabilityDisability means that, solely because of a covered injury or sickness, you are unable toperform the material duties of your regular occupation and you are unable to earn 80% ormore of your indexed earnings from working in your regular occupation. After benefits havebeen payable for 24 months, you are considered disabled if solely due to your injury orsickness, you are unable to perform the material duties of any occupation for which you are(or may reasonably become) qualified by education, training or experience, and you areunable to earn 80% or more of your indexed earnings.

DisabilityNebo School District

Voluntary BenefitsMetLife

4 3

Accident PlanMetLife

Group Accident Insurance (off-the-job)With MetLife, you’ll have a comprehensive plan which provides payments in addition to anyother insurance payments you may receive. Here are just some of the coveredevents/services:

Benefit Type MetLife Accident Insurance Pays You

Fractures $320 - $8,000 Dislocations $240 - $6,000Second and Third Degree Burns $100 - $20,000Concussions $200Cust / Lacerations $25 - $400Eye Injuries $250Ambulance $1,000 - $2,000Emergency Care $50 - $200Non-Emergency Care $50Physician Follow-Up $30Therapy Services (including physical therapy) $25 - $30Medical Testing Benefit $200Medical Appliances $100 - $1,00Inpatient Surgery $200 - $2,000Admission $500 - $1,000

Hospital Confinement $200 per day (non-ICU) up to 31 days$400 per day (ICU) up to 31 days

Inpatient Rehab (paid per accident) $75 a day, up to 15 daysEmployee receives 100% of amount shown. Spouse receives 50% and children receive 20% of amount shown

$50,000$100,000 for common carrier

Dismemberment, Loss & Paralysis $1,250 - $50,000 per injury

Lodging – pays for lodging for companion $100 per night up to 31 days per year; up to $3,100 total per calendar year

Health Screening Benefit $50 once per year

Accident Plan Premiums (10 month premiums)

Annual Premium Monthly Premium

Employee Only $120.72 $12.07Employee & Spouse $243.84 $24.38Employee & Child(ren) $242.88 $24.29Family $305.28 $30.53

4 4

Critical Illness PlanMetLife

Group Critical Illness InsuranceCritical Illness insurance provides a lump sum benefit to help you cover the out-of-pocketexpenses associated with a critical illness diagnosis.

Eligible Individual Initial Benefit Requirements

Employee $10,000 or $20,000 Coverage is guaranteed provided you are actively at work

Spouse / Domestic Partner

50% of the employee’s Initial Benefit

Coverage is guaranteed provided the employee is actively at work and the spouse/domestic partner is not subject to a medical restriction as set forth on

the enrollment form and in the Certificate

Dependent Child(ren) 50% of the employee’s Initial Benefit

Coverage is guaranteed provided the employee is actively at work and the dependent is not subject to a

medical restriction as set forth on the enrollment form and in the Certificate

Your Initial Benefit provides a lump-sum payment upon the first diagnosis of a Covered Condition. Your plan pays a Recurrence Benefit for the following Covered Conditions: Heart Attack, Stroke, Coronary Artery Bypass Graft, Full Benefit Cancer and Partial Benefit Cancer. A Recurrence Benefit is only available if an Initial Benefit has been paid for the Covered Condition. There is a Benefit Suspension Period between Recurrences.

The maximum amount that you can receive through your Critical Illness Insurance Plan is called the Total Benefit and is 3 times the amount of your Initial Benefit. This means you can receive multiple Initial Benefit and Recurrence Benefit payments until you reach the maximum of 300% or $45,000 or $90,000.

Eligible Individual Initial Benefit Requirements

Full Benefit Cancer 100% of Initial Benefit 50% of Initial Benefit

Partial Benefit Cancer 25% of Initial Benefit 12.5% of Initial Benefit

Heart Attack 100% of Initial Benefit 50% of Initial Benefit

Stroke 100% of Initial Benefit 50% of Initial Benefit

Coronary Artery Bypass Graft 100% Initial Benefit 50% of Initial Benefit

Kidney Failure 100% of Initial Benefit Not Applicable

Alzheimer’s Disease 100% of Initial Benefit Not Applicable

Major Organ Transplant Benefit 100% of Initial Benefit Not Applicable

22 Listed Conditions 25% of Initial Benefit Not Applicable

22 Listed ConditionsMetLife Critical Illness Insurance will pay 25% of the Initial Benefit Amount for each of the 22Listed Conditions until the Total Benefit Amount is reached. A Covered Person may onlyreceive one payment for each Listed Condition in his/her lifetime. For a complete list ofconditions, please see your plan documents.

4 5

Critical Illness PlanMetLife

Monthly Premium - $10,000 of coverage – Non-Tobacco (10 month premiums)

Issue Age Employee Only Employee + Spouse Employee + Child(ren) Family

< 30 $3.40 $6.20 $6.50 $9.3030 – 39 $5.20 $9.10 $8.30 $12.2040 – 49 $10.20 $17.30 $13.30 $20.5050 – 59 $19.50 $33.40 $22.60 $36.5060 – 69 $39.30 $68.00 $42.40 $71.1070+ $72.50 $122.30 $75.60 $125.40

Health Screening BenefitAfter your coverage has been in effect for 30 days, MetLife will provide an annual benefit of$50 per calendar year for taking one of the eligible screening/prevention measures. MetLifewill pay only one health screening benefit per covered person per calendar year. For acomplete list of screenings, please see your plan documents.

Monthly Premium - $10,000 of coverage – Tobacco (10 month premiums)


< 30 $4.30 $7.50 $7.40 $10.6030 – 39 $7.40 $12.60 $10.60 $15.7040 – 49 $16.30 $27.00 $19.30 $30.1050 – 59 $32.80 $55.60 $35.90 $58.7060 – 69 $67.90 $117.20 $71.00 $120.4070+ $127.40 $214.40 $130.60 $217.60

Monthly Premium - $20,000 of coverage – Tobacco (10 month premiums)


< 30 $8.60 $15.00 $14.80 $21.2030 – 39 $14.80 $25.20 $21.20 $31.4040 – 49 $32.60 $54.00 $38.60 $60.2050 – 59 $65.60 $111.20 $71.80 $117.4060 – 69 $135.80 $234.40 $142.00 $240.8070+ $254.80 $428.80 $261.20 $435.20

Monthly Premium - $20,000 of coverage – Non-Tobacco (10 month premiums)


< 30 $6.80 $12.40 $13.00 $18.6030 – 39 $10.40 $18.20 $16.60 $24.4040 – 49 $20.40 $34.60 $26.60 $41.0050 – 59 $39.00 $66.80 $45.20 $73.0060 – 69 $78.60 $136.00 $84.80 $142.2070+ $145.00 $244.60 $151.20 $250.80

4 6

Hospital Indemnity PlanMetLife

Hospital Plan Premiums (10 month premiums)

Annual Premium Monthly Premium

Employee Only $236.52 $23.65Employee & Spouse $455.88 $45.59

Employee & Child(ren) $370.44 $37.04

Family $620.40 $62.04

Group Hospital Indemnity InsuranceWith MetLife, you’ll have a comprehensive plan with provides payments in addition to anyother insurance payments you may receive. Here are just some of the coveredbenefits/services when an accident or illness puts you in the hospital:

Benefit Type MetLife Accident Insurance Pays You

Hospital Coverage (accident)

Admission – must occur within 180 days after the accident

$1,500 per accident (non-ICU)$2,000 per accident (ICU)

Confinement – must occur within 180 days after the accident

$150 per day up to 31 days (non-ICU)$400 per day up to 31 days (ICU)

Inpatient Rehab - stay must occur immediately following hospital confinement and occur within 365 days of an accident

$200 per day, up to 15 days per accident and 30 days per calendar year

Hospital Coverage (sickness)

Admission – payable one time per calendar year

$1,000 (non-ICU)$2,000 (ICU)

Confinement – paid per sickness $200 per day up to 31 days (non-ICU)$400 per day up to 31 days (ICU)

Other BenefitsHealth Screening (wellness) Benefit –provided if the covered insured takes one of the covered screening/prevention tests

$50 once per calendar year

Employee Assistance ProgramBlomquist Hale

4 8

When life gets too challenging, we can helpThe Blomquist Hale Employee Assistance Program provides direct, face-to-face guidance toaddress virtually any stressful life situation problem. Not to mention there is absolutely nocost to you. Meeting with our team is simple. Call to schedule an appointment today at800-926-9619

We can help with

You can count on

24/7 Crisis Service 100% Confidential Professional, Friendly Team

Convenient Locations Extended Hours No Co-Pay Required

Call us today or visit us at www.blomquisthale.com

Orem Branch891 W. Center Street

Orem, UT 84057801-225-9222

Employee Assistance ProgramBlomquist Hale

• Marital & Family Counseling• Stress, Anxiety or Depression• Personal & Emotional Challenges• Grief or Loss• Financial or Legal Problems• Substance Abuse or Addictions• Senior Care Planning

WellnessNebo School District

SelectHealth Healthy Living

5 0

How to participate in Healthy Living for SelectHealth ShareSelectHealth Share seeks to achieve better health, better care, and lower costs byencouraging healthy lifestyles while providing quality healthcare. As a SelectHealth Sharemember, use this information to learn how to complete you requirements and join thejourney to better health.

Employees who successfully complete the below requirements will be eligible for a reward.

1. Attend your Workplace Health Education and Screening Event. Make sure to check out theinformative health and wellness displays located in your facility and participate in abiometric screening and personalized health coaching. If preferred, you can be screened byyour personal physician as an alternative to your workplace event.

2. Create a My Health Account. My Health is a secure site where you can review your medicalclaims, see lab results, and more. My Health is also your gateway to Healthy Living. Whenregistering for My Health and participating in the Healthy Living program, you’ll need touse an up-to-date web browser such as Google, Chrome, Microsoft, Edge, or InternetExplorer (11 or above). If you have trouble creating a My Health account, please call OnlineServices at 800-442-5502 weekdays, from 7:00 a.m. to 8:00 p.m. and Saturdays, from 7:00a.m. to 3:00 p.m.

3. Select your Primary Care Physician. Log in to your My Health account. Choose “SelectPrimary Provider” from your Member Checklist. Then scroll down and click on “Select NewPrimary Care Provider” on the lower left hand corner or the page. Using the “Find a Doctor”tool, select “+Add as Primary Care Provider (PCP)” below the provider of your choice.

4. Create your Health Living Virgin Pulse account and Complete the Health Check. The HealthCheck is an online assessment that gives you a Health Score based on everyday things likenutrition, exercise, sleep, and your health history. To get started, click on the HealthAssessment icon from your Member Checklist on selecthealth.org to get to Virgin Pulse.The Health Check can also be found under the Program section of the Virgin Pulse tool.

5. Complete one or more Digital Coaching Journeys. Digital Coaching programs, known asJourneys, can help you create new healthy habits or keep the ones you have. Choose theJourney that’s right for you and check in daily to complete. Choose Digital Coaching fromyour Member Checklist to get to the Virgin Pulse home page. On the app, Journeys can befound under Menu or Programs.

6. Participate in two or more Activity Campaigns. There are three different types ofchallenges available in Virgin Pulse that you can choose from to earn your two ActivityCampaigns. You can choose from any combination of Company Team Challenges, 7,000Steps Challenges or four Healthy Habit Challenges.


5 1

Company Team ChallengesIn these four week, virtual destination challenges, you’ll join a team and compete againstothers to achieve a collective goal. Participants are encouraged to form teams of up to 10members-but you may also register and participate as an individual. As a team accumulatessteps, they take a virtual journey and unlock destinations that include a map, leaderboard,and online support. Track your steps (or step equivalents) in Virgin Pulse for the duration ofthe challenge. Activity tracking may be done manually on the Virgin Pulse website orsmartphone app. You may also automate your activity tracking by using a wearable device(e.g., Fitbit), or a compatible smartphone app if you sync it to the Virgin Pulse platform. Toreceive credit for completion, you’ll need to track your physical activity each week duringthe challenge.

7,000 Steps ChallengesGet at least 7,000 steps per day* for at least 20 days in a calendar month to earn one activityrequirement. For non-stepping activity (i.e. swimming,) the “add a workout” tool can beused to convert the activities to steps.

Healthy Habits ChallengeThese one-week challenges are offered once a month throughout the year. They can helpyou create a new healthy habit! To participate, you’ll track daily activities in one of ninewellness areas, such as being more active, choosing healthy foods, reducing stress, buildingrelationships, and managing finances. To “complete” the Healthy Habit Challenge, you mustreport successfully performing the target behavior at least five of seven days on the VirginPulse website or app. Completing four Healthy Habit Challenges equals one ActivityCampaign.

*If you have a medical condition or injury that limits your mobility, you could choose aCompany Team Challenge with no steps requirement or complete for Individual HealthyHabit Challenges.

Note: In the event that you participate in a Company Team Challenge and achieve 7,000steps for 20 days in the same month, only one of the activities will be counted.

7. Complete Prediabetes education, if Applicable. SelectHealth offers many helpfulresources for those at risk for diabetes. Some options include meeting with a dietician,taking a Prediabetes 101 class, and participating in The Weight to Health Program. You canearn incentives each year from SelectHealth by participating. Call 800-442-5260 fordetails.


5 2

8. Participate in Care Management if Applicable. SelectHealth subscribers and coveredspouses are eligible for financial incentives when you take steps to improve your health.This program is available to members with these ongoing health conditions: asthma,diabetes, chronic obstructive pulmonary disease (COPD), and heart failure. You can earnincentives each year from SelectHealth by participating.

9. Get your Preventive Care. Regular preventive care can help you stay healthy and identifyhealth problems early – when they are easier to treat and cure. It means taking smallactions now, when you may not have an illness or symptoms. The type of preventive careand screening you should receive is based on your age, gender, lifestyle and risk factors.

Important age and gender based screenings include: Colon cancer (men and women startingat age 50), breast cancer (women starting at age 40), and cervical (women starting at age 21).Consult your primary care physician for details on the frequency of the screenings and whatother preventive care/screenings that may be recommended for you. SelectHealth Sharecovers preventive care services at no additional cost to you. However, if a condition is foundduring a preventive service that needs further testing or treatment, regular copays,coinsurance, and deductibles may apply.

What if I have a Medical Condition?Healthy Living is designed to help you live the healthiest life possible. If you have a medicalcondition that limits your physical ability, you may be able to earn your wellness incentiveanother way. Contact your human resources department for more information.

Who will see my Personal Information?Your information, including personal health information will be provided to and keptconfidential by SelectHealth. We will only disclose your personal health information to thirdparties as permitted or required by law. Your screening data will be loaded into your secureHealthy Living user profiles and used to provide you with personal feedback. Your name maybe shared with your employer for incentive determination purposes.

Questions?If you have questions, call Member Services at 800-538-5038 weekdays, from 7:00 a.m. to8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m.

Premiums

$2,700/$5,400 Base Plan

Status Premium Nebo will MATCH into HSA for 2020-2021 (Sept. – June)

Single $25 monthly over 10 months (Sept. – June) $675*

Two-Party $85 monthly over 10 months (Sept. – June) $1,350*

Family $135 monthly over 10 months (Sept. – June) $1,350*

*Requires an employee contribution in order to receive MATCH. NSD will match up to this amount

Medical SelectHealth Share

PremiumsSeptember 1, 2020 – August 31, 2021

$1,600/$3,200 Option Plan


Single $34 monthly over 10 months (Sept. – June) $400*

Two-Party $107 monthly over 10 months (Sept. – June) $800*

Family $187 monthly over 10 months (Sept. – June) $800*

*Requires an employee contribution in order to receive MATCH. NSD will match up to this amount

$2,700/$5,400 Dual Base Plan (Both spouses working for the District)


Two-Party Dual $85 monthly over 10 months (Sept. – June)

$1,350* + non-match contribution of $1,350

(over 10 months)

Family Dual $135 monthly over 10 months (Sept. – June)

$1,350*+ non-match contribution of $1,350

(over 10 months)*Requires an employee contribution in order to receive MATCH. NSD will match up to this amount

$3,200 Dual Base Plan (Both spouses working for the District)


Two-Party Dual $94 monthly over 10 months (Sept. – June)

$800* + non-match contribution of $800

(over 10 months)

Family Dual $191 monthly over 10 months (Sept. – June)

$800*+ non-match contribution of $800

(over 10 months)*Requires an employee contribution in order to receive MATCH. NSD will match up to this amount

Employees working under 40 hours a week will pay a pro-rated premium.

Dental Plan Options – 10 Month Rates

Status Advantage Plus (100) Advantage Co-Pay Choice PPO

Single $17.48 $29.50 $39.02

Two-Party $35.45 $68.66 $89.45

Family $58.60 $107.00 $154.80

DentalEMI Health

PremiumsSeptember 1, 2020 – August 31, 2021

Vision Plan Options – 10 Month Rates

Status VSP EyeMed

Single $6.65 $13.13

Two-Party $13.32 $24.74

Family $21.43 $33.78

Critical Illness

Rates for the Critical Illness coverage are determined by age and other factors. Please see the MetLife booklet on the Employee Home Page (under Benefits 2020-21) for the detailed chart.

VisionVSP & EyeMed

Supplemental InsuranceMetLifeSupplemental Insurance is often used to help bridge the gap until money can be saved into an HSA. The plan pays cash to policy holders when qualified expenses occur. Please see the MetLife link on the Benefits page for detailed information.

Accident Plan

Non-Occupational Plan Premium (10 months)

Single $12.07Employee & Spouse $24.38Employee + Child(ren) $24.29Family $30.53

Hospital IndemnityHSA Plan 1 Premium (10 months)

Single $23.65Employee & Spouse $45.59Employee + Child(ren) $37.04Family $62.04

This guide was prepared for the employees of Nebo School District by GBS Benefits, Inc.

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