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HomeMy Public PortalAboutExhibit MSD 18F3 Ameritas-Dentalfor group dental and/or vision insurance 1. Applicant's legal name T7i_ 2. Doing business as aAn-LE- RS A b vu 3. City / State / ZIP P.O. Box /ZIP Code Exhibit MSD 18F3 See reverse side for additional information. LIFE INSURANCE CORP. Lincoln, NE A .\.I (. L' i S S E 5 cT- -35-o 0)n -.1,(4--f Street Address S I- 1-C:c, 5 Mo 6.3103 Phone No. Fax No. E-mail Address Tax I.D. No. L[3 lno 4. What is the nature of your business or industry? P o \% L l -'T r I 5. Eligibility Total Number of Eligible Employees Employees in Waiting Period 6. Are any classes or locations excluded? 'Yes No Are domestic partners included? Yes 'IS No Are retirees included? Yes No (If yes, please use reverse side for explanation.) 7. Are any subsidiary and/or affiliated companies to be insured? r_.; Yes No (If yes, please use reverse side to list name and location.) 8. How many hours per week equals full time employment? 377 4r1-16 9. Employee Participation Employer contributes % of employee premium. Tied -to -Medical (AII employees covered on employer's medical plan must be insured, except those listed under excluded classes or locations.) Non -Contributory (Policyholder contributes 100% of premiums. All employees must be insured, except those listed under excluded classes or locations.) 7 Non -Contributory, except covered elsewhere (If policy- holder contributes 100% of premiums, all employees must be insured, except those listed under excluded classes or locations and those covered elsewhere.) Contributory (Policyholder is required to contribute to the employee premium and must contribute at least 25% of the total employee and dependent premium.) Voluntary (Policyholder does not contribute towards premium, 100% contribution by employee.) 10. Dependent Participation: Employer contributes % of employee premium. I__ Tied -to -Medical (All eligible dependents covered on employer's medical plan must be insured, except those listed under excluded classes or locations.) Non -Contributory (Policyholder contributes 100% of premiums. All eligible dependents must be insured, except those listed under excluded classes or locations.) El Non -Contributory, except covered elsewhere (If policy- holder contributes 100% of premiums, all eligible depen- dents must be insured, except those listed under excluded classes or locations and those covered elsewhere.) Contributory (Policyholder is required to contribute to the employee premium and must contribute at least 25% of the total employee and dependent premium.) Voluntary (Policyholder does not contribute towards premium, 100% contribution by employee.) 11. Section 125 Plan Election Period l-)Q:Gy i [ Plan Year 21/ -- /3/ 12. Employee welfare benefit plans that are subject to ERISA must satisfy various reporting, disclosure and related obligations. These requirements include the provisioning of a Summary Plan Description or SPD. The certificate of coverage can serve as an SPD if certain information is additionally disclosed. Please check one of the following (failure to respond shall be consid- ered a positive response for A. and a negative response for B.). A. Plan is subject to ERISA (complete question 12.B.) Plan is NOT subject to ERISA — Church or Govt. employer or other safe -harbor exception (see DOL Reg. §2510.3-1(j)) B. 2 Applicant requests that Ameritas Life Ins. Corp. prepare a SPD for its dental and/or vision plan Yes No If yes, the company is to prepare a SPD. The following information is required under ERISA and MUST be included in the SPD. Plan No. Plan Fiscal Year Plan Administrator: Th Name: 5!F 7,s a (LT -Env ltd• �< Address: g&f5-'61 ;!S cn r-, i T ---,0,31%-& t 5 v1-47.1- ST nr City, State, ZIP ST. mv 63fc3 Phone No3/`J.-768—(9drxa Plan Fiscal Year?// &J C Please Note: Applicant remains responsible for ensuring that SPD form provided by Ameritas Life Ins. Corp. is complete and accurate and satisfies applicable laws and regulations. Moreover, applicant remains respon- sible for providing its plan participants with SPD updates as required by applicable law and regulations. GR 902 Rev. 7-07 Page 1 of 3 1105071 13. Waiting Period for those employed on or before the policy effective date. )-41 for those employed after the new policy effective date. month(s) calendar days IL working days 14. Effective Date and Termination Date Immediate First of Month Effective date / End of Month Termination date L Other 15. Premium Payment Mode (In advance) Monthly D Quarterly L J Semi -Annual L Annual Payroll Deduction (To choose this option, employee must pay employee and dependent premium.) If policy effective date is other than first of the month, is a first of the month premium due date desired? ,Yes Billing Options dome Office Li Third -Party Administration S Tv 1`7' ; ov es Contact Name F A Rr ; 1.S 0,9 ckifIp r L Title a 33_ I)/ Street Address S T. ( j';s / Mo 6,3)0.3 City / State / ZIP 3i4-7(02-43° ? 3(L(-7(g-�? Phone No. Fax No. E-mail Address 16. The following coverages are applied for: Employee & Dependents Benefits Dental Orthodontia _' Eye Care Other Employee Only Benefits Li Dental Li Orthodontia _ Eye Care Other This insurance shall be effective on: (Premiums due prior to the coverage period.) 17. Policy and Certificate Delivery (select one) A. eCert*/ePolicy (*generic cert, non -personalized) via PDF format sent via e-mail to: via eService and member portal B. Paper policy/personalized certificates L Initial employees only Subsequently added employees Note: eCert will be available on member portal for all members. 18. Insurance requested on this application will replace the coverage(s) checked. Coverages: +-Dental -Orthodontia Ll Eye Care Other Name of Current Carrier Ur)%+T&S 1.-1E. c "c4.1r Policy No. Sy 346 Coverage applied for is replacing comparable coverage now or previously in force with another carrier. It is intended that the insurance coverage applied for be in addition to, supplemented by, or supplemental to any similar coverage now in force, or to be in force, with this or any other carrier. A floe Termination Date Original Effective date Item 6: Exclusions a. Classes, include reason for exclusion. b. Locations, if location is different from applicant's, list city and state. C� v 1-C-1 e.)c () )...)6;,,\J 765 S7-• L i r — Item 7: Subsidiary and/or affiliated companies to be insured. List names and locations. Plan Design and Proposed Rates: Additional Remarks: GR 902 Rev. 7-07 Page 2 of 3 110507L Agreements This application will be subject to review and approval by the Home Office of Ameritas Life Insurance Corp. If this application is accepted, the final rates and benefits will be based on verification of this information and final enrollment numbers. This applicant represents that he/she has read the statements and answers to the above questions and that they are complete and true to the best of his/her knowledge and belief. Any policy including riders issued as a result of this application will, with this application, be the entire insurance contract. If this application is accepted at the Home Office of Ameritas Life Insurance Corp., group insurance at the Company's rates and under the terms applied for shall take effect as of the date set forth in the policy. If this application is not accepted, any premium advanced shall be refunded. Statements In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides false, incomplete, or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim. (See state -specific statements.) • Note for California Residents: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. For group policies issued, amended, delivered or renewed in California, dependent coverage includes individuals who are registered domestic partners and their dependents. • Note for Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts for information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insur- ance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. • Note for Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. • Note for Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. • Note for New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. • Note for Georgia, Kansas, Nebraska, Oregon, Vermont and Virginia Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law. • Note for Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. If you do not want your company name used by Ameritas Life Insurance Corp. in our effort to recruit PPO providers, check this box. Signed at: City State Date Soliciting Agent: Printed Name For FL agents only, provide FL license # Signature The policy provides dental and/or vision benefits only. Review your policy carefully. Signed by (Policyholder Representative): Printed name and title I understand and agree that if I'm not already appointed with Ameritas Life Insurance Corp., I must apply to and be appointed with Ameritas before I present this product to any client. JG.rJ Sr NIIP— MArki IC= 300►2GQ-S Signature Was a binder check received? `! Yes No If yes, then amount Check received by (agent) Authorized by (policyholder) ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO AMERITAS LIFE INSURANCE CORP. DO NOT MAKE CHECKS PAYABLE TO THE AGENT OR LEAVE PAYEE BLANK. GR 902 Rev. 7-07 Page 3 of 3 110507L LIFE INSURANCE CORP. A UNIFI Company A STOCK COMPANY LINCOLN, NEBRASKA CERTIFICATE GROUP DENTAL INSURANCE The Policyholder THE METROPOLITAN ST.LOUIS SEWER DISTRICT Policy Number Plan Effective Date 10-350651 Insured Person February 1, 2010 Certificate Effective Date Refer to Exceptions on 9070. Class Number 1 Ameritas Life Insurance Corp. certifies that you will be insured for the benefits described on the following pages, according to all the terns of the group policy numbered above which has been issued to the Policyholder. Possession of this certificate does not necessarily mean you are insured. You are insured only if you meet the requirements set out in this certificate. The group policy may be amended or cancelled without the consent of the insured person. The group policy and this certificate are governed by the laws of the state in which the group policy was delivered. President Notice of Grievance Procedures State of Missouri Please read this notice carefully. This notice contains important information about how to file grievances with your insurer. You have the right to ask your insurer to assist you in filing a grievance, review its decisions involving your requests for service, or your requests to have your claims paid. Please contact: In Writing: By Phone: By Facsimile: Quality Control Unit P.O. Box 82657 Lincoln, NE 68501-2657 877-897-4328 (Toll -Free) 402-309-2579 Also, you always have the right to contact the Missouri Department of Insurance if you have a question or concern regarding your coverage under this contract. The Missouri Department may be contacted: In Writing: Missouri Department of Insurance 301 West High Street Jefferson City, Missouri 65101 By Phone: 800-726-7390 You also have the right to ask a relative, friend, lawyer, the Department of Insurance or other representative to assist you in filing a grievance, review its decisions involving your requests for service, or your requests to have your claims paid. You have the right to request through our Quality Control Department a written statement of the clinical rationale relied upon in making any adverse deteminations, as defined below. I. Definitions "Adverse Determination" means a determination made by us that a claim for a proposed or given health care service has been reviewed and, based upon the information provided, does not meet our requirement for medical necessity or appropriateness and, therefore a benefit is denied, reduced or terminated. "Grievance" means a written complaint submitted by or on behalf of an enrollee regarding the availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review, claims payment, handling, or matters pertaining to the contractual relationship between an enrollee and us. "Utilization Review" means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. II. Levels of Review Reconsideration — A treating provider has the opportunity to request, on your behalf, reconsideration of an adverse determination. A reviewing provider will conduct the reconsideration discussion within one working day of the request. The reviewing provider will either be the reviewer who made the adverse determination or a clinical peer if the original r eviewer is not available in the required timeframe. If the reconsideration process does not resolve the difference of opinion, the appeal process is available. The following levels of review will be available to an enrollee or provider acting on behalf of the enrollee. First Level Grievance Review - for written grievances, including those resulting from an adverse determination. Second Level Grievance Review - following first level reviews if grievance not resolved. Expedited Review - only for adverse determinations of emergency requests. A. First Level Grievance Review A written grievance concerning any matter, including an adverse determination, may be submitted by an enrollee. First level reviews of an adverse determination will be conducted by a clinical peer. Any first level review will not be reviewed by the same person or persons who made the initial determination denying a claim or handling the matter that is the subject of the grievance. Upon receipt of a request for a first level grievance review, we shall acknowledge receipt in writing of the grievance within ten working days. We will conduct a complete investigation of the grievance within twenty working days after receipt of the grievance. If the investigation cammt be completed within the twenty working days after receipt of the grievance, the enrollee will be notified in writing on or before the twentieth working day and the investigation shall be completed within thirty working days thereafter. The notice will set forth the reasons for which additional time is needed for the investigation. Within five working days after the investigation is completed, someone not involved in the circumstances giving rise to the grievance or its investigation will decide upon the appropriate resolution of the grievance and notify the enrollee in writing of the decision and of their right to file an appeal for a second level review. Within fifteen working days after the investigation is completed, we will notify the person who submitted the grievance of our resolution. B. Second Level Grievance Review Upon receipt of a request for a second level review for any grievance not involving an adverse determination, we shall submit the grievance to a grievance advisory panel, which consists of other enrollees, representatives who were not involved in the circumstances giving rise to the grievance or in any subsequent investigation or determination of the grievance. Any second level review will not be reviewed by the same person or persons who made the initial determination denying a claim or handling the matter that is the subject of the grievance. Second level reviews of an adverse determination will be conducted by a clinical peer. Any second level grievance review will follow the same time frames as a first level review. C. Expedited Review If the time frame of the standard grievance procedures would seriously jeopardize the life or health of an enrollee, an expedited review may be requested. A request for an expedited review may be submitted orally or in writing. However, the request shall not be considered a grievance unless the request is submitted in writing. Expedited review procedures shall be available to an enrollee, the representative of an enrollee and to the provider acting on behalf of the enrollee. We will notify an enrollee orally within seventy-two hours after receiving a request for an expedited review of our determination. We will provide written confirmation of our decision covering an expedited review within three working days of providing notification of the determination. Expedited reviews of an adverse determination will be reviewed by clinical peers in the same or similar specialty as would normally manage the case under review. These clinical peers will not have been involved in the initial adverse determination. An expedited review is not available for retrospective adverse determinations. Written Decision When a decision is issued from any level of review, the following information will be included in the written decision: 1. a statement of the reviewer's understanding to the grievance; 2. the decision stated in clear teens and the contract basis or medical rationale supporting the decision, a reference to the evidence or documentation used as a basis for the decision; 3. if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, provide the enrollee and their designated representative with either the specific rule, guideline, protocol, or other similar criterion or a statement that such rule, guideline, protocol or other criterion relied upon in making the adverse determination. A copy of such will be provided free of charge to the enrollee and their designated representative upon request; 4. for first level reviews, a description of the process to obtain a second level grievance review and the time frame for review. 5. notice of the enrollee's right to contact the Missouri Department of Insurance. TABLE OF CONTENTS Name of Provision Page Number Schedule of Benefits Begins on 9040 Benefit Information, including Deductibles, Coinsurance, & Maximums Definitions Late Entrant, Dependent 9060 Conditions for Insurance Eligibility Eligibility Period Elimination Period Contribution Requirement Effective Date Termination Date Dental Expense Benefits Alternate Benefit provision Limitations, including Elimination Periods, Missing Tooth Clause, Cosmetic Clause, Late Entrant 9070 9219 Table of Dental Procedures 9232 Covered Procedures, Frequencies, Criteria Orthodontic Expense Benefits 9260 Coordination of Benefits 9300 General Provisions 9310 Claim Forms Proof of Loss Payment of Benefits ERISA Information and Notice of Your Rights ERISA Notice SCHEDULE OF BENEFITS OUTLINE OF COVERAGE The Insurance for each Insured and each Insured Dependent will be based on the Insured's class shown in this Schedule of Benefits. Benefit Class Class 1 DENTAL EXPENSE BENEFITS Class Description Employee Enrolled In The Passive Ppo Plan When you select a Participating Provider, a discounted fee schedule is used which is intended to provide you, the Insured, reduced out of pocket costs. Deductible Amount: Type 1 Procedures $0 Combined Type 2 and Type 3 Procedures - Each Benefit Period $50 On the date that the members of one family have satisfied the Maximum Family Deductible shown below, no covered Expenses incun-ed after that date by any other family member will be applied toward the satisfaction of any Deductible Amount for the rest of that Benefit Period. Maximum Family Deductible $ 150 Dental expenses incurred by an individual on or after January 1, 2010, but before February 1, 2010, will apply to the Deductible Amount if: a. proof is furnished to us that such dental expenses were applicable to the deductible under the Policyholder's dental insurance policy in force immediately prior to February 1, 2010; and b. such expenses would have been considered Covered Expenses under this policy had this policy been in force at the time the expenses were incurred. Coinsurance Percentage: Type 1 Procedures 100% Type 2 Procedures 80% Type 3 Procedures 50% Maximum Amount - Each Benefit Period $1,500 ORTHODONTIC EXPENSE BENEFITS Deductible Amount - Once per lifetime $0 Coinsurance Percentage 50% Maximum Benefit During Lifetime $1,500 The Maximum Benefit shown above will be modified for: a. any person who was insured for an Orthodontic Expense Benefit under the prior carrier on January 31, 2010, and b. on February 1, 2010 is both: insured under the policy, and ii. culTently undergoing a Treatment Program which would have been a covered Treatment Program under the prior carrier had the prior carrier's coverage remained in force. The modification will result in a reduction of the Maximum Benefit based on: a. the normal benefit payable under the policy for the current Treatment Program, minus b. any amounts to which the person is entitled from the prior carrier for such Treatment Program. Nothing stated above, however, will act to provide coverage or increase benefits, when the Treatment Program is subject to any limitation shown on 9260. DEFINITIONS COMPANY refers to Ameritas Life Insurance Corp. The words "we", "us" and "our" refer to Company. Our Horne Office address is 5900 "O" Street, Lincoln, Nebraska 68510. POLICYHOLDER refers to the Policyholder stated on the face page of the policy. INSURED refers to a person: a. who is a Member of the eligible class; and b. who has qualified for insurance by completing the eligibility period, if any; and c. for whom the insurance has become effective. CHILD. Child refers to the child of the Insured or a child of the Insured's spouse, if they otherwise meet the definition of Dependent. DEPENDENT refers to: a. an Insured's spouse. b. each unmarried child less than 25 years of age, for whom the Insured or the insured's spouse, is legally responsible, including: natural born children; ii. adopted children, eligible from: (a) the date of birth if a petition for adoption is filed within thirty days of the date of the birth of such child; or (b) from the date of placement for adoption if a petition for adoption is filed within thirty days of placement of such child. Such coverage shall continue unless the placement is disrupted prior to legal adoption and the child is removed from placement. "Placement" means in the physical custody of the adoptive parent. iii. children covered under a Qualified Medical Child Support Order as defined by applicable Federal and State laws. c. each unmarried child age 25 or older who: is Totally Disabled as defined below; and ii. becomes Totally Disabled while insured as a dependent under b. above. Coverage of such child will not cease if proof of dependency and disability is given within 31 days of attaining the limiting age and subsequently as may be required by us but not more frequently than annually after the initial two-year period following the child's attaining the limiting age. Any costs for providing continuing proof will be at our expense. TOTAL DISABILITY describes the Insured's Dependent as: 1 • Continuously incapable of self-sustaining employment by reason of mental or physical handicap; and 2. Chiefly dependent upon the Insured for support and maintenance. DEPENDENT UNIT refers to all of the people who are insured as the dependents of any one Insured. PROVIDER refers to any person who is licensed by the law of the state in which treatment is provided within the scope of the license. LATE ENTRANT refers to any person: a. whose Effective Date of insurance is more than 31 days from the date the person becomes eligible for insurance; or b. who has elected to become insured again after canceling a premium contribution agreement. PLAN EFFECTIVE DATE refers to the date coverage under the policy becomes effective. The Plan Effective Date for the Policyholder is shown on the policy cover. The effective date of coverage for an Insured is shown in the Policyholder's records. All insurance will begin at 12:01 A.M. on the Effective Date. It will end after 11:59 P.M. on the Termination Date. All times are stated as Standard Time of the residence of the Insured. PLAN CHANGE EFFECTIVE DATE refers to the date that the policy provisions originally issued to the Policyholder change as requested by the Policyholder. The Plan Change Effective date for the Policyholder will be shown on the policy cover, if the Policyholder has requested a change. The plan change effective date for an Insured is shown in the Policyholder's records or on the cover of the certificate. TOTAL DISABILITY describes the Insured's Dependent as: 1 Continuously incapable of self-sustaining employment by reason of mental or h handicap; and physical 2. Chiefly dependent upon the Insured for support and maintenance. DEPENDENT UNIT refers to all of the people who are insured as the dependents of any one Insured. PROVIDER refers to any person who is licensed by the law of the state in which treatment is provided ti scope of the license. LATE ENTRANT refers to any person: n the a. whose Effective Date of insurance is more than 31 days from the date the person becomes eligible for insurance; or b. who has elected to become insured again after canceling a premium contribution PLAN EFFECTIVE DATE refers to the date coverage under the policy becomes effect' hgrPemeEf Date for the Policyholder is shown on the policy cover. The effective date of covera e for the Policyholder's records. effective. The Plan Effective g an Insured is shown in All insurance will begin at 12:01 A.M. on the Effective Date. It will end after 11:59 P.M. on the Termination Date. All times are stated as Standard Time of the residence of the Insured. PLAN CHANGE EFFECTIVE DATE refers to the date that the policy Policyholder change as requested by the Policyholder. The Plan Change Effective be shown on the policy cover, if the Policyholder has requested a P y provisions originally issued to the be is shown in they cover, iftde P records hol e on the e of the g date for dive ate Policyholder will change. The plan change effective date for an certificate. CONDITIONS FOR INSURANCE COVERAGE ELIGIBILITY ELIGIBLE CLASS FOR MEMBERS. The members of the eligible class(es) are shown on the Schedule of Benefits. Each member of the eligible class (referred to as "Member") will qualify for such insurance on the day he or she completes the required eligibility period, if any. Members choosing to elect coverage will hereinafter be referred to as "Insured." If employment is the basis for membership, a member of the Eligible Class for Insurance is any employee enrolled in the passive ppo plan working at least 37 hours per week. If membership is by reason other than employment, then a member of the Eligible Class for Insurance is as defined by the Policyholder. if a husband and wife are both Members and if either of them insures their dependent children, then the husband or wife, whoever elects, will be considered the dependent of the other. As a dependent, the person will not be considered a Member of the Eligible Class, but will be eligible for insurance as a dependent. ELIGIBLE CLASS FOR DEPENDENT INSURANCE. Each Member of the eligible class(es) for dependent coverage is eligible for the Dependent Insurance under the policy and will qualify for this Dependent Insurance on the latest of: 1. the day he or she qualifies for coverage as a Member; 2. the day he or she first becomes a Member; or 3. the day he or she first has a dependent. For dependent children, a newborn child will be considered an eligible dependent from the moment of birth. A Member must be an Insured to also insure his or her dependents. If employment is the basis for membership, a member of the Eligible Class for Dependent Insurance is any employee enrolled in the passive ppo plan working at least 37 hours per week and has eligible dependents. If membership is by reason other than employment, then a member of the Eligible Class for Insurance is as defined by the Policyholder. Any husband or wife who elects to be a dependent rather than a member of the Eligible Class for Personal Insurance, as explained above, is not a member of the Eligible Class for Dependent Insurance. When a member of the Eligible Class for Dependent Insurance dies and, if at the date of death, has dependents insured, the Policyholder has the option of offering the dependents of the deceased employee continued coverage. If elected by the Policyholder and the affected dependents, the name of such deceased member will continue to be listed as a member of the Eligible Class for Dependent Insurance. CONTRIBUTION REQUIREMENTS. Member Insurance: An Insured is required to contribute to the payment of his or her insurance premiums. Dependent Insurance: An Insured is required to contribute to the payment of insurance premiums for his or her dependents. SECTION 125. This policy is provided as part of the Policyholder's Section 125 Plan. Each Member has the option under the Section 125 Plan of participating or not participating in this policy. If a Member does not elect to participate when initially eligible, the Member may elect to participate at the Policyholder's next Election Period. This Election Period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on February 1. Members may change their election option only during an Election Period, except for a change in family status. Such events would be marriage, divorce, birth of a child, death of a spouse or child, or termination of employment of a spouse. ELIGIBILITY PERIOD. For Members on the Plan Effective Date of the policy, coverage is effective immediately. For persons who become Members after the Plan Effective Date of the policy, qualification will occur after an eligibility period defined by the Policyholder is satisfied. The same eligibility period will be applied to all members. OPEN ENROLLMENT. If a Member does not elect to participate when initially eligible, the Member may elect to participate at the Policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on February 1. If employment is the basis for membership in the Eligible Class for Members, an Insured whose eligibility terminates and is established again, may or may not have to complete a new eligibility period before he or she can again qualify for insurance. ELIMINATION PERIOD. Certain covered expenses may be subject to an elimination period, please refer to the TABLE OF DENTAL PROCEDURES, DENTAL EXPENSE BENEFITS, and if applicable, the ORTHODONTIC EXPENSE BENEFITS pages for details. EFFECTIVE DATE. Each Member has the option of being insured and insuring his or her Dependents. To elect coverage, he or she must agree in writing to contribute to the payment of the insurance premiums. The Effective Date for each Member and his or her Dependents, will be: 1. the date on which the Member qualifies for insurance, if the Member agrees to contribute on or before that date. 7 the date on which the Member agrees to contribute, if that date is within 31 days after the date he or she qualifies for insurance. 3. the date we accept the Member and/or Dependent for insurance when the Member and/or Dependent is a Late Entrant. The Member and/or Dependent will be subject to any limitation concerning Late Entrants. EXCEPTIONS. If employment is the basis for membership, a Member must be in active service on the date the insurance, or any increase in insurance, is to take effect. If not, the insurance will not take effect until the day he or she returns to active service. Active service refers to the performance in the customary manner by an employee of all the regular duties of his or her employment with his or her employer on a full time basis at one of the employer's business establishments or at some location to which the employer's business requires the employee to travel. A Member will be in active service on any regular non -working day if he or she is not totally disabled on that day and if he or she was in active service on the regular working day before that day. If membership is by reason other than employment, a Member must not be totally disabled on the date the insurance, or any increase in insurance, is to take effect. The insurance will not take effect until the day after he or she ceases to be totally disabled. But any person who is not in active service or is totally disabled will be insured on the Effective Date if: a. the person was insured under a policy of group insurance providing like benefits which ended on the day immediately before the Effective Date of the policy providing this coverage; and b. the person is considered a Member or an eligible Dependent under the policy providing this coverage; and had the prior policy contained the same definition of eligibility, would have been a Member or Dependent under the prior policy. TERMINATION DATES INSUREDS. The insurance for any Insured, will automatically terminate on the earliest of: 1. the date the Insured ceases to be a Member; 2. the last day of the period for which the Insured has contributed, if required, to the payment of insurance premiums; or 3. the date the policy is terminated. DEPENDENTS. The insurance for all of an Insured's dependents will automatically terminate on the earliest of: 1. the date on which the Insured's coverage terminates; 2. the date on which the Insured ceases to be a Member; 3. the last day of the period for which the Insured has contributed, if required, to the payment of insurance premiums; or 4. the date all Dependent Insurance under the policy is terminated. The insurance for any Dependent will automatically terminate on the day before the date on which the dependent no longer meets the definition of a dependent. See "Definitions." CONTINUATION OF COVERAGE. If coverage ceases according to TERMINATION DATE, some or all of the insurance coverages may be continued. Contact your plan administrator for details. Death, Divorce or Separation For Dependents Only The following provisions are applicable for employers with 20 or more employees and any policy with 20 or more certificate holders, 1. Eligibility The Insured's spouse may continue coverage for themselves and any dependent children if coverage would terminate and the spouse is 55 years of age or older at the time of the expiration of coverage provided by Consolidated Omnibus Budget Reconciliation Act ("COBRA") because of: a. the death of the insured; or b. the dissolution of marriage or legal separation from the insured. 2. Benefits. This continuation applies to all benefits payable under the policy. 3. How to Apply a. Within 60 days of legal separation or the entry of a decree of dissolution of marriage or prior to the expiration of a 36 month federal COBRA continuation period covering a legally separated or divorced spouse, if such spouse has elected and maintained such COBRA coverage, a legally separated or divorced spouse eligible for continued coverage who seeks such coverage shall give the plan administrator written notice of the legal separation or dissolution and the mailing address of the spouse. b. Within 30 days of the death of the insured whose surviving spouse is eligible for continued coverage, or prior to the expiration of a 36 month COBRA continuation period covering such surviving spouse, if such spouse has elected and maintained such COBRA coverage, the policyholder shall give the plan administrator written notice of the death and the mailing address of the surviving spouse. c. Within 14 days of receipt of notice, the plan administrator will notify the legally separated, divorced or surviving spouse that coverage may be continued. This notice will be mailed to the mailing address provided to the plan administrator and will include: i. a form for election to continue the coverage; ii. a statement of the amount of periodic premiums to be charged for the continuation of coverage and method and place of payment; and iii. instructions for returning the election form by mail within 60 days after the date the notice is mailed. Failure of the legally separated, divorced or surviving spouse to exercise this election will terminate the right to continuation of benefits. If the plan administrator was properly notified and failed to notify the legally separated, divorce or surviving spouse as required, such spouse's coverage shall continue in effect, and the obligation to make any premium payment for continuation coverage shall be postponed for the period of time beginning on the date the spouse's coverage would otherwise terminate and ending 31 days after the date the required notice was provided. Failure or delay in providing the notice will not reduce, eliminate or postpone any obligation to pay premiums on behalf of such legally separated, divorced or surviving spouse during such period. 4. Premiums a. During the period of time covered by COBRA, the monthly contribution for the premium shall not be greater than the amount that would be charged if the legally separated, divorced or surviving spouse were a current certificate holder of the group policy, plus the amount that the group policy holder would contribute toward the premium if the legally separated, divorced surviving spouse were a certificate holder, plus an additional amount not to exceed two percent of the certificate holder or group policyholder's contributions for the cost of administration. After the period of time covered by the insurance premium provisions of COBRA has expired, the monthly contribution for the premium shall not be greater than the amount that would have been charged if the legally separated, divorced or surviving spouse were a current certificate holder of the policy, plus the amount that the group policy holder would contribute toward the premium if the legally separated, divorced or surviving spouse were a certificate holder, plus an amount not to exceed twenty-five percent of the certificate or group policyholder's contributions. Such additional contributions shall be determined by each individual plan administrator and shall be subject to review by the Missouri Department of Insurance. b. The first premium shall be paid by the legally separated, divorced or surviving spouse within 45 days of the date of the election. 5. Termination a. The right to continuation of coverage shall terminate upon the earliest of any of the following: i. The failure to pay premiums when due, including any grace period allowed by the policy; The date that the group policy is terminated as to all group members, except that if a different group policy is made available, the legally separated, divorced or surviving spouse shall be eligible for continuation of coverage as if the original policy had not been terminated; iii. The date on which the legally separated, divorced or surviving spouse becomes insured under another group health plan; or iv. The date on which the legally separated, divorced or surviving spouse remarries and becomes insured under another group health plan; or The date on which the legally separated, divorced or surviving spouse attains his or her 65th birthday. DENTAL EXPENSE BENEFITS We will determine dental expense benefits according to the terms of the group policy for dental expenses incurred by an Insured. An Insured person has the freedom of choice to receive treatment from any Provider. PARTICIPATING AND NON -PARTICIPATING PROVIDERS. The Insured person may select a Participating Provider or a Non -Participating Provider. A Participating Provider agrees to provide services at a discounted fee to our Insureds. A Non -Participating Provider is any other Provider. DETERMINING BENEFITS. The benefits payable will be determined by totaling all of the Covered Expenses submitted into each benefit type as shown in the Table of Dental Procedures. This amount is reduced by the Deductible, if any. The result is then multiplied by the Coinsurance Percentage(s) shown in the Schedule of Benefits. Benefits are subject to the Maximum Amount, if any, shown in the Schedule of Benefits. BENEFIT PERIOD. Benefit Period refers to the period shown in the Table of Dental Procedures. DEDUCTIBLE. The Deductible is shown on the Schedule of Benefits and is a specified amount of Covered Expenses that must be incurred and paid by each Insured person prior to any benefits being paid. MAXIMUM AMOUNT. The Maximum Amount shown in the Schedule of Benefits is the maximum amount that may be paid for the Covered Expenses incurred by an Insured. COVERED EXPENSES. Covered Expenses include: 1. only those expenses for dental procedures performed by a Provider; and 2. only those expenses for dental procedures listed and outlined on the Table of Dental Procedures. Covered Expenses are subject to "Limitations." See Limitations and Table of Dental Procedures. Benefits payable for Covered Expenses also will be limited to the lesser of: 1. the actual charge of the Provider. 2. the usual and customary ("U&C") as determined by us, if services are provided by a Non Participating Provider. 3. the Maximum Allowable Charge ("MAC") as determined by us. Usual and Customary ("U&C") describes those dental charges that we have determined to be the usual and customary charge for a given dental procedure within a particular ZIP code area. The U&C is based upon a combination of dental charge information taken from our own database as well as from data received from nationally recognized industry databases. From the array of charges ranked by amount, your Policyholder (in most cases your employer) has selected a percentile that will be used to determine the maximum U&C for your plan. The U&C is reviewed and updated periodically. The U&C can differ from the actual fee charged by your provider and is not indicative of the appropriateness of the provider's fee. Instead, the U&C is simply a plan provision used to determine the extent of benefit coverage purchased by your Policyholder. MAC - The Maximum Allowable Charge is derived from the array of provider charges within a particular ZIP code area. These allowances are the charges accepted by general dentists who are Participating Providers. The MAC is reviewed and updated periodically to reflect increasing provider fees within the ZIP code area. ALTERNATIVE PROCEDURES. If two or more procedures are considered adequate and appropriate treatment to correct a certain condition under generally accepted standards of dental care, the amount of the Covered Expense will be equal to the charge for the least expensive procedure. This provision is NOT intended to dictate a course of treatment. Instead, this provision is designed to deternine the amount of the plan allowance for a submitted treatment when an adequate and appropriate alternative procedure is available. Accordingly, you may choose to apply the alternate benefit amount determined under this provision toward payment of the submitted treatment. We may request pre -operative dental x-ray films, periodontal charting and/or additional diagnostic data to determine the plan allowance for the procedures submitted. We strongly encourage pre-treatment estimates so you understand your benefits before any treatment begins. Ask your provider to submit a claim form for this purpose. EXPENSES INCURRED. An expense is incurred at the time the impression is made for an appliance or change to an appliance. An expense is incurred at the time the tooth or teeth are prepared for a dental prosthesis or prosthetic crown. For root canal therapy, an expense is incurred at the time the pulp chamber is opened. All other expenses are incurred at the time the service is rendered or a supply furnished. LIMITATIONS. Covered Expenses will not include and benefits will not be payable for expenses incurred: 1. in the first 12 months that a person is insured if the person is a Late Entrant; except for evaluations, prophylaxis (cleanings), and fluoride application. 2. a. for initial placement of any dental prosthesis or prosthetic crown unless such placement is needed because of the extraction of one or more teeth while the insured person is covered under this contract. But the extraction of a third molar (wisdom tooth) will not qualify under the above. Any such dental prosthesis or prosthetic crown must include the replacement of the extracted tooth or teeth, unless the insured person is covered on February 1, 2010. For those Insureds covered on February 1, 2010, see b. b. Limitation a. will be waived for those Insureds whose coverage was effective on February 1, 2010 and i. the person has the tooth extracted while insured under the prior contract: and ii. has a dental prosthesis or prosthetic crown installed to replace the extracted tooth while insured under our contract; but such extraction and installation must take place within a twelve-month period; and iii. the dental prosthesis or prosthetic crown noted above must be an initial placement. 3. for appliances, restorations, or procedures to: a. alter vertical dimension; b. restore or maintain occlusion; or c. splint or replace tooth structure lost as a result of abrasion or attrition. 4. for any procedure begun after the insured person's insurance under this contract terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the Insured's insurance under this contract terminates. 5. to replace lost or stolen appliances. 6. for any treatment which is for cosmetic purposes. 7. for any procedure not shown in the Table of Dental Procedures. (There may be additional frequencies and limitations that apply, please see the Table of Dental Procedures for details.) 8. for orthodontic treatment under this benefit provision. (If orthodontic expense benefits have been included in this policy, please refer to the Schedule of Benefits and Orthodontic Expense Benefits provision found on 9260). 9. for which the Insured person is entitled to benefits under any workmen's compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit. 10. for charges which the Insured person is not liable or which would not have been made had no insurance been in force. 11. for services that are not required for necessary care and treatment or are not within the generally accepted parameters of care. 12. because of war or any act of war, declared or not. TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFO FREQUENCIES AND PROVISIONS AT ON CAREFULLY FOR YOUR PROCEDURE The attached is a list of dental procedures for which benefits are payable under this section; and Current Dental Terminology © American Dental Association. No benefits are a able for a not listed. �s based upon the rocedui•e that is Your benefits are based on a Calendar Year. A Calendar Year runs from January 1 through Benefit Period means the period from January 1 of any year through December 3] of the same December 3 ] . during the first year a person is insured, a benefit period means the period fromhis or her effective tyeer.Butwe date through December 31 of that year. Covered Procedures are subject to all plan provisions, procedure and frequency limitation review. s, and/or consultant Reference to "traumatic injury" under this plan is defined as injury, caused by external forces (ie. outside the mouth) and specifically excludes injury caused by internal forces such as biuxism Benefits for replacement dental prosthesis or prosthetic crown will be based (grinding of teeth). Frequencies which reference Benefit Period will be measured forward within thehimitsodefed asplacement the B. Period. All other frequencies will be measured forward from the last covered date of service. as Benefit. X-ray films, periodontal charting and supporting diagnostic data may be requested for our review. y We recommend that a pre-treatment estimate be submitted for all anticipated work that is considered to be expensive by our insured. A pre-treatment estimate is not a pre -authorization or guarantee of payment or eligibility; rather it is an indication of the estimated benefits available if the described procedures are performed. g TYPE 1 PROCEDURES PAYMENT BASIS - NON PARTICIPATING PROVIDERS - Usual and Customary PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations ROUTINE ORAL EVALUATION D0120 Periodic oral evaluation - established patient. D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver. D0150 Comprehensive oral evaluation - new or established patient. D0180 Comprehensive periodontal evaluation - new or established patient. COMPREHENSIVE EVALUATION: D0150, D0180 • Coverage is limited to 1 of each of these procedures per 1 provider. • In addition, D0150, D0180 coverage is limited to 2 of any of these procedures per 1 benefit period. • 00120, D0145, also contribute(s) to this limitation. • If frequency met, will be considered at an alternate benefit of a 00120/D0145 and count towards this frequency. ROUTINE EVALUATION: D0120. 00145 • Coverage is limited to 2 of any of these procedures per 1 benefit period. • D0150, D0180, also contribute(s) to this limitation. • Procedure D0120 will be considered for individuals age 3 and over. Procedure D0145 will be considered for individuals age 2 and under. COMPLETE SERIES OR PANORAMIC FILM D0210 Intraoral - complete series (including bitewings). D0330 Panoramic film. COMPLETE SERIES/PANORAMIC FILMS: D0210. D0330 • Coverage is limited to 1 of any of these procedures per 3 year(s). OTHER XRAYS D0220 Intraoral - periapical first film. D0230 Intraoral - periapical each additional film. D0240 Intraoral - occlusal film. D0250 Extraoral - first film. D0260 Extraoral - each additional film. PERIAPICAL FILMS: D0220, D0230 • The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. BITEWING FILMS D0270 Bitewing - single film. D0272 Bitewings - two films. D0273 Bitewings - three films. D0274 Bitewings - four films. D0277 Vertical bitewings - 7 to 8 films. BITEWING FILMS: D0270, D0272, D0273, D0274 • Coverage is limited to 2 of any of these procedures per 1 benefit period. • D0277, also contribute(s) to this limitation. • The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. VERTICAL BITEWING FILM: D0277 • Coverage is limited to 1 of any of these procedures per 3 year(s). • The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. PROPHYLAXIS (CLEANING) AND FLUORIDE D1110 Prophylaxis - adult. D1120 Prophylaxis - child. D1203 Topical application of fluoride - child. D1204 Topical application of fluoride - adult. D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients. FLUORIDE: D1203, D1204, D1206 TYPE 1 PROCEDURES • Coverage is limited to 1 of any of these procedures per 1 benefit period. • Benefits are considered for persons age 18 and under. An adult fluoride is considered for individuals age 14 and over. A child fluoride is considered for individuals age 13 and under. PROPHYLAXIS: D1110,D1120 • Coverage is limited to 2 of any of these procedures per 1 benefit period. D4910, also contributes) to this limitation. An adult prophylaxis (cleaning) is considered for individuals age 14 and over. A child prophylaxis (cleaning) is considered for individuals age 13 and under. Benefits for prophylaxis (cleaning) are not available when performed on the same date as periodontal procedures. SEALANT D1351 Sealant - per tooth. SEALANT: D1351 • Coverage is limited to 1 of any of these procedures per 3 year(s). • Benefits are considered for persons age 16 and under. • Benefits are considered on permanent molars only. • Coverage is allowed on the occlusal surface only. APPLIANCE THERAPY D8210 Removable appliance therapy. D8220 Fixed appliance therapy. APPLIANCE THERAPY: D8210, D8220 • Coverage is limited to the conection of thumb -sucking. TYPE 2 PROCEDURES PAYMENT BASIS - NON PARTICIPATING PROVIDERS - Usual and Customary PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations LIMITED ORAL EVALUATION D0140 Limited oral evaluation - problem focused. D0170 Re-evaluation - limited, problem focused (established patient; not post -operative visit). LIMITED ORAL EVALUATION: D0140, D0170 • Coverage is allowed for accidental injury only. If not due to an accident, will be considered at an alternate benefit of a D0120%D0145 and count towards this frequency. ORAL PATHOLOGY/LABORATORY D0472 Accession of tissue, gross examination, preparation and transmission of written report. D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report. D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report. ORAL PATHOLOGY LABORATORY: D0472, D0473, D0474 • Coverage is limited to 1 of any of these procedures per 12 month(s). • Coverage is limited to 1 examination per biopsy/excision. SPACE MAINTAINERS D1510 Space maintainer - fixed - unilateral. D1515 Space maintainer - fixed - bilateral. D1520 Space maintainer - removable - unilateral. D1525 Space maintainer - removable - bilateral. D1550 Re -cementation of space maintainer. D1555 Removal of fixed space maintainer. SPACE MAINTAINER: D1510, D1515, D1520, D1525 • Coverage is limited to space maintenance for unerupted teeth, following extraction of primary teeth. Allowances include all adjustments within 6 months of placement date. AMALGAM RESTORATIONS (FILLINGS) D2140 Amalgam - one surface, primary or permanent. D2150 Amalgam - two surfaces, primary or permanent. D2160 Amalgam - three surfaces, primary or permanent. D2161 Amalgam - four or more surfaces, primary or permanent. AMALGAM RESTORATIONS: D2140, D2150, D2160. D2161 • Coverage is limited to 1 of any of these procedures per 6 nionth(s). • D2330, D233I, 02332. 02335. D2391, D2392, D2393, D2394, D9911, also contribute(s) to this limitation. RESIN RESTORATIONS (FILLINGS) D2330 D2331 D2332 D2335 D2391 D2392 D2393 D2394 D2410 D2420 D2430 Resin -based composite Resin -based composite Resin -based composite Resin -based composite Resin -based composite Resin -based composite Resin -based composite Resin -based composite Gold foil - one surface. Gold foil - two surfaces. Gold foil - three surfaces. - one surface, anterior. - two surfaces, anterior. - three surfaces, anterior. - four or more surfaces or involving incisal angle (anterior). - one surface, posterior. - two surfaces, posterior. - three surfaces, posterior. - four or more surfaces, posterior. COMPOSITE RESTORATIONS: D2330. D2331, D2332, D2335. D2391, D2392, D2393, D2394 TYPE 2 PROCEDURES • Coverage is limited to 1 of any of these procedures per 6 month(s). • D2140, D2150, D2160, D2161, D991 I, also contribute(s) to this limitation. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable restorations. GOLD FOIL RESTORATIONS: D2410, D2420. D2430 • Gold foils are considered at an alternate benefit of an amalgam/composite restoration. ENDODONTICS MISCELLANEOUS D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament. D3221 Pulpal debridement, primary and permanent teeth. D3222 Partial Pulpotomy for apexogenesis - permanent tooth with incomplete root development. D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration). D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration). D3333 Internal root repair of perforation defects. D3351 Apexification/reca]cification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352 Apexication/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.). D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.). D3430 Retrograde filling - per root. D3450 Root amputation - per root. D3920 Hemisection (including any root removal), not including root canal therapy. ENDODONTICS MISCELLANEOUS: D3333, D3430, D3450, D3920 • Procedure D3333 is limited to permanent teeth only. ENDODONTIC THERAPY (ROOT CANALS) D3310 Endodontic therapy, anterior tooth. D3320 Endodontic therapy, bicuspid tooth. D3330 Endodontic therapy, molar. D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth. D3346 Retreatment of previous root canal therapy - anterior. D3347 Retreatment of previous root canal therapy - bicuspid. D3348 Retreatment of previous root canal therapy - molar. ROOT CANALS: D3310, D3320, D3330, D3332 • Benefits are considered on permanent teeth only. • Allowances include intraoperative films and cultures but exclude final restoration. RETREATMENT OF ROOT CANAL: D3346, D3347, D3348 • Coverage is limited to 1 of any of these procedures per 12 month(s). • D3310, D3320, D3330, also contribute(s) to this limitation. • Benefits are considered on permanent teeth only. • Coverage is limited to service dates more than 12 months after root canal therapy. Allowances include intraoperative films and cultures but exclude final restoration. SURGICAL ENDODONTICS D3410 Apicoectomy/periradicular D3421 Apicoectomy/periradicular D3425 Apicoectomy/periradicular D3426 Apicoectomy/periradicular surgery - anterior. surgery - bicuspid (first root). surgery - molar (first root). surgery (each additional root) • SURGICAL PERIODONTICS D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant. TYPE 2 PROCEDURES D421 1 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant. D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant. D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant. D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant. D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant. D4263 Bone replacement graft - first site in quadrant. D4264 Bone replacement graft - each additional site in quadrant. D4265 Biologic materials to aid in soft and osseous tissue regeneration. D4270 Pedicle soft tissue graft procedure. D4271 Free soft tissue graft procedure (including donor site surgery). D4273 Subepithelial connective tissue graft procedures, per tooth. D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the salve anatomical area). D4275 Soft tissue allograft. D4276 Combined connective tissue and double pedicle graft, per tooth. BONE GRAFTS: D4263, D4264, D4265 • Each quadrant is limited to 1 of each of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. GINGIVECTOMY: D4210,D4211 • Each quadrant is limited to 1 of each of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. OSSEOUS SURGERY: D4240, D4241, D4260, D4261 • Each quadrant is limited to 1 of each of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. TISSUE GRAFTS: D4270, D427I, D4273, D4275, D4276 • Each quadrant is limited to 2 of any of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. NON -SURGICAL PERIODONTICS D4341 Periodontal scaling and root planing - four or more teeth per quadrant. D4342 Periodontal scaling and root planing - one to three teeth, per quadrant. D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report. CHEMOTHERAPEUTIC AGENTS: D4381 • Each quadrant is limited to 2 of any of these procedures per 2 year(s). PERIODONTAL SCALING & ROOT PLANING: D4341. D4342 • Each quadrant is limited to 1 of each of these procedures per 2 year(s). FULL MOUTH DEBRIDEMENT D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis. FULL MOUTH DEBRIDEMENT: D4355 • Coverage is limited to 1 of any of these procedures per 5 year(s). PERIODONTAL MAINTENANCE D4910 Periodontal maintenance. PERIODONTAL MAINTENANCE: D4910 • Coverage is limited to 2 of any of these procedures per 1 benefit period. • Dl ] 10, D1120, also contribute(s) to this limitation. • Coverage is contingent upon evidence of full mouth active periodontal therapy. Benefits are not available if performed on the same date as any other periodontal procedure. NON -SURGICAL EXTRACTIONS D7111 Extraction, coronal remnants - deciduous tooth. D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal). TYPE 2 PROCEDURES SURGICAL EXTRACTIONS D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. D7220 Removal of impacted tooth - soft tissue. D7230 Removal of impacted tooth - partially bony. D7240 Removal of impacted tooth - completely bony. D7241 Removal of impacted tooth - completely bony, with unusual surgical complications. D7250 Surgical removal of residual tooth roots (cutting procedure). OTHER ORAL SURGERY D7260 Oroantral fistula closure. D7261 Primary closure of a sinus perforation. D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth. D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization). D7280 Surgical access of an unerupted tooth. D7282 Mobilization of erupted or malpositioned tooth to aid eruption. D7283 Placement of device to facilitate eruption of impacted tooth. D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant. D7311 Alveoplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant. D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant. D7321 Alveoplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant. D7340 Vestibuloplasty - ridge extension (secondary epithelialization). D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue). D7410 Excision of benign lesion up to 1.25 cm. D7411 Excision of benign lesion greater than 1.25 cm. D7412 Excision of benign lesion, complicated. D7413 Excision of malignant lesion up to 1.25 cm. D7414 Excision of malignant lesion greater than 1.25 cm. D7415 Excision of malignant lesion, complicated. D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm. D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm. D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm. D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm. D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm. D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm. D7465 Destruction of lesion(s) by physical or chemical method, by report. D7471 Removal of lateral exostosis (maxilla or mandible). D7472 Removal of torus palatinus. D7473 Removal of torus mandibularis. D7485 Surgical reduction of osseous tuberosity. D7490 Radical resection of maxilla or mandible. D7510 Incision and drainage of abscess - intraoral soft tissue. D7520 Incision and drainage of abscess - extraoral soft tissue. D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue. TYPE 2 PROCEDURES D7540 Removal of reaction producing foreign bodies, musculoskeletal system. D7550 Partial ostectomy/sequestrectomy for removal of non -vital bone. D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body. D7910 Suture of recent small wounds up to 5 cm. D7911 Complicated suture - up to 5 cm. D7912 Complicated suture - greater than 5 cm. D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure. D7963 Frenuloplasty. D7970 Excision of hyperplastic tissue - per arch. D7972 Surgical reduction of fibrous tuberosity. D7980 Sialolithotomy. D7983 Closure of salivary fistula. REMOVAL OF BONE TISSUE: D7471, D7472, D7473 • Coverage is limited to 5 of any of these procedures per 1 lifetime. BIOPSY OF ORAL TISSUE D7285 Biopsy of oral tissue - hard (bone, tooth). D7286 Biopsy of oral tissue - soft. D7287 Exfoliative cytological sample collection. D7288 Brush biopsy - transepithelial sample collection. PALLIATIVE D9110 Palliative (emergency) treatment of dental pain - minor procedure. PALLIATIVE TREATMENT: D9110 • Not covered in conjunction with other procedures, except diagnostic x-ray films. ANESTHESIA-GENERAL/IV D9220 Deep sedation/general anesthesia - first 30 minutes. D9221 Deep sedation/general anesthesia - each additional 15 minutes. D9241 Intravenous conscious sedation/analgesia - first 30 minutes. D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes. GENERAL ANESTHESIA: D9220, D9221, D9241, D9242 • Coverage is only available with a cutting procedure. Verification of the dentist's anesthesia permit and a copy of the anesthesia repot is required. A maximum of two additional units (D922I or D9242) will be considered. PROFESSIONAL CONSULT/VISIT/SERVICES D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician. D9430 Office visit for observation (during regularly scheduled hours) - no other services performed. D9440 Office visit - after regularly scheduled hours. D9930 Treatment of complications (post -surgical) - unusual circumstances; by report. CONSULTATION: D9310 • Coverage is limited to 1 of any of these procedures per 1 provider. OFFICE VISIT: D9430. D9440 • Procedure D9430 is allowed for accidental injury only. Procedure D9440 will he allowed on the basis of services rendered or visit, whichever is greater. OCCLUSAL GUARD D9940 Occlusal guard, by report. OCCLUSAL GUARD: D9940 • Coverage is limited to 1 of any of these procedures per 3 year(s). • Benefits will not be available if performed for athletic purposes. OCCLUSAL ADJUSTMENT D9951 Occlusal adjustment - limited. D9952 Occlusal adjustment - complete. TYPE 2 PROCEDURES OCCLUSAL ADJUSTMENT: D9951, D9952 • Coverage is considered only when performed in conjunction with periodontal procedures for the treatment of periodontal disease. MISCELLANEOUS D0486 Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report. D2951 Pin retention - per tooth, in addition to restoration. D9911 Application of desensitizing resin for cervical and/or root surfaces, per tooth. DESENSITIZATION: D9911 • Coverage is limited to 1 of any of these procedures per 6 month(s). D2I40, D2150, D2I60, D2161, D2330, D2331, D2332, D2335, D2391, 02392, D2393, 02394, also contributes) to this limitation. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable restorations. TYPE 3 PROCEDURES PAYMENT BASIS - NON PARTICIPATING PROVIDERS - Usual and Customary PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations STAINLESS STEEL CROWN (PREFABRICATED CROWN) D2390 Resin -based composite crown, anterior. D2930 Prefabricated stainless steel crown - primary tooth. D2931 Prefabricated stainless steel crown - permanent tooth. D2932 Prefabricated resin crown. D2933 Prefabricated stainless steel crown with resin window. D2934 Prefabricated esthetic coated stainless steel crown - primary tooth. STAINLESS STEEL CROWN: D2390, D2930, D2931. D2932, D2933, D2934 • Replacement is limited to 1 of any of these procedures per 12 month(s). • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. INLAY RESTORATIONS D2510 Inlay - metallic - one surface. D2520 Inlay - metallic - two surfaces. D2530 Inlay - metallic - three or more surfaces. D2610 Inlay - porcelain/ceramic - one surface. D2620 Inlay - porcelain/ceramic - two surfaces. D2630 Inlay - porcelain/ceramic - three or more surfaces. D2650 Inlay - resin -based composite - one surface. D2651 Inlay - resin -based composite - two surfaces. D2652 Inlay - resin -based composite - three or more surfaces. INLAY: D2510. D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652 • Inlays will be considered at an alternate benefit of an amalgam/composite restoration and only when resulting from caries (tooth decay) or traumatic injury. ONLAY RESTORATIONS D2542 Onlay - metallic - two surfaces. D2543 Onlay - metallic - three surfaces. D2544 Onlay - metallic - four or more surfaces. D2642 Onlay - porcelain/ceramic - two surfaces. D2643 Onlay - porcelain/ceramic - three surfaces. D2644 Onlay - porcelain/ceramic - four or more surfaces. D2662 Onlay - resin -based composite - two surfaces. D2663 Onlay - resin -based composite - three surfaces. D2664 Onlay - resin -based composite - four or more surfaces. ONLAY: D2542, D2543, D2544, D2642, D2643, D2644, D2662, D2663, D2664 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604. D6605, D6606, D6607. D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Coverage is limited to necessary, placement resulting from caries (tooth decay) or traumatic injury. • Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. CROWNS SINGLE RESTORATIONS D2710 Crown - resin -based composite (indirect). D2712 Crown - 3/4 resin -based composite (indirect). D2720 Crown - resin with high noble metal. TYPE 3 PROCEDURES D2721 Crown - resin with predominantly base metal. D2722 Crown - resin with noble metal. D2740 Crown - porcelain/ceramic substrate. D2750 Crown porcelain fused to high noble metal. D2751 Crown - porcelain fused to predominantly base metal. D2752 Crown - porcelain fused to noble metal. D2780 Crown - 3/4 cast high noble metal. D2781 Crown - 3/4 cast predominantly base metal. D2782 Crown - 3/4 cast noble metal. D2783 Crown - 3/4 porcelain/ceramic. D2790 Crown - full cast high noble metal. D2791 Crown - full cast predominantly base metal. D2792 Crown - full cast noble metal. D2794 Crown - titanium. CROWN: D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, 02792. D2794 Replacement is limited to 1 of any of these procedures per 5 year(s). D2510, D2520, D2530, D2542, D2543, 02544, D2610, D2620, D2630, 02642, 02643. D2644, D2650, D2651, D2652, D2662, D2663. D2664, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D661 1, D6612, D6613, D6614, D66I5, D6624, D6634, D6710, D6720, D6721, D6722. D6740, D6750, D6751, D6752, D6780, D678I, D6782, D6783, D6790, D6791, D6792, D6794, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury. Benefits will not he considered if procedure D2390. D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. RECEMENT D2910 Recement inlay, onlay, or partial coverage restoration. D2915 Recement cast or prefabricated post and core. D2920 Recement crown. D6092 Recement implant/abutment supported crown. D6093 Recement implant/abutment supported fixed partial denture. D6930 Recement fixed partial denture. SEDATIVE FILLING D2940 Sedative filling. CORE BUILD-UP D2950 Core buildup, including any pins. D6973 Core build up for retainer, including any pins. POST AND CORE D2952 Post and core in addition to crown, indirectly fabricated. D2954 Prefabricated post and core in addition to crown. FIXED CROWN AND PARTIAL DENTURE REPAIR D2980 Crown repair, by report. D6980 Fixed partial denture repair, by report. D9120 Fixed partial denture sectioning. CROWN LENGTHENING D4249 Clinical crown lengthening - hard tissue. PROSTHODONTICS - FIXED/REMOVABLE (DENTURES) D5110 Complete denture - maxillary. TYPE 3 PROCEDURES D5120 Complete denture - mandibular. D5130 Immediate denture - maxillary. D5140 Immediate denture - mandibular. D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth). D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth). D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth). D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth). D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth). D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth). D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth). D5670 Replace all teeth and acrylic on cast metal framework (maxillary). D5671 Replace all teeth and acrylic on cast metal framework (mandibular). D5810 Interim complete denture (maxillary). D5811 Interim complete denture (mandibular). D5820 Interim partial denture (maxillary). D5821 Interim partial denture (mandibular). D5860 Overdenture - complete, by report. D5861 Overdenture - partial, by report. D6053 Implant/abutment supported removable denture for completely edentulous arch. D6054 Implant/abutment supported removable denture for partially edentulous arch. D6078 Implant/abutment supported fixed denture for completely edentulous arch. D6079 Implant/abutment supported fixed denture for partially edentulous arch. COMPLETE DENTURE: D5110, D5120, D5130, D5140, D5860, D6053, D6078 • Replacement is limited to 1 of any of these procedures per 5 year(s). • Frequency is waived for accidental injury. • Allowances include adjustments within 6 months after placement date. Procedures D5860, D6053, and D6078 are considered at an alternate benefit of a D5110/D5120. PARTIAL DENTURE: D5211, D5212, D5213, D5214, D5225, D5226, 05281, D5670, D5671, D5861, 06054, 06079 • Replacement is limited to 1 of any of these procedures per 5 year(s). - • Frequency is waived for accidental injury. • Allowances include adjustments within 6 months of placement date. Procedures D5861, D6054, and D6079 are considered at an alternate benefit of a D5213/05214. DENTURE ADJUSTMENTS D5410 Adjust complete denture - maxillary. D5411 Adjust complete denture - mandibular. D5421 Adjust partial denture - maxillary. D5422 Adjust partial denture - mandibular. DENTURE ADJUSTMENT: D5410, D5411, D542], D5422 • Coverage is limited to dates of service more than 6 months after placement date. DENTURE REPAIR D5510 Repair broken complete denture base. D5520 Replace missing or broken teeth - complete denture (each tooth). D5610 Repair resin denture base. D5620 Repair cast framework. D5630 Repair or replace broken clasp. D5640 Replace broken teeth - per tooth. ADD TOOTH/CLASP TO EXISTING PARTIAL D5650 Add tooth to existing partial denture. TYPE 3 PROCEDURES D5660 Add clasp to existing partial denture. DENTURE REBASES D5710 Rebase complete maxillary denture. D5711 Rebase complete mandibular denture. D5720 Rebase maxillary partial denture. D5721 Rebase mandibular partial denture. DENTURE RELINES D5730 Reline complete maxillary denture (chairside). D5731 Reline complete mandibular denture (chairside). D5740 Reline maxillary partial denture (chairside). D5741 Reline mandibular partial denture (chairside). D5750 Reline complete maxillary denture (laboratory). D5751 Reline complete mandibular denture (laboratory). D5760 Reline maxillary partial denture (laboratory). D5761 Reline mandibular partial denture (laboratory). DENTURE. RELINE: D5730, D5731, D5740, D5741, D5750, D5751, D5760, 05761 • Coverage is limited to service dates more than 6 months after placement date. TISSUE CONDITIONING D5850 Tissue conditioning, maxillary. D5851 Tissue conditioning, mandibular. PROSTHODONTICS - FIXED D6058 Abutment supported porcelain/ceramic crown. D6059 Abutment supported porcelain fused to metal crown (high noble metal). D6060 Abutment supported porcelain fused to metal crown (predominantly base metal). D6061 Abutment supported porcelain fused to metal crown (noble metal). D6062 Abutment supported cast metal crown (high noble metal). D6063 Abutment supported cast metal crown (predominantly base metal). D6064 Abutment supported cast metal crown (noble metal). D6065 Implant supported porcelain/ceramic crown. D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal). D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal). D6068 Abutment supported retainer for porcelain/ceramic FPD. D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal). D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal). D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal). D6072 Abutment supported retainer for cast metal FPD (high noble metal). D6073 Abutment supported retainer for cast metal FPD (predominantly base metal). D6074 Abutment supported retainer for cast metal FPD (noble metal). D6075 Implant supported retainer for ceramic FPD. D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal). D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble metal). D6094 Abutment supported crown - (titanium). D6194 Abutment supported retainer crown for FPD - (titanium). D6205 Pontic - indirect resin based composite. D6210 Pontic - cast high noble metal. D6211 Pontic - cast predominantly base metal. TYPE 3 PROCEDURES D6212 Pontic - cast noble metal. D6214 Pontic - titanium. D6240 Pontic - porcelain fused to high noble metal. D6241 Pontic - porcelain fused to predominantly base metal. D6242 Pontic - porcelain fused to noble metal. D6245 Pontic - porcelain/ceramic. D6250 Pontic - resin with high noble metal. D6251 Pontic - resin with predominantly base metal. D6252 Pontic - resin with noble metal. D6545 Retainer - cast metal for resin bonded fixed prosthesis. D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis. D6600 Inlay - porcelain/ceramic, two surfaces. D6601 Inlay - porcelain/ceramic, three or more surfaces. D6602 Inlay - cast high noble metal, two surfaces. D6603 Inlay - cast high noble metal, three or more surfaces. D6604 Inlay - cast predominantly base metal, two surfaces. D6605 Inlay - cast predominantly base metal, three or more surfaces. D6606 Inlay - cast noble metal, two surfaces. D6607 Inlay - cast noble metal, three or more surfaces. D6608 Onlay - porcelain/ceramic, two surfaces. D6609 Onlay - porcelain/ceramic, three or more surfaces. D6610 Onlay - cast high noble metal, two surfaces. D6611 Onlay - cast high noble metal, three or more surfaces. D6612 Onlay - cast predominantly base metal, two surfaces. D6613 Onlay - cast predominantly base metal, three or more surfaces. D6614 Onlay - cast noble metal, two surfaces. D6615 Onlay - cast noble metal, three or more surfaces. D6624 Inlay - titanium. D6634 Onlay - titanium. D6710 Crown - indirect resin based composite. D6720 Crown - resin with high noble metal. D6721 Crown - resin with predominantly base metal. D6722 Crown - resin with noble metal. D6740 Crown - porcelain/ceramic. D6750 Crown - porcelain fused to high noble metal. D6751 Crown - porcelain fused to predominantly base metal. D6752 Crown - porcelain fused to noble metal. D6780 Crown - 3/4 cast high noble metal. D6781 Crown - 3/4 cast predominantly base metal. D6782 Crown - 3/4 cast noble metal. D6783 Crown - 3/4 porcelain/ceramic. D6790 Crown - full cast high noble metal. D6791 Crown - full cast predominantly base metal. D6792 Crown - full cast noble metal. D6794 Crown - titanium. D6940 Stress breaker. FIXED PARTIAL CROWN: D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781. D6782, D6783. D6790, D6791, D6792. D6794 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D2510. D2520. D2530, D2542, D2543, D2544. D2610, D2620, D2630, D2642, D2643. D2644, D2650. D2651, D2652, D2662, D2663. D2664. D2710. D2712, D2720, D2721, D2722, D2740. D2750. D2751, D2752, D2780, D2781, D2782. D2783, D2790. D2791. D2792, D2794, D6600, D6601. D6602, D6603, D6604, D6605. D6606, D6607, D6608. D6609. D6610, D6611, D6612, D6613. D6614, D6615, D6624. D6634. also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. TYPE 3 PROCEDURES • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL INLAY: 06600, 06601,1)6602, D6603, D6604, 06605, D6606, D6607, D6624 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D2510, D2520, D2530, D2542, D2543, 02544, D2610, D2620, D2630, D2642, 02643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D27I2, 02720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6608, D6609, D6610, 06611, D6612, D6613, D6614, D6615, D6634, D6710, D6720, D6721, 06722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Benefits will not be considered if procedure D2390. 02930, D2931, D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL ONLAY: D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6634 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D2510, D2520, D2530, D2542, D2543, D2544, 02610, D2620, D2630, D2642, D2643, D2644, D2650, D2651. D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, 02750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, 02791, D2792, D2794, D6600, 06601, D6602, 06603, D6604, D6605, D6606, D6607, D6624, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, 06790, D6791, D6792, 06794, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL PONTIC: D6205, D6210, D6211, 06212, 06214, D6240, D624I, D6242, D6245, D6250, D6251, D6252 • Replacement is limited to 1 of any of these procedures per 5 year(s). • 05211, D5212, D5213, D5214, D5225, 05226, D5281, D6058, D6059, D6060, D6061, D6062, 06063, D6064, D6065, D6066, D6067, D6068, D6069, 06070, 06071, D6072, D6073,1)6074, D6075, 06076, 06077, D6094, 06194, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. IMPLANT SUPPORTED CROWN: D6058, D6059, 06060, 06061, D6062, D6063, D6064, D6065, 06066, D6067, D6094 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6194, D6205, D6210, 06211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D625I, 06252, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. IMPLANT SUPPORTED RETAINER: 06068, D6069, D6070, D6071, 06072, D6073, D6074, D6075, D6076, D6077, D6194 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D5211, D5212, D5213, 05214, 05225, D5226, 05281, D6058, D6059, D6060, D6061, D6062, D6063, D6064, 06065, 06066, D6067, D6094, D6205, D6210, D6211, 06212, D6214, D6240, D6241, 06242, D6245, 06250. 06251, D6252, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. CAST POST AND CORE FOR PARTIALS D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated. D6972 Prefabricated post and core in addition to fixed partial denture retainer. ORTHODONTIC EXPENSE BENEFITS We will determine orthodontic expense benefits according to the terms of the group policy for orthodontic expenses incurred by an Insured. DETERMINING BENEFITS. The benefits payable will be determined by totaling all of the Covered Expenses submitted. This amount is reduced by the Deductible, if any. The result is then multiplied by the Coinsurance Percentage shown in the Schedule of Benefits. Benefits are subject to the Maximum Amount shown in the Schedule of Benefits. DEDUCTIBLE. The Deductible is shown on the Schedule of Benefits and is a specified amount of Covered Expenses that must be incurred and paid by each Insured person prior to any benefits being paid. MAXIMUM AMOUNT. The Maximum Benefit During Lifetime shown in the Schedule of Benefits is the maximum amount that may be paid for the Covered Expenses incunTed by an Insured during his or her lifetime. COVERED EXPENSES. Covered Expenses refer to the usual and customary charges made by a provider for necessary orthodontic treatment rendered while the person is insured under this section. Expenses are limited to the Maximum Amount shown in the Schedule of Benefits and Limitations. Usual and Customary ("U&C") describes those dental charges that we have determined to be the usual and customary charge for a given dental procedure within a particular ZIP code area. The U&C is based upon a combination of dental charge information taken from our own database as well as from data received from nationally recognized industry databases. From the array of charges ranked by amount, your Policyholder (in most cases your employer) has selected a percentile that will be used to determine the maximum U&C for your plan. The U&C is reviewed and updated periodically. The U&C can differ from the actual fee charged by your provider and is not indicative of the appropriateness of the provider's fee. Instead, the U&C is simply a plan provision used to determine the extent of benefit coverage purchased by your Policyholder. ORTHODONTIC TREATMENT. Orthodontic Treatment refers to the movement of teeth by means of active appliances to correct the position of maloccluded or malpositioned teeth. TREATMENT PROGRAM. Treatment Program ("Program") means an interdependent series of orthodontic services prescribed by a provider to correct a specific dental condition. A Program will start when the active appliances are inserted. A Program will end when the services are done, or after eight calendar quarters starting with the day the appliances were inserted, whichever is earlier. EXPENSES INCURRED. Benefits will be payable when a Covered Expense is incurred: a. at the end of every quarter (three-month period) of a Program for an Insured who pursues a Program, but not beyond the date the Program ends; or b. at the time the service is rendered for an Insured who incurs Covered Expenses but does not pursue a Program. The Covered Expenses for a Program are based on the estimated cost of the Insured's Program. They are pro- rated by quarter (three-month periods) over the estimated length of the Program, up to a maximum of eight quarters. However, the first payment will be 25 percent of the total allowed Covered Expense. The last quarterly payment for a Program may be changed if the estimated and actual cost of the Program differ. BENEFITS PAYABLE UPON TERMINATION. If coverage terminates during a Program quarter, the quarterly benefit payable for that quarter will be pro -rated by day for the period of time that coverage was in -force and premium was received. MITATIONS. Covered Expenses will not include and benefits will not be payable for expenses incun•ed: 1. for a Program begun on or after the Insured's 19 birthday. 2. for a Program begun before the Insured became covered under this section, unless the Insured was covered for Orthodontic Expense Benefits under the prior carrier on January 31, 2010 and are both: a. insured under this policy; and b. currently undergoing a Treatment Program on February 1, 2010. 3. in the first 12 months that a person is insured if the person is a Late Entrant. 4. if the Insured's insurance under this section terminates. 5. for which the Insured is entitled to benefits under any workmen's compensation or similar law, or for charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit. 6. for charges the Insured is not legally required to pay or would not have been made had no insurance been in force. 7. for services not required for necessary care and treatment or not within the generally accepted parameters of care. 8. because of war or any act of war, declared or not. 9. To replace lost or stolen appliances. COORDINATION OF BENEFITS This section applies if an Insured person has dental coverage under more than one Plan definition below. All benefits provided under this policy are subject to this section. EFFECT ON BENEFITS. The Order of Benefit Determination rules below determine which Plan will pay as the primary Plan. If all or any part of an Allowable Expense under this Plan is an Allowable Expense under any other Plan, then benefits will be reduced so that, when they are added to benefits payable under any other Plan for the same service or supply, the total does not exceed 100% of the total Allowable Expense. If another Plan is primary and this Plan is considered secondary, the amount by which benefits have been reduced during the Claim Determination Period will be used by us to pay the Allowable Expenses not otherwise paid which were incurred by you in the same Claim Determination Period. We will determine our obligation to pay for Allowable Expenses as each claim is submitted, based on all claims submitted in the current Claim Determination Period. DEFINITIONS. The following apply only to this provision of the policy. 1. "Plan" refers to the group policy and any of the following plans, whether insured or uninsured, providing benefits for dental services or supplies: a. Any group or blanket insurance policy. b. Any group Blue Cross, group Blue Shield, or group prepayment arrangement. c. Any labor/management, trusteed plan, labor organization, employer organization, or employee organization plan, whether on an insured or uninsured basis. d. Any coverage under a governmental plan that allows coordination of benefits, or any coverage required or provided by law. This does not include a state plan under Medicaid (Tit1eXVIII and XIX of the Social Security Act as enacted or amended). It also does not include any plan whose benefits by law are excess to those of any private insurance program or other non-govenmlental program. 2 "Plan" does not include the following: a. Individual or family benefits provided through insurance contracts, subscriber contracts, coverage through individual HMOs or other prepayment arrangements. b. Coverages for school type accidents only, including athletic injuries. 3. "Allowable Expense" refers to any necessary, reasonable and customary item of expense at least a portion of which is covered under at least one of the Plans covering the Insured person for whom that claim is made. When a Plan provides services rather than cash payments, the reasonable cash value of each service will be both an Allowable Expense and a benefit paid. Benefits payable under another Plan include benefits that would have been payable had a claim been made for them. 4. "Claim Determination Period" refers to a Benefit Period, but does not include any time during which a person has no coverage under this Plan. 5. "Custodial Parent" refers to a parent awarded custody of a minor child by a court decree. In the absence of a court decree, it is the parent with whom the child resides more than half of the calendar year without regard to any temporary visitation. ORDER OF BENEFIT DETERMINATION. When two or more Plans pay benefits, the rules for determining the order of payment are as follows: 1. A Plan that does not have a coordination of benefits provision is always considered primary and will pay benefits first. 2. If a Plan also has a coordination of benefits provision, the first of the following rules that describe which Plan pays its benefits before another Plan is the rule to use: a. The benefits of a Plan that covers a person as an employee, member or subscriber are dete„iiined before those of a Plan that covers the person as a dependent. b. If a Dependent child is covered by more than one Plan, then the primary Plan is the Plan of the parent whose birthday is earlier in the year if: i. the parents are married; ii. the parents are not separated (whether or not they ever have been married); or iii. a court decree awards joint custody without specifying that one party has the responsibility to provide Dental coverage. If both parents have the same birthday, the Plan that covered either of the parents longer is primary. c. If the Dependent child is covered by divorced or separated parents under two or more Plans, benefits for that Dependent child will be determined in the following order: i. the Plan of the Custodial Parent; ii. the Plan of the spouse of the Custodial Parent; iii. the Plan of the non -Custodial Parent; and then iv. the Plan of the spouse of the non -Custodial Parent. However, if the specific terms of a court decree establish a parent's responsibility for the child's Dental expenses and the Plan of that parent has actual knowledge of those terms, that Plan is primary. This rule applies to Claim Determination Periods or Benefit Periods commencing after the Plan is given notice of the court decree. d. The benefits of a Plan that cover a person as an employee who is neither laid -off nor retired (or as that employee's dependent) are determined before those of a Plan that covers that person as a laid -off or retired employee (or as that employee's dependent). If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule will be ignored. e. If a person whose coverage is provided under a right of continuation provided by a federal or state law also is covered under another Plan, the Plan covering the person as an employee, member, subscriber or retiree (or as that person's dependent) is primary, and the continuation coverage is secondary. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule will be ignored. The benefits of a Plan that has covered a person for a longer period will be determined first. If the preceding rules do not determine the primary Plan, the allowable expenses shall be shared equally between the Plans meeting the definition of Plan under this provision. In addition, this Plan will not pay more than what it would have paid had it been primary. RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION. We may without your consent and notice to you: 1. Release any information with respect to your coverage and benefits under the policy; and 2. Obtain from any other insurance company, organization or person any information with respect to your coverage and benefits under another Plan. You must provide us with any information necessary to coordinate benefits. FACILITY OF PAYMENT. When other Plans make payments that should have been made under this Plan according to the above terms, we will, at our discretion, pay to any organizations making these payments any amounts that we decide will satisfy the intent of the above terns. Amounts paid in this way will be benefits paid under this Plan. We will not be liable to the extent of these payments. RIGHT OF RECOVERY. When we make payments for Allowable Expenses in excess of the amount that will satisfy the intent of the above terms, we will recover these payments, to the extent of the excess, from any persons or organizations to or for whom these payments were made. The request will not be made more than twelve months after a claim has been paid except in cases of fraud or misrepresentation by the provider. The amount of the payments made includes the reasonable cash value of any benefits provided in the form of services. GENERAL PROVISIONS NOTICE OF CLAIM. Written notice of a claim must be given to us within 30 days after the incurred date of the services provided for which benefits are payable. Notice must be given to us at our Home Office, or to one of our agents. Notice should include the Policyholder's name, Insured's name, and policy number. If it was not reasonably possible to give written notice within the 30 day period stated above, we will not reduce or deny a claim for this reason if notice is filed as soon as is reasonably possible. CLAIM FORMS. When we receive the notice of a claim, we will send the claimant forms for filing proof of loss. If these forms are not furnished within 15 days after the giving of such notice, the claimant will meet our proof of loss requirements by giving us a written statement of the nature and extent of loss within the time limit for filing proofs of loss. PROOF OF LOSS. Written proof of loss must be given to us within 90 days after the incurred date of the services provided for which benefits are payable. If it is impossible to give written proof within the 90 -day period, we will not reduce or deny a claim for this reason if the proof is filed as soon as is reasonably possible. TIME OF PAYMENT. We will pay all benefits within 30 days of when we receive due proof. Any balance remaining unpaid at the end of any period for which we are liable will be paid at that time. PAYMENT OF BENEFITS. All benefits will be paid to the Insured unless otherwise agreed upon through your authorization or provider contracts. FACILITY OF PAYMENT. If an Insured or beneficiary is not capable of giving us a valid receipt for any payment or if benefits are payable to the estate of the Insured, then we may, at our option, pay the benefit up to an amount not to exceed $2,000, to any relative by blood or connection by marriage of the Insured who is considered by us to be equitably entitled to the benefit. Any equitable payment made in good faith will release us from liability to the extent of payment. PROVIDER -PATIENT RELATIONSHIP. The Insured may choose any Provider who is licensed by the law of the state in which treatment is provided within the scope of their license. We will in no way disturb the provider -patient relationship. LEGAL PROCEEDINGS. No legal action can be brought against us until 60 days after the Insured sends us the required proof of loss. No legal action against us can start more than five years after proof of loss is required. INCONTESTABILITY. Any statement made by the Policyholder to obtain the Policy is a representation and not a warranty. No misrepresentation by the Policyholder will be used to deny a claim or to deny the validity of the Policy unless: 1. The Policy would not have been issued if we had known the truth; and 2. We have given the Policyholder a copy of a written instrument signed by the Policyholder that contains the misrepresentation. The validity of the Policy will not be contested after it has been in force for one year, except for nonpayment of premiums or fraudulent misrepresentations. WORKER'S COMPENSATION. The coverage provided under the Policy is not a substitute for coverage under a workmen's compensation or state disability income benefit law and does not relieve the Policyholder of any obligation to provide such coverage. ERISA INFORMATION AND NOTICE OF YOUR RIGHTS A. Eligibility and Benefits Provided Under the Group Policy Please refer to the Conditions for Insurance within the Group Policy and Certificate of Coverage for a detailed description of the eligibility for participation under the plan as well as the benefits provided. If this plan includes a participating provider (PPO) option, provider lists are furnished without charge, as a separate document. If you have any questions about your benefits or concerns about our services related to this Group Policy, you may call Customer Service Toll Free at 1-800-487-5553. B. Qualified Medical Child Support Order ("QMCSO") QMCSO Determinations. A Plan participant or beneficiary can obtain, without charge, a copy of the Plan's procedures governing Qualified Medical Child Support Order determinations from the Plan Administrator. C. Termination Of The Group Policy The Group Policy which provides benefits for this plan may be terminated by the Policyholder at any time with prior written notice to Ameritas Life Insurance Corp. It will terminate automatically if the Policyholder fails to pay the required premium. Ameritas Life Insurance Corp. may terminate the Group Policy on any Premium Due Date if the number of persons insured is less than the required minimum, or if Ameritas Life Insurance Corp. believes the Policyholder has failed to perfonm its obligations relating to the Group Policy. After the first policy year, Ameritas Life Insurance Corp. may also terminate the Group Policy on any Premium Due Date for any reason by providing a 60 -day advance written notice to the Policyholder. The Group Policy may be changed in whole or in part. No change or amendment will be valid unless it is approved in writing by a Ameritas Life Insurance Corp. executive officer. D. Claims For Benefits Claims procedures are furnished automatically, without charge, as a separate document. E. Continuation of Coverage Provisions (COBRA) COBRA (Consolidation Omnibus Budget Reconciliation Act of 1985) gives Qualified Beneficiaries the right to elect COBRA continuation after insurance ends because of a Qualifying Event. The law generally covers group health plans maintained by employers with 20 or more employees in the prior year. The law does not, however, apply to plans sponsored by the Federal government and certain church -related organizations. i. Definitions For This Section Qualified Beneficiary means an Insured Person who is covered by the plan on the day before a qualifying event. Any child born to or placed for adoption with a covered employee during the period of COBRA coverage is considered a qualified beneficiary. A Qualifying Event occurs when: 1. The Member dies (hereinafter referred to as Qualifying Event 1); 2. The Member's employment terminates for reasons other than gross misconduct as determined by the Employer (hereinafter refen-ed to as Qualifying Event 2); 3. The Member's work hours fall below the minimum number required to be a Member (hereinafter referred to as Qualifying Event 3); 4. The Member becomes divorced or legally separated from a Spouse (hereinafter refen-ed to as Qualifying Event 4); 5. The Member becomes entitled to receive Medicare benefits under Title XVII of the Social Security Act (hereinafter refen-ed to as Qualifying Event 5); 6. The Child of a Member ceases to be a Dependent (hereinafter refen-ed to as Qualifying Event 6); 7. The Employer files a petition for reorganization under Title 11 of the U.S. Bankruptcy Code, provided the Member is retired from the Employer and is insured on the date the petition is filed (hereinafter referred to as Qualifying Event 7). ii. Electing COBRA Continuation A. Each Qualified Beneficiary has the right to elect to continue coverage that was in effect on the day before the Qualifying Event. The Qualified Beneficiary must apply in writing within 60 days of the later of: 1. The date on which Insurance would otherwise end; and 2. The date on which the Employer or Plan Administrator gave the Qualified Beneficiary notice of the right to COBRA continuation. B. A Qualified Beneficiary who does not elect COBRA Continuation coverage during their original election period may be entitled to a second election period if the following requirements are satisfied: 1. The Member's Insurance ended because of a trade related termination of their employment, which resulted in being certified eligible for trade adjustment assistance; 2. The Member is certified eligible for trade adjustment assistance (as determined by the appropriate governmental agency) within 6 months of the date Insurance ended due to the trade related termination of their employment; and 3. The Qualified Beneficiary must apply in writing within 60 days after the first day of the month in which they are certified eligible for trade adjustment assistance. iii. Notice Requirements 1. When the Member becomes insured, the Plan Administrator must inform the Member and Spouse in writing of the right to COBRA continuation. 2. The Qualified Beneficiary must notify the Plan Administrator in writing of Qualifying Event 4 or 6 above within 60 days of the later of: a. The date of the Qualifying Event; or b. The date the Qualified Beneficiary loses coverage due to the Qualifying Event. 3. A Qualified Beneficiary, who is entitled to COBRA continuation due to the occurrence of Qualifying Event 2 or 3 and who is disabled at any time during the first 60 days of continuation coverage as determined by the Social Security Administration pursuant to Title II or XVI of the Social Security Act, must notify the Plan Administrator of the disability in writing within 60 days of the later of: a. The date of the disability determination; b. The date of the Qualifying Event; or c. The date on the Qualified Beneficiary loses coverage due to the Qualifying Event. 4. Each Qualified Beneficiary who has become entitled to COBRA continuation with a maximum duration of 18 or 29 months must notify the Plan Administrator of the occurrence of a second Qualifying Event within 60 days of the later of: a. The date of the Qualifying Event; or b. The date the Qualified Beneficiary loses coverage due to the Qualifying Event. 5. The Employer must give the Plan Administrator written notice within 30 days of the occurrence of Qualifying Event 1, 2, 3, 5, or 7. 6. Within 14 days of receipt of the Employer's notice, the Plan Administrator must notify each Qualified Beneficiary in writing of the right to elect COBRA continuation. In order to protect your rights, Members and Qualified Beneficiaries should inform the Plan Administrator in writing of any change of address. iv. COBRA Continuation Period 1. 18 -month COBRA Continuation Each Qualified Beneficiary may continue Insurance for up to 18 months after the date of Qualifying Event 2 or 3. 2. 29 -month COBRA Continuation Each Qualified Beneficiary, who is entitled to COBRA continuation due to the occurrence of Qualifying Event 2 or 3 and who is disabled at any time during the first 60 days of continuation coverage as determined by the Social Security Administration pursuant to Title 1I or XVI of the Social Security Act, may continue coverage for up to 29 months after the date of the Qualifying Event. All Insured Persons in the Qualified Beneficiary's family may also continue coverage for up to 29 months. 3. 36 -Month COBRA Continuation If you are a Dependent, you may continue Coverage for up to 36 months after the date of Qualifying Event 1, 4, 5, or 6. Each Qualified Beneficiary who is entitled to continue Insurance for 18 or 29 months may be eligible to continue coverage for up to 36 months after the date of their original Qualifying Event if a second Qualifying Event occurs while they are on continuation coverage. Note: The total period of COBRA continuation available in 1 through 3 will not exceed 36 months. 4. COBRA Continuation For Certain Bankruptcy Proceedings If the Qualifying Event is 7, the COBRA continuation period for a retiree or retiree's Spouse is the lifetime of the retiree. Upon the retiree's death, the COBRA continuation period for the surviving Dependents is 36 months from the date of the retiree's death. v. Premium Requirements Insurance continued under this provision will be retroactive to the date insurance would have ended because of a Qualifying Event. The Qualified Beneficiary must pay the initial required premium not later than 45 days after electing COBRA continuation, and monthly premium on or before the Premium Due Date thereafter. The monthly premium is a percentage of the total premium (both the portion paid by the employee and any portion paid by the employer) currently in effect on each Premium Due Date. The premium rate may change after you cease to be Actively at Work. The percentage is as follows: 18 month continuation - 102% 29 month continuation - 102% during the first 18 months, 150% during the next 11 months 36 month continuation - 102% vi. When COBRA Continuation Ends COBRA continuation ends on the earliest of: 1. The date the Group Policy terminates; 2. 31 days after the date the last period ends for which a required premium payment was made; 3. The last day of the COBRA continuation period. 4. The date the Qualified Beneficiary first becomes entitled to Medicare coverage under Title XVII of the Social Security Act; 5. The first date on which the Qualified Beneficiary is: (a) covered under another group Dental policy and (b) not subject to any preexisting condition limitation in that policy. F. Your Rights under ERISA As a participant in this Plan, you are entitled to certain rights and protections under the Employment Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Plan Administrator's office and at other specified locations, such as work -sites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies. Receive a summary of the plan's annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Plan Coverage Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights. Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the plan, have a duty to operate and administer this plan prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. If it should happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance with Your Rights If you have any questions about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling those publications hotline of the Employee Benefits Security Administration. CLAIMS REVIEW PROCEDURES AS REQUIRED UNDER EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA) The following provides information regarding the claims review process and your rights to request a review of any part of a claim that is denied. Please note that certain state laws may also require specified claims payment procedures as well as internal appeal procedures and/or independent external review processes. Therefore, in addition to the review procedures defined below, you may also have additional rights provided to you under state law. If your state has specific grievance procedures, an additional notice specific to your state will also be included within the group policy and your certificate. CLAIMS FOR BENEFITS Claims may be submitted by mailing the completed claim fonnn along with any requested information to: Ameritas Life Insurance Corp. PO Box 82520 Lincoln, NE 68501 NOTICE OF DECISION OF CLAIM We will evaluate your claim promptly after we receive it. Utilization Review Program. Generally, utilization review means a set of criteria designed to monitor the use of, or evaluate the medical necessity, appropriateness, or efficiency of health care services. We have established a utilization review program to ensure that any guidelines and criteria used to evaluate the medical necessity of a health care service are clearly documented and include procedures for applying such criteria based on the needs of the individual patients. The program was developed in conjunction with licensed dentists and is reviewed at least annually to ensure that criteria are applied consistently and are current with dental technology, evidence -based research and any dental trends. We will provide you written notice regarding the payment under the claim within 30 calendar days following receipt of the claim. This period may be extended for an additional 15 days, provided that we have determined that an extension is necessary due to matters beyond our control, and notify you, prior to the expiration of the initial 30 -day period, of the circumstances requiring the extension of time and the date by which we expect to render a decision. If the extension is due to your failure to provide information necessary to decide the claim, the notice of extension shall specifically describe the required information we need to decide the claim. If we request additional information, you will have 45 days to provide the information. If you do not provide the requested information within 45 days, we may decide your claim based on the information we have received. If we deny any part of your claim, you will receive a written notice of denial containing: a. The reasons for our decision. b. Reference to the parts of the Group Policy on which our decision is based. c. Reference to any internal rule or guideline relied upon in making our decision, along with your right to receive a copy of these guidelines, free of charge, upon request. d. A statement that you may request an explanation of the scientific or clinical judgment we relied upon to exclude expenses that are experimental or investigational, or are not necessary or accepted according to generally accepted standards of Dental practice. e. A description of any additional information needed to support your claim and why such information is necessary. f. Information concerning your right to a review of our decision. g. Information concerning your right to bring a civil action for benefits under section 502(a) of ERISA following an adverse benefit determination on review. APPEAL PROCEDURE If all or part of a claim is denied, you may request a review in writing within 180 days after receiving notice of the benefit denial. You may send us written comments or other items to support your claim. You may review and receive copies of any non -privileged information that is relevant to your appeal. There will be no charge for such copies. You may request the names of the experts we consulted who provided advice to us about your claim. The appeal review will be conducted by the Plan's named fiduciary and will be someone other than the person who denied the initial claim and will not be subordinate to that person. The person conducting the review will not give deference to the initial denial decision. If the denial was based in whole or in part on a medical judgment, including determinations with regard to whether a service was considered experimental, investigational, and/or not medically necessary, the person conducting the review will consult with a qualified health care professional. This health care professional will be someone other than the person who made the original judgment and will not be subordinate to that person. Our review will include any written comments or other items you submit to support your claim. We will review your claim promptly after we receive your request. If your appeal is about urgent care, you may call Toll Free at 877-897-4328, and an Expedited Review will be conducted. Verbal notification of our decision will be made within 72 hours, followed by written notice within 3 calendar days after that. If your appeal is about benefit decisions related to clinical or medical necessity, a Standard Consultant Review will be conducted. A written decision will be provided within 30 calendar days of the receipt of the request for appeal. If your appeal is about benefit decisions related to coverage, a Standard Administrative Review will be conducted. A written decision will be provided within 60 calendar days of the receipt of the request for appeal. If we deny any part of your claim on review, you will receive a written notice of denial containing: a. The reasons for our decision. b. Reference to the parts of the Group Policy on which our decision is based. c. Reference to any internal rule or guideline relied upon in making our decision along with your right to receive a copy of these guidelines, free of charge, upon request. d. Information concerning your right to receive, free of charge, copies of non -privileged documents and records relevant to your claim. e. A statement that you may request an explanation of the scientific or clinical judgment we relied upon to exclude expenses that are experimental or investigational, or are not necessary or accepted according to generally accepted standards of Dental practice. f. Information concerning your right to bring a civil action for benefits under section 502(a) of ERISA. Certain state laws also require specified internal appeal procedures and/or external review processes. In addition to the review procedures defined above, you may also have additional rights provided to you under state law. Please review your certificate for such information, call us, or contact your state insurance regulatory agency for assistance. In any event, you need not exhaust such state law procedures prior to bringing civil action under Section 502(a) of ERISA. Any request for appeal should be directed to: Quality Control, P.O. Box 82657, Lincoln, NE 68501-2657. NOTICE OF PROTECTED HEALTH INFORMATION PRIVACY PRACTICES We are required by law to maintain the privacy of our insured members' and their dependents' personal health information and to provide notice of our legal duties and privacy practices with respect to your personal health information. We are required to abide by the terns of this Notice as long as it remains in effect. We reserve the right to change the terms of this Notice as necessary and to make the new Notice effective for all personal health information maintained by us. Copies of revised Notices will be provided to you directly or to your group's Plan Sponsor (usually your employer) by regular mail or e-mail with instructions to deliver a paper copy to each certificate holder. THIS NOTICE DESCRIBES OUR PRACTICES REGARDING YOUR PROTECTED HEALTH INFORMATION MAINTAINED BY THE GROUP DENTAL LINE OF BUSINESS WITHIN THE UNIFI COMPANIES. THIS NOTICE MORE PARTICULARLY DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Contact Information All of the entities affiliated under the common control of the UNIFI Mutual Holding Company that pay for the cost of healthcare, including Ameritas Life Insurance Corp. and First Ameritas Life Insurance Corp. of New York, are required by federal law to maintain the privacy of your protected health information and to provide notice of the legal duties and privacy practices with respect to your protected health information. This Notice fulfills the "Notice" requirements of the Final Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If you have any questions about any part of this Notice of Protected Health Information Privacy Practices or desire to have further information concerning the information practices at the UNIFI Companies, please direct your inquiries to: The Privacy Office, Attn. HIPAA Privacy, P.O. Box 81889, Lincoln, NE 68501-1889, or e-mail us at privacy@ameritas.com. THIS NOTICE IS PUBLISHED AND BECOMES EFFECTIVE: APRIL 14, 2003 OUR PLEDGE REGARDING YOUR PROTECTED HEALTH INFORMATION We understand that information about you and your family is personal and we are committed to protecting your privacy and the security of your protected health information. This Notice explains the ways in which we use and disclose protected health information about you and your covered dependents and details certain obligations we have in connection with such use and disclosure. It also describes your rights with regard to your protected health information. We are required by both law and internal policy to: make sure that protected health information that identifies you and/or your covered dependents is kept private; give you notice of our legal duties and privacy practices and your rights with respect to your protected health information; and follow the practices outlined in this Notice. WHO WILL FOLLOW THE PRIVACY PRACTICES DESCRIBED IN THIS NOTICE The Protected Health Information Privacy Practices described in this Notice have been adopted and implemented by all of the divisions and associates who work directly or indirectly with your protected health information within the following UNIFI Companies: Ameritas Life Insurance Corp.; and First Ameritas Life Insurance Corp. of New York. All of the associates who need access to your protected health information in order to service your products and administer your claims have received proper training about how to protect your privacy, secure your protected health information and adhere to our Privacy of Protected Health Information Policies, Practices and Procedures. In order to keep costs of your coverage down and provide you with the best customer service, we may contract with outside carriers and/or vendors, known as "business associates," to assist us with the administration of your policy. For example, we may contract with third party administrators who process claims and collect premium payments; or paper -shredding companies who destroy records when they are no longer needed. Because these business associates need access to your protected health information in order to fulfill their obligations to us, we require them to agree in writing to keep your protected health information confidential in the same manner that we do as described in this Notice. TYPES OF PROTECTED HEALTH INFORMATION WE MAY HAVE AND HOW WE OBTAIN IT Protected Health Information is: Any information that identifies you that we obtain from you or others that relates to your past, present or future healthcare including the payment for such healthcare. In the regular course of business we receive protected health information about you in order to provide you with our products and services. Some of this protected health information comes directly from you. For example, when you purchase one of our health insurance products for you and your family, you provide us with information about you and your covered dependents such as name, address, phone number, social security number, etc. Some of the protected health information we obtain about you comes from your provider. For example, as you and your covered dependents utilize your coverage, your healthcare provider sends us information about services and treatments performed so that we can process and pay your claims. All of this information we receive about you and your covered dependents is necessary in order for us to provide you and your covered dependents with quality health insurance products and to comply with legal requirements. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION The following categories describe different ways we may use and disclose your protected health information without your authorization. For each category of uses and disclosures, we will explain what we mean and give an example. Not every use or disclosure in a category will be listed. All of the ways we are permitted to use and disclose information will fall within one of the identified categories. For Payment: We may use and disclose protected health information about you and your covered dependents in order to verify your coverage to your provider, process payment for claims filed under your policy or coordinate benefits with another carrier. For example, we may need to disclose your protected health information to a provider whom you have seen or are planning to see in order to pre -approve that a particular treatment you are seeking is covered under your plan. It is also necessary for us to use the information received from your medical provider concerning the services rendered to you so the health plan can pay the provider or reimburse you for the cost of the treatment under the terms of your plan. Finally, when you have more than one insurance policy that covers some of the same procedures as your plan with us, it may be necessary for us to exchange payment information with the carrier of your other insurance plan in order to coordinate the payment of your claim with that other carrier. For Health Care Operations: We may use and disclose protected health information about you and your covered dependents as necessary to operate your health insurance plan and promote quality service. For example, we may use or disclose your personal health information for quality assessment and quality improvement, credentialing health care providers, conducting or arranging for medical review or compliance. We may also disclose your personal health information to another health plan, health care facility or health care provider for activities such as quality assurance or case management. Business Associates: We may disclose protected health information to other persons or organizations, known as business associates, who provide services on our behalf under contract. However, in order to assure the protection of your private information, we require our business associates to adhere to our Privacy Policies concerning the use and disclosure of your protected health information and appropriately safeguard the information we disclose to them. We prohibit our business associates from using and disclosing any of your protected health information in any manner except for the purpose intended by the contract. Business associates are expressly prohibited from using your protected health information to create any marketing target lists. Plan Sponsors: We may disclose your protected health information to your plan sponsor (usually your employer). It is our policy not to disclose your protected health information to your Plan's sponsor. There may by exceptional occasions that your Plan Sponsor requests protected health information. We will only disclose your protected health information to your Plan Sponsor if we have your authorization to do so, or if the plan sponsor certifies that the information will be maintained in a confidential manner and will not be utilized or disclosed for employment -related actions and decisions or in connection with any other benefit or employee benefit plan of the plan sponsor. Public policy uses and disclosures of your protected health information We may use and disclose your protected health information for public policy purposes. For example: As Required By Law: We will disclose protected health information about you or your covered dependent when required to do so by federal, state or local law. For example, we may be required by law to disclose certain protected health information about you pursuant to a court order or subpoena served upon us. About Victims of Abuse, Neglect or Domestic Violence: For example, if we believe that you have been a victim of abuse, neglect or domestic violence, we may disclose your protected health information to the governmental entity or agency authorized to receive such information. In this case the disclosure will be made consistent with the requirements of applicable federal and state laws. Workers' Compensation: We may release your protected health information for workers' compensation or similar programs that provide benefits to you for work -related injuries or illness but only in a manner consistent with applicable laws. Public Health: We may have an occasion to disclose protected health information about you or your covered dependent for public health activities to a public health authority that is permitted by law to collect or receive the information. A public health activity would be, for example, an activity conducted by a public health authority in the furtherance of preventing or controlling disease, injury or disability; reporting births, deaths or reactions to medications; or notifying people of recalls of products they may be using. AUTHORIZED USES AND DISCLOSURES From time to time you may request that we disclose your protected health information to other individuals or entities. For example, you may request that we disclose your claims history to an attorney that you have hired to assist you in a civil matter. Likewise, we may ask your permission to use or disclose your protected health information. Any disclosures, such as these that do not fit into one of the categories in the previous section require us to obtain your written authorization prior to making such disclosure. In the event that you do provide us with written authorization to use or disclose your information, you may revoke such authorization at any time by writing to the Privacy Officer at the address indicated in the "Contact" section of this Notice below. YOUR RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION You have the following rights regarding protected health information that we maintain about you. All requests must be made in writing. Your Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice. You have a right to receive this Notice because you are insured by a health plan offered by Ameritas Life Insurance Corp. or First Ameritas Life Insurance Corp. of New York. You may ask us to give you a copy of this Notice at any time and we will comply. Even if you have agreed to receive this Notice electronically, you are entitled to a paper copy of this Notice if you so request. Your Right to an Accounting of Disclosures: You have the right to request a listing of any disclosures of your protected health information that we have made that are required by law. This listing would exclude disclosures we made to you, or pursuant to your authorization or request, or for payment of your claims as described above, or for health care operations as described above. Your request must state a time period that may not be longer than six years and may not include dates prior to April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically, fax etc.). The first accounting of disclosures you request within a 12 -month period will be free. We may charge for the costs of providing additional lists during that same 12 -month period. In the event that you may incur a charge, we will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred. Your Right to Request an Amendment: You have the right to request an amendment to the protected health information that we maintain about you if you believe that our information is incorrect or incomplete. You maintain the right to request an amendment for as long as the information is kept by or for the UNIFI Companies. You must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that: 1) was not created by us; 2) is not part of the medical information kept by or for a UNIFI Company; 3) is not part of the information which you would be permitted to inspect and copy under the law; or 4) is accurate and complete. Your Right to Request a Restriction: You have the right to request a restriction or limitation on the protected health infonnation we use or disclose about you for, payment or health plan operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for care, like a family member or friend. We are not required to agree to your request. If we do agree to a requested restriction, we will comply with your request unless the information is needed to facilitate emergency treatment. To request restrictions, you must make your request in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. Your Right to Request Confidential Communications: You have the right to request that we communicate with you about payment for your medical matters in an alternative means (such as by fax) or at an alternative location (such as to your office). To request confidential communications, you must make your request in writing. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Your Rights to Inspect and Copy: You have the right to inspect and copy protected health information that we maintain about you that may be used to make decisions about payment for your care. To inspect this protected health information you may contact the Privacy Officer. To obtain copies of such protected health infonnation, you must submit your request in writing as indicated below. If you request a copy of the infonnation, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your protected health information, in most situations you may request that the denial be reviewed by a licensed health care professional who did not take part in the decision to deny access. We will comply with the outcome of the review. Your Right to Make Complaints: If you believe that your privacy rights have been violated you may make a complaint to the UNIFI Companies Privacy Office or to the Secretary of Health and Human Resources as follows: UNIFI Privacy Office Attn. HIPAA Privacy P.O. Box 81889 Lincoln, NE 68510 Secretary, Health and Human Services, Office of Civil Rights United States Department of Health and Human Services 200 Independence Avenue, SW Room 509F HHH Building Washington D.C. 20201 Any complaint you file will not cause you to suffer retaliation from our company. We will promptly investigate your complaint as soon as we receive it. When we have completed our investigation, we will notify you of our findings. If the investigation reveals that your privacy rights have indeed been violated, we will immediately take the appropriate measures to correct the violation pursuant to our Privacy Practices and Procedures. Individual Rights Contact To assert any of your rights with respect to this Notice, or to obtain an authorization form, please call 1-800-487- 5553 and request the appropriate form. Effective Date This Notice will become effective as of April 14, 2003. LIFE INSURANCE CORP. A UNIFI Company A STOCK COMPANY LINCOLN. NEBRASKA CERTIFICATE GROUP DENTAL INSURANCE The Policyholder THE METROPOLITAN ST.LOUIS SEWER DISTRICT Policy Number Plan Effective Date 10-350651 Insured Person February 1, 2010 Certificate Effective Date Refer to Exceptions on 9070. Class Number 2 Ameritas Life Insurance Corp. certifies that you will be insured for the benefits described on the following pages, according to all the terms of the group policy numbered above which has been issued to the Policyholder. Possession of this certificate does not necessarily mean you are insured. You are insured only if you meet the requirements set out in this certificate. The group policy may be amended or cancelled without the consent of the insured person. The group policy and this certificate are governed by the laws of the state in which the group policy was delivered. clLArj\tA :...� President Notice of Grievance Procedures State of Missouri Please read this notice carefully. This notice contains important information about how to file grievances with your insurer. You have the right to ask your insurer to assist you in filing a grievance, review its decisions involving your requests for service, or your requests to have your claims paid. Please contact: In Writing: By Phone: By Facsimile: Quality Control Unit P.O. Box 82657 Lincoln, NE 68501-2657 877-897-4328 (Toll -Free) 402-309-2579 Also, you always have the right to contact the Missouri Department of Insurance if you have a question or concern regarding your coverage under this contract. The Missouri Department may be contacted: In Writing: Missouri Department of Insurance 301 West High Street Jefferson City, Missouri 65101 By Phone: 800-726-7390 You also have the right to ask a relative, friend, lawyer, the Department of Insurance or other representative to assist you in filing a grievance, review its decisions involving your requests for service, or your requests to have your claims paid. You have the right to request through our Quality Control Department a written statement of the clinical rationale relied upon in making any adverse deteminations, as defined below. I. Definitions "Adverse Determination" means a determination made by us that a claim for a proposed or given health care service has been reviewed and, based upon the information provided, does not meet our requirement for medical necessity or appropriateness and, therefore a benefit is denied, reduced or terminated. "Grievance" means a written complaint submitted by or on behalf of an enrollee regarding the availability, delivery or quality of health care services, including a'Complaint regarding an adverse determination made pursuant to utilization review, claims payment, handling, or matters pertaining to the contractual relationship between an enrollee and us. "Utilization Review" means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. II. Levels of Review Reconsideration — A treating provider has the opportunity to request, on your behalf, reconsideration of an adverse determination. A reviewing provider will conduct the reconsideration discussion within one working day of the request. The reviewing provider will either be the reviewer who made the adverse determination or a clinical peer if the original r eviewer is not available in the required timeframe. If the reconsideration process does not resolve the difference of opinion, the appeal process is available. The following levels of review will be available to an enrollee or provider acting on behalf of the enrollee. First Level Grievance Review - for written grievances, including those resulting from an adverse determination. Second Level Grievance Review - following first level reviews if grievance not resolved. Expedited Review - only for adverse determinations of emergency requests. A. First Level Grievance Review A written grievance concerning any matter, including an adverse determination, may be submitted by an enrollee. First level reviews of an adverse determination will be conducted by a clinical peer. Any first level review will not be reviewed by the same person or persons who made the initial determination denying a claim or handling the matter that is the subject of the grievance. Upon receipt of a request for a first level grievance review, we shall acknowledge receipt in writing of the grievance within ten working days. We will conduct a complete investigation of the grievance within twenty working days after receipt of the grievance. If the investigation cannot be completed within the twenty working days after receipt of the grievance, the enrollee will be notified in writing on or before the twentieth working day and the investigation shall be completed within thirty working days thereafter. The notice will set forth the reasons for which additional time is needed for the investigation. Within five working days after the investigation is completed, someone not involved in the circumstances giving rise to the grievance or its investigation will decide upon the appropriate resolution of the grievance and notify the enrollee in writing of the decision and of their right to file an appeal for a second level review. Within fifteen working days after the investigation is completed, we will notify the person who submitted the grievance of our resolution. B. Second Level Grievance Review Upon receipt of a request for a second level review for any grievance not involving an adverse determination, we shall submit the grievance to a grievance advisory panel, which consists of other enrollees, representatives who were not involved in the circumstances giving rise to the grievance or in any subsequent investigation or determination of the grievance. Any second level review will not be reviewed by the same person or persons who made the initial determination denying a claim or handling the matter that is the subject of the grievance. Second level reviews of an adverse determination will be conducted by a clinical peer. Any second level grievance review will follow the same time frames as a first level review. C. Expedited Review If the time frame of the standard grievance procedures would seriously jeopardize the life or health of an enrollee, an expedited review may be requested. A request for an expedited review may be submitted orally or in writing. However, the request shall not be considered a grievance unless the request is submitted in writing. Expedited review procedures shall be available to an enrollee, the representative of an enrollee and to the provider acting on behalf of the enrollee. We will notify an enrollee orally within seventy-two hours after receiving a request for an expedited review of our determination. We will provide written confirmation of our decision covering an expedited review within three working days of providing notification of the determination. Expedited reviews of an adverse determination will be reviewed by clinical peers in the same or similar specialty as would normally manage the case under review. These clinical peers will not have been involved in the initial adverse determination. An expedited review is not available for retrospective adverse determinations. III. Written Decision When a decision is issued from any level of review, the following information will be included in the written decision: 1. a statement of the reviewer's understanding to the grievance; 2. the decision stated in clear terms and the contract basis or medical rationale supporting the decision, a reference to the evidence or documentation used as a basis for the decision; 3. if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, provide the enrollee and their designated representative with either the specific rule, guideline, protocol, or other similar criterion or a statement that such rule, guideline, protocol or other criterion relied upon in making the adverse determination. A copy of such will be provided free of charge to the enrollee and their designated representative upon request; 4. for first level reviews, a description of the process to obtain a second level grievance review and the time frame for review. 5. notice of the enrollee's right to contact the Missouri Department of Insurance. TABLE OF CONTENTS Name of Provision Page Number Schedule of Benefits Begins on 9040 Benefit Information, including Deductibles, Coinsurance, & Maximums Definitions Late Entrant, Dependent 9060 Conditions for Insurance Eligibility Eligibility Period Elimination Period Contribution Requirement Effective Date Termination Date Dental Expense Benefits Alternate Benefit provision Limitations, including Elimination Periods, Missing Tooth Clause, Cosmetic Clause, Late Entrant 9070 9219 Table of Dental Procedures 9232 Covered Procedures, Frequencies, Criteria Orthodontic Expense Benefits 9260 Coordination of Benefits 9300 General Provisions 9310 Claim Forms Proof of Loss Payment of Benefits ERISA Information and Notice of Your Rights ERISA Notice SCHEDULE OF BENEFITS OUTLINE OF COVERAGE The Insurance for each Insured and each Insured Dependent will be based on the Insured's class shown in this Schedule of Benefits. Benefit Class Class 2 DENTAL EXPENSE BENEFITS Class Description Employee Enrolled In The Network Plan When you select a Participating Provider, a discounted fee schedule is used which is intended to provide you, the Insured, reduced out of pocket costs. Deductible Amount: When a Participating Provider is used: Type 1, Type 2, and Type 3 Procedures $0 When a Non -Participating Provider is used: Type 1 Procedures $0 Combined Type 2 and Type 3 Procedures - Each Benefit Period $100 On the date that the members of one family have satisfied the Maximum Family Deductible shown below, no covered Expenses incurred after that date by any other family member will be applied toward the satisfaction of any Deductible Amount for the rest of that Benefit Period. Maximum Family Deductible Participating Provider Non -Participating Provider $ 0 $ 300 Dental expenses incurred by an individual on or after January 1, 2010, but before February 1, 2010, will apply to the Deductible Amount if: a. proof is furnished to us that such dental expenses were applicable to the deductible under the Policyholder's dental insurance policy in force immediately prior to February 1, 2010; and b. such expenses would have been considered Covered Expenses under this policy had this policy been in force at the time the expenses were incurred. Coinsurance Percentage: Type 1 Procedures 100% 70% Type 2 Procedures 80% 50% Type 3 Procedures 50% 20% Participating Provider Non -Participating Provider When a Non -Participating Provider is used: Maximum Amount - Each Benefit Period 51,000 When a Participating Provider is used: Maximum Amount - Each Benefit Period S2,000 ORTHODONTIC EXPENSE BENEFITS Participating Provider Non -Participating Provider Deductible Amount - Once per lifetime Coinsurance Percentage Maximum Benefit During Lifetime The Maximum Benefit shown above will be modified for: $0 $0 50% 50% $1,500 $1,000 a. any person who was insured for an Orthodontic Expense Benefit under the prior carrier on January 31, 2010, and b. on February 1, 2010 is both: insured under the policy, and ii. currently undergoing a Treatment Program which would have been a covered Treatment Program under the prior carrier had the prior carrier's coverage remained in force. The modification will result in a reduction of the Maximum Benefit based on: a. the normal benefit payable under the policy for the current Treatment Program, minus b. any amounts to which the person is entitled from the prior carrier for such Treatment Program. Nothing stated above, however, will act to provide coverage or increase benefits, when the Treatment Program is subject to any limitation shown on 9260. DEFINITIONS COMPANY refers to Ameritas Life Insurance Corp. The words "we", "us" and "our" refer to Company. Our Home Office address is 5900 "O" Street, Lincoln, Nebraska 68510. POLICYHOLDER refers to the Policyholder stated on the face page of the policy. INSURED refers to a person: a. who is a Member of the eligible class; and b. who has qualified for insurance by completing the eligibility period, if any; and c. for whom the insurance has become effective. CHILD. Child refers to the child of the Insured or a child of the Insured's spouse, if they otherwise meet the definition of Dependent. DEPENDENT refers to: a. an Insured's spouse. b. each umnarried child less than 25 years of age, for whom the Insured or the insured's spouse, is legally responsible, including: i. natural born children; ii. adopted children, eligible from: (a) the date of birth if a petition for adoption is filed within thirty days of the date of the birth of such child; or (b) from the date of placement for adoption if a petition for adoption is filed within thirty days of placement of such child. Such coverage shall continue unless the placement is disrupted prior to legal adoption and the child is removed from placement. "Placement" means in the physical custody of the adoptive parent. children covered under a Qualified Medical Child Support Order as defined by applicable Federal and State laws. c. each unmarried child age 25 or older who: i. is Totally Disabled as defined below; and ii becomes Totally Disabled while insured as a dependent under b. above. Coverage of such child will not cease if proof of dependency and disability is given within 31 days of attaining the limiting age and subsequently as may be required by us but not more frequently than annually after the initial two-year period following the child's attaining the limiting age. Any costs for providing continuing proof will be at our expense. TOTAL DISABILITY describes the Insured's Dependent as: I. Continuously incapable of self-sustaining employment by reason of mental or physical handicap; and 2. Chiefly dependent upon the Insured for support and maintenance. DEPENDENT UNIT refers to all of the people who are insured as the dependents of any one Insured. PROVIDER refers to any person who is licensed by the law of the state in which treatment is provided within the scope of the license. LATE ENTRANT refers to any person: a. whose Effective Date of insurance is more than 31 days from the date the person becomes eligible for insurance; or b. who has elected to become insured again after canceling a premium contribution agreement. PLAN EFFECTIVE DATE refers to the date coverage under the policy becomes effective. The Plan Effective Date for the Policyholder is shown on the policy cover. The effective date of coverage for an Insured is shown in the Policyholder's records. All insurance will begin at 12:01 A.M. on the Effective Date. It will end after 11:59 P.M. on the Termination Date. All times are stated as Standard Time of the residence of the insured. PLAN CHANGE EFFECTIVE DATE refers to the date that the policy provisions originally issued to the Policyholder change as requested by the Policyholder. The Plan Change Effective date for the Policyholder will be shown on the policy cover, if the Policyholder has requested a change. The plan change effective date for an Insured is shown in the Policyholder's records or on the cover of the certificate. CONDITIONS FOR INSURANCE COVERAGE ELIGIBILITY ELIGIBLE CLASS FOR MEMBERS. The members of the eligible class(es) are shown on the Schedule of Benefits. Each member of the eligible class (referred to as "Member") will qualify for such insurance on the day he or she completes the required eligibility period, if any. Members choosing to elect coverage will hereinafter be referred to as "Insured." If employment is the basis for membership, a member of the Eligible Class for Insurance is any employee enrolled in the network plan working at least 37 hours per week. If membership is by reason other than employment, then a member of the Eligible Class for Insurance is as defined by the Policyholder. If a husband and wife are both Members and if either of them insures their dependent children, then the husband or wife, whoever elects, will be considered the dependent of the other. As a dependent, the person will not be considered a Member of the Eligible Class, but will be eligible for insurance as a dependent. ELIGIBLE CLASS FOR DEPENDENT INSURANCE. Each Member of the eligible class(es) for dependent coverage is eligible for the Dependent Insurance under the policy and will qualify for this Dependent Insurance on the latest of: 1. the day he or she qualifies for coverage as a Member; 2. the day he or she first becomes a Member; or 3. the day he or she first has a dependent. For dependent children, a newborn child will be considered an eligible dependent from the moment of birth. A Member must be an Insured to also insure his or her dependents. If employment is the basis for membership, a member of the Eligible Class for Dependent Insurance is any employee enrolled in the network plan working at least 37 hours per week and has eligible dependents. If membership is by reason other than employment, then a member of the Eligible Class for Insurance is as defined by the Policyholder. Any husband or wife who elects to be a dependent rather than a member of the Eligible Class for Personal Insurance, as explained above, is not a member of the Eligible Class for Dependent Insurance. When a member of the Eligible Class for Dependent Insurance dies and, if at the date of death, has dependents insured, the Policyholder has the option of offering the dependents of the deceased employee continued coverage. If elected by the Policyholder and the affected dependents, the name of such deceased member will continue to be listed as a member of the Eligible Class for Dependent Insurance. CONTRIBUTION REQUIREMENTS. Member Insurance: An Insured is required to contribute to the payment of his or her insurance premiums. Dependent Insurance: An Insured is required to contribute to the payment of insurance premiums for his or her dependents. SECTION 125. This policy is provided as part of the Policyholder's Section 125 Plan. Each Member has the option under the Section 125 Plan of participating or not participating in this policy. If a Member does not elect to participate when initially eligible, the Member may elect to participate at the Policyholder's next Election Period. This Election Period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on February 1. Members may change their election option only during an Election Period, except for a change in family status. Such events would be marriage, divorce, birth of a child, death of a spouse or child, or termination of employment of a spouse. ELIGIBILITY PERIOD. For Members on the Plan Effective Date of the policy, coverage is effective immediately. For persons who become Members after the Plan Effective Date of the policy, qualification will occur after an eligibility period defined by the Policyholder is satisfied. The same eligibility period will be applied to all members. OPEN ENROLLMENT. Ha Member does not elect to participate when initially eligible, the Member may elect to participate at the Policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on February 1. If employment is the basis for membership in the Eligible Class for Members, an Insured whose eligibility terminates and is established again, may or may not have to complete a new eligibility period before he or she can again qualify for insurance. ELIMINATION PERIOD. Certain covered expenses may be subject to an elimination period, please refer to the TABLE OF DENTAL PROCEDURES, DENTAL EXPENSE BENEFITS, and if applicable, the ORTHODONTIC EXPENSE BENEFITS pages for details. EFFECTIVE DATE. Each Member has the option of being insured and insuring his or her Dependents. To elect coverage, he or she must agree in writing to contribute to the payment of the insurance premiums. The Effective Date for each Member and his or her Dependents, will be: 1. the date on which the Member qualifies for insurance, if the Member agrees to contribute on or before that date. 2. the date on which the Member agrees to contribute, if that date is within 31 days after the date he or she qualifies for insurance. 3. the date we accept the Member and/or Dependent for insurance when the Member and/or Dependent is a Late Entrant. The Member and/or Dependent will be subject to any limitation concerning Late Entrants. EXCEPTIONS. If employment is the basis for membership, a Member must be in active service on the date the insurance, or any increase in insurance, is to take effect. If not, the insurance will not take effect until the day he or she returns to active service. Active service refers to the performance in the customary manlier by an employee of all the regular duties of his or her employment with his or her employer on a full time basis at one of the employer's business establishments or at some location to which the employer's business requires the employee to travel. A Member will be in active service on any regular non -working day if he or she is not totally disabled on that day and if he or she was in active service on the regular working day before that day. If membership is by reason other than employment, a Member must not be totally disabled on the date the insurance, or any increase in insurance, is to take effect. The insurance will not take effect until the day after he or she ceases to be totally disabled. But any person who is not in active service or is totally disabled will be insured on the Effective Date if: a. the person was insured under a policy of group insurance providing like benefits which ended on the day immediately before the Effective Date of the policy providing this coverage; and b. the person is considered a Member or an eligible Dependent under the policy providing this coverage; and had the prior policy contained the same definition of eligibility, would have been a Member or Dependent under the prior policy. TERMINATION DATES INSUREDS. The insurance for any Insured, will automatically terminate on the earliest of: 1. the date the Insured ceases to be a Member; 2. the last day of the period for which the insured has contributed, if required, to the payment of insurance premiums; or 3. the date the policy is terminated. DEPENDENTS. The insurance for all of an Insured's dependents will automatically terminate on the earliest of: 1. the date on which the Insured's coverage tein,inates; 2. the date on which the Insured ceases to be a Member; 3. the last day of the period for which the Insured has contributed, if required, to the payment of insurance premiums; or 4. the date all Dependent Insurance under the policy is terminated. The insurance for any Dependent will automatically terminate on the day before the date on which the dependent no longer meets the definition of a dependent. See "Definitions." CONTINUATION OF COVERAGE. If coverage ceases according to TERMINATION DATE, some or all of the insurance coverages may be continued. Contact your plan administrator for details. Death, Divorce or Separation For Dependents Only The following provisions are applicable for employers with 20 or more employees and any policy with 20 or more certificate holders. 1. Eligibility The Insured's spouse may continue coverage for themselves and any dependent children if coverage would terminate and the spouse is 55 years of age or older at the time of the expiration of coverage provided by Consolidated Omnibus Budget Reconciliation Act ("COBRA") because of: a. the death of the insured; or b. the dissolution of marriage or legal separation from the insured. 2. Benefits. This continuation applies to all benefits payable under the policy. 3. How to Apply a. Within 60 days of legal separation or the entry of a decree of dissolution of marriage or prior to the expiration of a 36 month federal COBRA continuation period covering a legally separated or divorced spouse, if such spouse has elected and maintained such COBRA coverage, a legally separated or divorced spouse eligible for continued coverage who seeks such coverage shall give the plan administrator written notice of the legal separation or dissolution and the mailing address of the spouse. b. Within 30 days of the death of the insured whose surviving spouse is eligible for continued coverage, or prior to the expiration of a 36 month COBRA continuation period covering such surviving spouse, if such spouse has elected and maintained such COBRA coverage, the policyholder shall give the plan administrator written notice of the death and the mailing address of the surviving spouse. c. Within 14 days of receipt of notice, the plan administrator will notify the legally separated, divorced or surviving spouse that coverage may be continued. This notice will be mailed to the mailing address provided to the plan administrator and will include: i. a form for election to continue the coverage; ii. a statement of the amount of periodic premiums to be charged for the continuation of coverage and method and place of payment; and instructions for returning the election form by mail within 60 days after the date the notice is mailed. Failure of the legally separated, divorced or surviving spouse to exercise this election will terminate the right to continuation of benefits. If the plan administrator was properly notified and failed to notify the legally separated, divorce or surviving spouse as required, such spouse's coverage shall continue in effect, and the obligation to make any premium payment for continuation coverage shall be postponed for the period of time beginning on the date the spouse's coverage would otherwise terminate and ending 31 days after the date the required notice was provided. Failure or delay in providing the notice will not reduce, eliminate or postpone any obligation to pay premiums on behalf of such legally separated, divorced or surviving spouse during such period. 4. Premiums a. During the period of time covered by COBRA, the monthly contribution for the premium shall not be greater than the amount that would be charged if the legally separated, divorced or surviving spouse were a current certificate holder of the group policy, plus the amount that the group policy holder would contribute toward the premium if the legally separated, divorced surviving spouse were a certificate holder, plus an additional amount not to exceed two percent of the certificate holder or group policyholder's contributions for the cost of administration. After the period of time covered by the insurance premium provisions of COBRA has expired, the monthly contribution for the premium shall not be greater than the amount that would have been charged if the legally separated, divorced or surviving spouse were a current certificate holder of the policy, plus the amount that the group policy holder would contribute toward the premium if the legally separated, divorced or surviving spouse were a certificate holder, plus an amount not to exceed twenty-five percent of the certificate or group policyholder's contributions. Such additional contributions shall be determined by each individual plan administrator and shall be subject to review by the Missouri Department of Insurance. b. The first premium shall be paid by the legally separated, divorced or surviving spouse within 45 days of the date of the election. 5. Termination a. The right to continuation of coverage shall terminate upon the earliest of any of the following: i. The failure to pay premiums when due, including any grace period allowed by the policy; ii The date that the group policy is terminated as to all group members, except that if a different group policy is made available, the legally separated, divorced or surviving spouse shall be eligible for continuation of coverage as if the original policy had not been terminated; iii. The date on which the legally separated, divorced or surviving spouse becomes insured under another group health plan; or iv. The date on which the legally separated, divorced or surviving spouse remarries and becomes insured under another group health plan; or The date on which the legally separated, divorced or surviving spouse attains his or her 65th birthday. DENTAL EXPENSE BENEFITS We will determine dental expense benefits according to the terms of the group policy for dental expenses incurred by an Insured. An Insured person has the freedom of choice to receive treatment from any Provider. PARTICIPATING AND NON -PARTICIPATING PROVIDERS. The Insured person may select a Participating Provider or a Non -Participating Provider. A Participating Provider agrees to provide services at a discounted fee to our Insureds. A Non -Participating Provider is any other Provider. DETERMINING BENEFITS. The benefits payable will be determined by totaling all of the Covered Expenses submitted into each benefit type as shown in the Table of Dental Procedures. This amount is reduced by the Deductible, if any. The result is then multiplied by the Coinsurance Percentage(s) shown in the Schedule of Benefits. Benefits are subject to the Maximum Amount, if any, shown in the Schedule of Benefits. BENEFIT PERIOD. Benefit Period refers to the period shown in the Table of Dental Procedures. DEDUCTIBLE. The Deductible is shown on the Schedule of Benefits and is a specified amount of Covered Expenses that must be incurred and paid by each Insured person prior to any benefits being paid. MAXIMUM AMOUNT. The Maximum Amount shown in the Schedule of Benefits is the maximum amount that may be paid for the Covered Expenses incurred by an Insured. COVERED EXPENSES. Covered Expenses include: 1. only those expenses for dental procedures performed by a Provider; and 2. only those expenses for dental procedures listed and outlined on the Table of Dental Procedures. Covered Expenses are subject to "Limitations." See Limitations and Table of Dental Procedures. Benefits payable for Covered Expenses also will be limited to the lesser of: 1. the actual charge of the Provider. 2. the Maximum Allowable Charge ("MAC") as determined by us. 3. the Maximum Allowable Benefit ("MAB") as determined by us, if services are provided by a Non Participating Provider. MAC - The Maximum Allowable Charge is derived from the array of provider charges within a particular ZIP code area. These allowances are the charges accepted by general dentists who are Participating Providers. The MAC is reviewed and updated periodically to reflect increasing provider fees within the ZIP code area. MAB - The Maximum Allowable Benefit is derived from a blending of submitted provider charges within a ZIP code area. These allowances are an option for policyholders who want to offer their insured members affordable yet comprehensive coverage. The MAB is reviewed and updated periodically to reflect increasing provider fees within the ZIP code area. ALTERNATIVE PROCEDURES. If two or more procedures are considered adequate and appropriate treatment to correct a certain condition under generally accepted standards of dental care, the amount of the Covered Expense will be equal to the charge for the least expensive procedure. This provision is NOT intended to dictate a course of treatment. Instead, this provision is designed to determine the amount of the plan allowance for a submitted treatment when an adequate and appropriate alternative procedure is available. Accordingly, you may choose to apply the alternate benefit amount determined under this provision toward payment of the submitted treatment. We may request pre -operative dental x-ray films, periodontal charting and/or additional diagnostic data to determine the plan allowance for the procedures submitted. We strongly encourage pre-treatment estimates so you understand your benefits before any treatment begins. Ask your provider to submit a claim form for this purpose. EXPENSES INCURRED. An expense is incurred at the time the impression is made for an appliance or change to an appliance. An expense is incurred at the time the tooth or teeth are prepared for a dental prosthesis or prosthetic crown. For root canal therapy, an expense is incurred at the time the pulp chamber is opened. All other expenses are incurred at the time the service is rendered or a supply furnished. LIMITATIONS. Covered Expenses will not include and benefits will not be payable for expenses incurred: 1. in the first 12 months that a person is insured if the person is a Late Entrant; except for evaluations, prophylaxis (cleanings), and fluoride application. 2. a. for initial placement of any dental prosthesis or prosthetic crown unless such placement is needed because of the extraction of one or more teeth while the insured person is covered under this contract. But the extraction of a third molar (wisdom tooth) will not qualify under the above. Any such dental prosthesis or prosthetic crown must include the replacement of the extracted tooth or teeth, unless the insured person is covered on February 1, 2010. For those Insureds covered on February 1, 2010, see b. b. Limitation a. will be waived for those Insureds whose coverage was effective on February 1, 2010 and i. the person has the tooth extracted while insured under the prior contract: and ii has a dental prosthesis or prosthetic crown installed to replace the extracted tooth while insured under our contract; but such extraction and installation must take place within a twelve-month period; and iii. the dental prosthesis or prosthetic crown noted above must be an initial placement. 3. for appliances, restorations, or procedures to: a. alter vertical dimension; b. restore or maintain occlusion; or c. splint or replace tooth structure lost as a result of abrasion or attrition. 4. for any procedure begun after the insured person's insurance under this contract terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the Insured's insurance under this contract terminates. 5. to replace lost or stolen appliances. 6. for any treatment which is for cosmetic purposes. 7. for any procedure not shown in the Table of Dental Procedures. (There may be additional frequencies and limitations that apply, please see the Table of Dental Procedures for details.) 8. for orthodontic treatment under this benefit provision. (If orthodontic expense benefits have been included in this policy, please refer to the Schedule of Benefits and Orthodontic Expense Benefits provision found on 9260). 9. for which the Insured person is entitled to benefits under any workmen's compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit. 10. for charges which the Insured person is not liable or which would not have been made had no insurance been in force. 11. for services that are not required for necessary care and treatment or are not within the generally accepted parameters of care. 12. because of war or any act of war, declared or not. TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures for which benefits are payable under this section; and is based upon the Current Dental Terminology © American Dental Association. No benefits are payable for a procedure that is not listed. Your benefits are based on a Calendar Year. A Calendar Year runs from January 1 through December 31. Benefit Period means the period from January 1 of any year through December 31 of the same year. But during the first year a person is insured, a benefit period means the period from his or her effective date through December 31 of that year. Covered Procedures are subject to all plan provisions, procedure and frequency limitations, and/or consultant review. >= Reference to "traumatic injury" under this plan is defined as injury caused by external forces (ie. outside the mouth) and specifically excludes injury caused by internal forces such as bruxism (grinding of teeth). Benefits for replacement dental prosthesis or prosthetic crown will be based on the prior placement date. Frequencies which reference Benefit Period will be measured forward within the limits defined as the Benefit Period. All other frequencies will be measured forward from the last covered date of service. X-ray films, periodontal charting and supporting diagnostic data may be requested for our review. Y We recommend that a pre-treatment estimate be submitted for all anticipated work that is considered to be expensive by our insured. A pre-treatment estimate is not a pre -authorization or guarantee of payment or eligibility; rather it is an indication of the estimated benefits available if the described procedures are performed. TYPE 1 PROCEDURES PAYMENT BASIS - NON PARTICIPATING PROVIDERS - Maximum Allowable Benefit BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations ROUTINE ORAL EVALUATION D0120 Periodic oral evaluation - established patient. D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver. D0150 Comprehensive oral evaluation - new or established patient. D0180 Comprehensive periodontal evaluation - new or established patient. COMPREHENSIVE EVALUATION: D0150, D0180 ® Coverage is limited to 1 of each of these procedures per 1 provider. In addition, D0150, DO180 coverage is limited to 2 of any of these procedures per 1 benefit period. • D0120, D0145, also contributes) to this limitation. • If frequency met, will be considered at an alternate benefit of a 00120/D0145 and count towards this frequency. ROUTINE EVALUATION: D0120, D0145 • Coverage is limited to 2 of any of these procedures per 1 benefit period. D0150, D0180, also contribute(s) to this limitation. Procedure D0120 will be considered for individuals age 3 and over. Procedure D0145 will he considered for individuals age 2 and under. COMPLETE SERIES OR PANORAMIC FILM D0210 Intraoral - complete series (including bitewings). D0330 Panoramic film. COMPLETE SERIES/PANORAMIC FILMS: D0210, D0330 • Coverage is limited to I of any of these procedures per 3 year(s). OTHER XRAYS D0220 Intraoral - periapical first film. D0230 Intraoral - periapical each additional film. D0240 Intraoral - occlusal film. D0250 Extraoral - first film. D0260 Extraoral - each additional film. PERIAPiCAL FILMS: D0220, D0230 • The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. BITEWING FILMS D0270 Bitewing - single film. D0272 Bitewings - two films. D0273 Bitewings - three films. D0274 Bitewings - four films. D0277 Vertical bitewings - 7 to 8 films. BITEWING FILMS: D0270, D0272, D0273, D0274 • Coverage is limited to 2 of any of these procedures per 1 benefit period. • D0277, also contribute(s) to this limitation. • The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. VERTICAL BITEWING FILM: D0277 • Coverage is limited to I of any of these procedures per 3 year(s). • The maximum amount considered for x-ray films taken on one day will he equivalent to an allowance of a D0210. PROPHYLAXIS (CLEANING) AND FLUORIDE DI 110 Prophylaxis - adult. D1120 Prophylaxis - child. D1203 Topical application of fluoride - child. D1204 Topical application of fluoride - adult. D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients. FLUORIDE: D1203, D1204, D1206 • Coverage is limited to 1 of any of these procedures per 1 benefit period. TYPE 1 PROCEDURES • Benefits are considered for persons age 18 and under. • An adult fluoride is considered for individuals age 14 and over. A child fluoride is considered for individuals age 13 and under. PROPHYLAXIS: D1110, DI120 • Coverage is limited to 2 of any of these procedures per 1 benefit period. • D4910, also contribute(s) to this limitation. • An adult prophylaxis (cleaning) is considered for individuals age 14 and over. A child prophylaxis (cleaning) is considered for individuals age 13 and under. Benefits for prophylaxis (cleaning) are not available when performed on the same date as periodontal procedures. SEALANT D1351 Sealant - per tooth. SEALANT: D1351 • Coverage is limited to 1 of any of these procedures per 3 year(s). • Benefits are considered for persons age 16 and under. • Benefits are considered on permanent molars only. • Coverage is allowed on the occlusal surface only. APPLIANCE THERAPY D8210 Removable appliance therapy. D8220 Fixed appliance therapy. APPLIANCE THERAPY: D8210. D8220 • Coverage is limited to the con ection of thumb -sucking. OCCLUSAL GUARD D9940 Occlusal guard, by report. OCCLUSAL GUARD: D9940 • Coverage is limited to 1 of any of these procedures per 3 year(s). • Benefits will not be available if performed for athletic purposes. TYPE 2 PROCEDURES PAYMENT BASIS - NON PARTICIPATING PROVIDERS - Maximum Allowable Benefit BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations LIMITED ORAL EVALUATION D0140 Limited oral evaluation - problem focused. D0170 Re-evaluation - limited, problem focused (established patient; not post -operative visit). LIMITED ORAL EVALUATION: D0140. D0170 • Coverage is allowed for accidental injury only. If not due to an accident, will be considered at an alternate benefit of a D0120/D0145 and count towards this frequency. ORAL PATHOLOGY/LABORATORY D0472 Accession of tissue, gross examination, preparation and transmission of written report. D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report. D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report. ORAL PATHOLOGY LABORATORY: D0472, D0473, D0474 • Coverage is limited to 1 of any of these procedures per 12 month(s). • Coverage is limited to 1 examination per biopsy/excision. SPACE MAINTAINERS D1510 Space maintainer - fixed - unilateral. D1515 Space maintainer - fixed - bilateral. D1520 Space maintainer - removable - unilateral. D1525 Space maintainer - removable - bilateral. D1550 Re -cementation of space maintainer. D1555 Removal of fixed space maintainer. SPACE MAINTAINER: 01510, D1515, D1520, D1525 • Coverage is limited to space maintenance for unerupted teeth, following extraction of primary teeth. Allowances include all adjustments within 6 months of placement date. AMALGAM RESTORATIONS (FILLINGS) D2140 Amalgam - one surface, primary or permanent. D2150 Amalgam - two surfaces, primary or permanent. D2160 Amalgam - three surfaces, primary or permanent. D2161 Amalgam - four or more surfaces, primary or permanent. AMALGAM RESTORATIONS: D2140. D2150, 02160, D2161 • Coverage is limited to 1 of any of these procedures per 6 month(s). • D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394. D9911. also contribute(s) to this limitation. RESIN RESTORATIONS (FILLINGS) D2330 Resin -based composite - one surface, anterior. D2331 Resin -based composite - two surfaces, anterior. D2332 Resin -based composite - three surfaces, anterior. D2335 Resin -based composite - four or more surfaces or involving incisal angle (anterior). D2391 Resin -based composite - one surface, posterior. D2392 Resin -based composite - two surfaces, posterior. D2393 Resin -based composite - three surfaces, posterior. D2394 Resin -based composite - four or more surfaces, posterior. D2410 Gold foil - one surface. D2420 Gold foil - two surfaces. D2430 Gold foil - three surfaces. COMPOSITE RESTORATIONS: D2330. D2331, D2332. D2335. D2391, D2392, D2393, D2394 TYPE 2 PROCEDURES • Coverage is limited to 1 of any of these procedures per 6 month(s). • D2140, D2150, D2160, D2161, D991 I, also contribute(s) to this limitation. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable restorations. GOLD FOIL RESTORATIONS: D2410, D2420, D2430 • Gold foils are considered at an alternate benefit of an amalgam/composite restoration. ENDODONTICS MISCELLANEOUS D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp corona] to the dentinocemental junction and application of medicament. D3221 Pulpal debridement, primary and permanent teeth. D3222 Partial Pulpotomy for apexogenesis - permanent tooth with incomplete root development. D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration). D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration). D3333 Internal root repair of perforation defects. D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352 Apexication/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.). D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.). D3430 Retrograde filling - per root. D3450 Root amputation - per root. D3920 Hemisection (including any root removal), not including root canal therapy. ENDODONTICS MISCELLANEOUS: D3333, D3430, D3450, D3920 • Procedure D3333 is limited to permanent teeth only. ENDODONTIC THERAPY (ROOT CANALS) D3310 Endodontic therapy, anterior tooth. D3320 Endodontic therapy, bicuspid tooth. D3330 Endodontic therapy, molar. D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth. D3346 Retreatment of previous root canal therapy - anterior. D3347 Retreatment of previous root canal therapy - bicuspid. D3348 Retreatment of previous root canal therapy - molar. ROOT CANALS: D3310, D3320. D3330, D3332 • Benefits are considered on permanent teeth only. • Allowances include intraoperative films and cultures but exclude final restoration. RETREATMENT OF ROOT CANAL: D3346, D3347, D3348 • Coverage is limited to 1 of any of these procedures per 12 month(s). • D3310, D3320, D3330. also contributes) to this limitation. • Benefits are considered on permanent teeth only. • Coverage is limited to service dates more than 12 months after root canal therapy. Allowances include intraoperative films and cultures but exclude final restoration. SURGICAL ENDODONTICS D3410 Apicoectomy/periradicular surgery - anterior. D3421 Apicoectomy/periradicular surgery - bicuspid (first root). D3425 Apicoectomy/periradicular surgery - molar (first root). D3426 Apicoectomy/periradicular surgery (each additional root). SURGICAL PERIODONTICS D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant. TYPE 2 PROCEDURES D421 1 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant. D4240 Gingival flap procedure, including root planing - tooth bounded spaces per quadrant. D4241 Gingival flap procedure, including root planing - bounded spaces per quadrant. D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant. D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant. D4263 Bone replacement graft - first site in quadrant. D4264 Bone replacement graft - each additional site in quadrant. D4265 Biologic materials to aid in soft and osseous tissue regeneration. D4270 Pedicle soft tissue graft procedure. D4271 Free soft tissue graft procedure (including donor site surgery). D4273 Subepithelial connective tissue graft procedures, per tooth. D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area). D4275 Soft tissue allograft. D4276 Combined connective tissue and double pedicle graft, per tooth. BONE GRAFTS: D4263, D4264. D4265 • Each quadrant is limited to 1 of each of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. GINGIVECTOMY: D4210, D4211 • Each quadrant is limited to 1 of each of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. OSSEOUS SURGERY: D4240, D4241, D4260, D4261 • Each quadrant is limited to 1 of each of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. TISSUE GRAFTS: D4270, D4271, D4273. D4275, D4276 • Each quadrant is limited to 2 of any of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. four or more contiguous teeth or one to three contiguous teeth or tooth NON -SURGICAL PERIODONTICS D4341 Periodontal scaling and root planing - four or more teeth per quadrant. D4342 Periodontal scaling and root planing - one to three teeth, per quadrant. D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report. CHEMOTHERAPEUTIC AGENTS: D4381 • Each quadrant is limited to 2 of any of these procedures per 2 year(s). PERIODONTAL SCALING & ROOT PLANING: D4341, D4342 • Each quadrant is limited to I of each of these procedures per 2 year(s). FULL MOUTH DEBRIDEMENT D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis. FULL MOUTH DEBRIDEMENT: D4355 • Coverage is limited to 1 of any of these procedures per 5 year(s), PERIODONTAL MAINTENANCE D4910 Periodontal maintenance. PERIODONTAL MAINTENANCE: D4910 • Coverage is limited to 2 of any of these procedures per 1 benefit period. • D1110, D1120, also contribute(s) to this limitation. • Coverage is contingent upon evidence of full mouth active periodontal therapy. Benefits are not available if performed on the same date as any other periodontal procedure. NON -SURGICAL EXTRACTIONS D7111 Extraction, coronal remnants - deciduous tooth. D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal). TYPE 2 PROCEDURES SURGICAL EXTRACTIONS D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. D7220 Removal of impacted tooth - soft tissue. D7230 Removal of impacted tooth - partially bony. D7240 Removal of impacted tooth - completely bony. D7241 Removal of impacted tooth - completely bony, with unusual surgical complications. D7250 Surgical removal of residual tooth roots (cutting procedure). OTHER ORAL SURGERY D7260 Oroantral fistula closure. D7261 Primary closure of a sinus perforation. D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth. D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization). D7280 Surgical access of an unerupted tooth. D7282 Mobilization of erupted or malpositioned tooth to aid eruption. D7283 Placement of device to facilitate eruption of impacted tooth. D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant. D7311 Alveoplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant. D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant. D7321 Alveoplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant. D7340 Vestibuloplasty - ridge extension (secondary epithelialization). D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue). D7410 Excision of benign lesion up to 1.25 cm. D7411 Excision of benign lesion greater than 1.25 cm. D7412 Excision of benign lesion, complicated. D7413 Excision of malignant lesion up to 1.25 cm. D7414 Excision of malignant lesion greater than 1.25 cm. D7415 Excision of malignant lesion, complicated. D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm. D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm. D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm. D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm. D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm. D7461 Removal of benign nonodontogenic cyst or turnor - lesion diameter greater than 1.25 cm. D7465 Destruction of lesion(s) by physical or chemical method, by report. D7471 Removal of lateral exostosis (maxilla or mandible). D7472 Removal of torus palatinus. D7473 Removal of torus mandibularis. D7485 Surgical reduction of osseous tuberosity. D7490 Radical resection of maxilla or mandible. D7510 Incision and drainage of abscess - intraoral soft tissue. D7520 Incision and drainage of abscess - extraoral soft tissue. D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue. TYPE 2 PROCEDURES D7540 Removal of reaction producing foreign bodies, musculoskeletal system. D7550 Partial ostectomy/sequestrectomy for removal of non -vital bone. D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body. D7910 Suture of recent small wounds up to 5 cm. D7911 Complicated suture - up to 5 cm. D7912 Complicated suture - greater than 5 cm. D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure. D7963 Frenuloplasty. D7970 Excision of hyperplastic tissue - per arch. D7972 Surgical reduction of fibrous tuberosity. D7980 Sialolithotomy. D7983 Closure of salivary fistula. REMOVAL OF BONE TISSUE: D7471, D7472, D7473 • Coverage is limited to 5 of any of these procedures per 1 lifetime. BIOPSY OF ORAL TISSUE D7285 Biopsy of oral tissue - hard (bone, tooth). D7286 Biopsy of oral tissue - soft. D7287 Exfoliative cytological sample collection. D7288 Brush biopsy - transepithelial sample collection. PALLIATIVE D9110 Palliative (emergency) treatment of dental pain - minor procedure. PALLIATIVE TREATMENT: D9110 • Not covered in conjunction with other procedures, except diagnostic x-ray films. ANESTHESIA-GENERAL/IV D9220 Deep sedation/general anesthesia - first 30 minutes. D9221 Deep sedation/general anesthesia - each additional 15 minutes. D9241 Intravenous conscious sedation/analgesia - first 30 minutes. D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes. GENERAL ANESTHESIA: D9220, D9221, D9241, D9242 • Coverage is only available with a cutting procedure. Verification of the dentist's anesthesia permit and a copy of the anesthesia report is required. A maximum of two additional units (D9221 or D9242) will be considered. PROFESSIONAL CONSULT/VISIT/SERVICES D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician. D9430 Office visit for observation (during regularly scheduled hours) - no other services performed. D9440 Office visit - after regularly scheduled hours. D9930 Treatment of complications (post -surgical) - unusual circumstances, by report. CONSULTATION: D9310 • Coverage is limited to 1 of any of these procedures per 1 provider. OFFICE VISIT: D9430, D9440 • Procedure D9430 is allowed for accidental injury only. Procedure D9440 will be allowed on the basis of services rendered or visit, whichever is greater. OCCLUSAL ADJUSTMENT D9951 Occlusal adjustment - limited. D9952 Occlusal adjustment - complete. OCCLUSAL ADJUSTMENT: D9951. D9952 • Coverage is considered only when performed in conjunction with periodontal procedures for the treatment of periodontal disease. MISCELLANEOUS TYPE 2 PROCEDURES D0486 Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report. D2951 Pin retention - per tooth, in addition to restoration. D9911 Application of desensitizing resin for cervical and/or root surfaces, per tooth. DESENSITIZATION: D9911 • Coverage is limited to 1 of any of these procedures per 6 month(s). • D2140, D2150, D2160, D2161.. D2330, D2331. D2332, D2335, 02391, D2392, D2393, D2394, also contribute(s) to this limitation. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable restorations. TYPE 3 PROCEDURES PAYMENT BASIS - NON PARTICIPATING PROVIDERS - Maximum Allowable Benefit BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations STAINLESS STEEL CROWN (PREFABRICATED CROWN) D2390 Resin -based composite crown, anterior. D2930 Prefabricated stainless steel crown - primary tooth. D2931 Prefabricated stainless steel crown - permanent tooth. D2932 Prefabricated resin crown. D2933 Prefabricated stainless steel crown with resin window. D2934 Prefabricated esthetic coated stainless steel crown - primary tooth. STAINLESS STEEL CROWN: D2390, D2930, D2931. D2932, D2933, D2934 • Replacement is limited to 1 of any of these procedures per 12 month(s). • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. INLAY RESTORATIONS D2510 Inlay - metallic - one surface. D2520 Inlay - metallic - two surfaces. D2530 Inlay - metallic - three or more surfaces. D2610 Inlay - porcelain/ceramic - one surface. D2620 Inlay - porcelain/ceramic - two surfaces. D2630 Inlay - porcelain/ceramic - three or more surfaces. D2650 Inlay - resin -based composite - one surface. D2651 Inlay - resin -based composite - two surfaces. D2652 Inlay - resin -based composite - three or more surfaces. INLAY: D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652 • Inlays will be considered at an alternate benefit of an amalgam/composite restoration and only when resulting from caries (tooth decay) or traumatic injury. ONLAY RESTORATIONS D2542 Onlay - metallic - two surfaces. D2543 Onlay - metallic - three surfaces. D2544 Onlay - metallic - four or more surfaces. D2642 Onlay - porcelain/ceramic - two surfaces. D2643 Onlay - porcelain/ceramic - three surfaces. D2644 Onlay - porcelain/ceramic - four or more surfaces. D2662 Onlay - resin -based composite - two surfaces. D2663 Onlay - resin -based composite - three surfaces. D2664 Onlay - resin -based composite - four or more surfaces. ONLAY: D2542, D2543, D2544, D2642. D2643, D2644. D2662, D2663, D2664 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D2510, D2520, D2530, D2610, D2620. D2630, D2650, D2651, D2652, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751. D2752, D2780, D2781, D2782, D2783, D2790, D2791. D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720. D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only, • Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury. • Benefits will not be considered if procedure D2390, D2930. D2931, D2932, D2933 or D2934 has been performed within 12 months. CROWNS SINGLE RESTORATIONS D2710 Crown - resin -based composite (indirect). D2712 Crown - 3/4 resin -based composite (indirect). D2720 Crown - resin with high noble metal. D2721 Crown - resin with predominantly base metal. TYPE 3 PROCEDURES D2722 Crown - resin with noble metal. D2740 Crown - porcelain/ceramic substrate. D2750 Crown - porcelain fused to high noble metal. D2751 Crown - porcelain fused to predominantly base metal. D2752 Crown - porcelain fused to noble metal. D2780 Crown - 3/4 cast high noble metal. D2781 Crown - 3/4 cast predominantly base metal. D2782 Crown - 3/4 cast noble metal. D2783 Crown - 3/4 porcelain/ceramic. D2790 Crown - full cast high noble metal. D2791 Crown - full cast predominantly base metal. D2792 Crown - full cast noble metal. D2794 Crown - titanium. CROWN: D2710, D27I2, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791 D2792, D2794 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D2510, D2520, D2530, D2542, D2543, D2544. D2610, D2620, D2630, D2642, D2643, D2644, 02650, D2651, D2652, D2662, D2663, D2664. D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, 06781, D6782, D6783, D6790, D6791, D6792, D6794, also contribute(s) to this limitation, • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury. • Benefits will not be considered if procedure D2390, D2930, D2931, 02932, D2933 or D2934 has been performed within 12 months. RECEMENT D2910 Recement inlay, onlay, or partial coverage restoration. D2915 Recement cast or prefabricated post and core. D2920 Recement crown. D6092 Recement implant/abutment supported crown. D6093 Recement implant/abutment supported fixed partial denture. D6930 Recement fixed partial denture. SEDATIVE FILLING D2940 Sedative filling. CORE BUILD-UP D2950 Core buildup, including any pins. D6973 Core build up for retainer, including any pins. POST AND CORE D2952 Post and core in addition to crown, indirectly fabricated. D2954 Prefabricated post and core in addition to crown. FIXED CROWN AND PARTIAL DENTURE REPAIR D2980 Crown repair, by report. D6980 Fixed partial denture repair, by report. D9120 Fixed partial denture sectioning. CROWN LENGTHENING D4249 Clinical crown lengthening - hard tissue. PROSTHODONTICS - FIXED/REMOVABLE (DENTURES) D5110 Complete denture - maxillary. D5120 Complete denture - mandibular. TYPE 3 PROCEDURES D5130 Immediate denture - maxillary. D5140 Immediate denture - mandibular. D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth). D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth). D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth). D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth). D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth). D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth). D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth). D5670 Replace all teeth and acrylic on cast metal framework (maxillary). D5671 Replace all teeth and acrylic on cast metal framework (mandibular). D5810 Interim complete denture (maxillary). D5811 Interim complete denture (mandibular). D5820 Interim partial denture (maxillary). D5821 Interim partial denture (mandibular). D5860 Overdenture - complete, by report. D5861 Overdenture - partial, by report. D6053 Implant/abutment supported removable denture for completely edentulous arch. D6054 Implant/abutment supported removable denture for partially edentulous arch. D6078 Implant/abutment supported fixed denture for completely edentulous arch. D6079 Implant/abutment supported fixed denture for partially edentulous arch. COMPLETE DENTURE: D5110, D5120, D5130, D5140, D5860, D6053, D6078 • Replacement is limited to 1 of any of these procedures per 5 year(s). • Frequency is waived for accidental injury. • Allowances include adjustments within 6 months after placement date. Procedures D5860, D6053, and D6078 are considered at an alternate benefit of a D5110/1)5120. PARTIAL DENTURE: D5211, D5212, D5213, D5214, D5225, D5226, D5281, D5670, D5671, D5861, D6054, D6079 • Replacement is limited to 1 of any of these procedures per 5 year(s). • Frequency is waived for accidental injury. • Allowances include adjustments within 6 months of placement date. Procedures D5861, D6054, and D6079 are considered at an alternate benefit of a D5213/D5214. DENTURE ADJUSTMENTS D5410 Adjust complete denture - maxillary. D5411 Adjust complete denture - mandibular. D5421 Adjust partial denture - maxillary. D5422 Adjust partial denture - mandibular. DENTURE ADJUSTMENT: D5410, D5411, D5421, D5422 • Coverage is limited to dates of service more than 6 months after placement date. DENTURE REPAIR D5510 Repair broken complete denture base. D5520 Replace missing or broken teeth - complete denture (each tooth). D5610 Repair resin denture base. D5620 Repair cast framework. D5630 Repair or replace broken clasp. D5640 Replace broken teeth - per tooth. ADD TOOTH/CLASP TO EXISTING PARTIAL D5650 Add tooth to existing partial denture. D5660 Add clasp to existing partial denture. TYPE 3 PROCEDURES DENTURE REBASES D5710 Rebase complete maxillary denture. D5711 Rebase complete mandibular denture. D5720 Rebase maxillary partial denture. D5721 Rebase mandibular partial denture. DENTURE RELINES D5730 Reline complete maxillary denture (chairside). D5731 Reline complete mandibular denture (chairside). D5740 Reline maxillary partial denture (chairside). D5741 Reline mandibular partial denture (chairside). D5750 Reline complete maxillary denture (laboratory). D5751 Reline complete mandibular denture (laboratory). D5760 Reline maxillary partial denture (laboratory). D5761 Reline mandibular partial denture (laboratory). DENTURE RELINE: D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761 • Coverage is limited to service dates more than 6 months after placement date. TISSUE CONDITIONING D5850 Tissue conditioning, maxillary. D5851 Tissue conditioning, mandibular. PROSTHODONTICS - FIXED D6058 Abutment supported porcelain/ceramic crown. D6059 Abutment supported porcelain fused to metal crown (high noble metal). D6060 Abutment supported porcelain fused to metal crown (predominantly base metal). D6061 Abutment supported porcelain fused to metal crown (noble metal). D6062 Abutment supported cast metal crown (high noble metal). D6063 Abutment supported cast metal crown (predominantly base metal). D6064 Abutment supported cast metal crown (noble metal). D6065 Implant supported porcelain/ceramic crown. D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal). D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal). D6068 Abutment supported retainer for porcelain/ceramic FPD. D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal). D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal). D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal). D6072 Abutment supported retainer for cast metal FPD (high noble metal). D6073 Abutment supported retainer for cast metal FPD (predominantly base metal). D6074 Abutment supported retainer for cast metal FPD (noble metal). D6075 Implant supported retainer for ceramic FPD. D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal). D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble metal). D6094 Abutment supported crown - (titanium). D6194 Abutment supported retainer crown for FPD (titanium). D6205 Pontic - indirect resin based composite. D6210 Pontic - cast high noble metal. D6211 Pontic - cast predominantly base metal. D6212 Pontic - cast noble metal. TYPE 3 PROCEDURES D6214 Pontic - titanium. D6240 Pontic - porcelain fused to high noble metal. D6241 Pontic - porcelain fused to predominantly base metal. D6242 Pontic - porcelain fused to noble metal. D6245 Pontic - porcelain/ceramic. D6250 Pontic - resin with high noble metal. D6251 Pontic - resin with predominantly base metal. D6252 Pontic - resin with noble metal. D6545 Retainer - cast metal for resin bonded fixed prosthesis. D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis. D6600 Inlay - porcelain/ceramic, two surfaces. D6601 . Inlay - porcelain/ceramic, three or more surfaces. D6602 Inlay - cast high noble metal, two surfaces. D6603 Inlay - cast high noble metal, three or more surfaces. D6604 Inlay - cast predominantly base metal, two surfaces. D6605 Inlay - cast predominantly base metal, three or more surfaces. D6606 Inlay - cast noble metal, two surfaces. D6607 Inlay - cast noble metal, three or more surfaces. D6608 Onlay - porcelain/ceramic, two surfaces. D6609 Onlay - porcelain/ceramic, three or more surfaces. D6610 Onlay - cast high noble metal, two surfaces. D6611 Onlay - cast high noble metal, three or more surfaces. D6612 Onlay - cast predominantly base metal, two surfaces. D6613 Onlay - cast predominantly base metal, three or more surfaces. D6614 Onlay - cast noble metal, two surfaces. D6615 Onlay - cast noble metal, three or more surfaces. D6624 Inlay - titanium. D6634 Onlay - titanium. D6710 Crown - indirect resin based composite. D6720 Crown - resin with high noble metal. D6721 Crown - resin with predominantly base metal. D6722 Crown - resin with noble metal. D6740 Crown - porcelain/ceramic. D6750 Crown - porcelain fused to high noble metal. D6751 Crown - porcelain fused to predominantly base metal. D6752 Crown - porcelain fused to noble metal. D6780 Crown - 3/4 cast high noble metal. D6781 Crown - 3/4 cast predominantly base metal. D6782 Crown - 3/4 cast noble metal. D6783 Crown - 3/4 porcelain/ceramic. D6790 Crown - full cast high noble metal. D6791 Crown - full cast predominantly base metal. D6792 Crown - full cast noble metal. D6794 Crown - titanium. D6940 Stress breaker. FIXED PARTIAL CROWN: D6710, D6720. D6721. D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790. D6791, D6792, D6794 9 Replacement is limited to 1 of any of these procedures per 5 year(s). o D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D660I, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D66I2, D6613, D6614, D6615, D6624, D6634, also contribute(s) to this limitation. = Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. ® Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. TYPE 3 PROCEDURES • Benefits will not be considered if procedure D2390,1)2930, D2931. D2932, D2933 or 1)2934 has been performed within 12 months. FIXED PARTIAL INLAY: D6600. D6601, D6602. D6603, D6604, 1)6605, D6606, D6607. D6624 • Replacement is limited to I of any of these procedures per 5 year(s). • D2510,1)2520. D2530,1)2542, D2543, D2544, D2610, D2620, D2630. D2642, D2643, D2644. D2650. D2651. D2652. D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750. D2751. D2752, D2780, D2781, D2782, D2783. D2790, D2791, D2792. D2794, D6608. D6609, D6610, D6611, D6612, D6613. D6614, D6615, D6634, D6710, D6720, D6721, D6722, 1)6740. D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, 1)6791, D6792, D6794. also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only, • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Benefits will not be considered if procedure D2390. D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL ONLAY: D6608, D6609, D6610, D6611, D6612, D6613, D66I4, D6615. D6634 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D2510,1)2520, D2530, D2542. D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664. D2710, D2712, D2720, D2721, D2722,1)2740, D2750, D2751,1)2752, D2780, D2781, D2782, D2783. D2790. D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6624, D6710. D6720, D6721, D6722,1)6740, D6750, D6751. D6752, D6780, D6781, D6782, D6783, D6790. D6791, D6792, D6794, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL PONTIC: D6205,1)6210, D6211, D6212,1)6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D5211,1)5212, D5213,1)5214, D5225, D5226, D5281, D6058, D6059, D6060. D6061, 1)6062. D6063. D6064, D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073,1)6074, D6075, D6076, D6077, D6094. D6194, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. IMPLANT SUPPORTED CROWN: D6058, 1)6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6094 • Replacement is limited to I of any of these procedures per 5 year(s). • D5211, D5212, D5213, 1)5214, D5225, D5226,1)5281, D6194,1)6205, D6210. D6211, D6212, D6214, D6240, D6241,1)6242. D6245, D6250, D6251, D6252, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. IMPLANT SUPPORTED RETAINER: D6068, D6069, D6070, D6071, 1)6072, D6073, D6074, D6075, D6076, D6077. D6194 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6058, D6059,1)6060,1)6061, D6062, D6063,1)6064. D6065. D6066, D6067, D6094, D6205, D6210, D6211, D6212,1)6214, D6240,1)6241, D6242, D6245,1)6250, D6251. D6252, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the conesponding noble metal allowance. CAST POST AND CORE FOR PARTIALS D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated. D6972 Prefabricated post and core in addition to fixed partial denture retainer. TYPE 1 PROCEDURES PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations ROUTINE ORAL EVALUATION D0120 Periodic oral evaluation - established patient. D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver. D0150 Comprehensive oral evaluation - new or established patient. D0180 Comprehensive periodontal evaluation - new or established patient. COMPREHENSIVE EVALUATION: D0150, D0180 • Coverage is limited to 1 of each of these procedures per 1 provider. • In addition, D0150, D0180 coverage is limited to 2 of any of these procedures per 1 benefit period. • D0120, D0145, also contribute(s) to this limitation, • If frequency met, will be considered at an alternate benefit of a D0120'D0145 and count towards this frequency. ROUTINE EVALUATION: D0120, D0145 • Coverage is limited to 2 of any of these procedures per I benefit period. • D0150, D0180, also contrihute(s) to this limitation. • Procedure D0120 will be considered for individuals age 3 and over. Procedure D0145 will be considered for individuals age 2 and under. COMPLETE SERIES OR PANORAMIC FILM D0210 Intraoral - complete series (including bitewings). D0330 Panoramic film. COMPLETE SERIES/PANORAMIC FILMS: D0210, D0330 • Coverage is limited to 1 of any of these procedures per 3 year(s). OTHER XRAYS D0220 Intraoral - periapical first film. D0230 Intraoral - periapical each additional film. D0240 Intraoral - occlusal film. D0250 Extraoral - first film. D0260 Extraoral - each additional film. PERIAPICAL FILMS: D0220, D0230 • The maximum amount considered for x-ray films taken on one day will he equivalent to an allowance of a D0210. BITEWING FILMS D0270 Bitewing - single film. D0272 Bitewings - two films. D0273 Bitewings - three films. D0274 Bitewings - four films. D0277 Vertical bitewings - 7 to 8 films. BITEWING FILMS: D0270, D0272, D0273, D0274 • Coverage is limited to 2 of any of these procedures per 1 benefit period. • D0277, also contribute(s) to this limitation. • The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. VERTICAL BITEWING FILM: D0277 • Coverage is limited to 1 of any of these procedures per 3 year(s). • The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. PROPHYLAXIS (CLEANING) AND FLUORIDE DI 110 Prophylaxis - adult. D1120 Prophylaxis - child. D1203 Topical application of fluoride - child. D1204 Topical application of fluoride - adult. D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients. FLUORIDE: D1203, D1204. D1206 • Coverage is limited to 1 of any of these procedures per 1 benefit period. TYPE 1 PROCEDURES • Benefits are considered for persons age 18 and under. • An adult fluoride is considered for individuals age 14 and over. A child fluoride is considered for individuals age 13 and under. PROPHYLAXIS: D1110, D1120 • Coverage is limited to 2 of any of these procedures per 1 benefit period. • D4910, also contribute(s) to this limitation. • An adult prophylaxis (cleaning) is considered for individuals age 14 and over. A child prophylaxis (cleaning) is considered for individuals age 13 and under. Benefits for prophylaxis (cleaning) are not available when performed on the same date as periodontal procedures. SEALANT D1351 Sealant - per tooth. SEALANT: D1351 • Coverage is limited to 1 of any of these procedures per 3 year(s). • Benefits are considered for persons age 16 and under. • Benefits are considered on permanent molars only. • Coverage is allowed on the occlusal surface only. APPLIANCE THERAPY D8210 Removable appliance therapy. D8220 Fixed appliance therapy. APPLIANCE THERAPY: D8210, D8220 • Coverage is limited to the correction of thumb -sucking. OCCLUSAL GUARD D9940 Occlusal guard, by report. OCCLUSAL GUARD: D9940 • Coverage is limited to 1 of any of these procedures per 3 year(s). • Benefits will not he available if performed for athletic purposes. TYPE 2 PROCEDURES PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations LIMITED ORAL EVALUATION D0140 Limited oral evaluation - problem focused. D0170 Re-evaluation - limited, problem focused (established patient; not post -operative visit). LIMITED ORAL EVALUATION: D0140. D0170 • Coverage is allowed for accidental injury only. Ifnot due to an accident, will be considered at an alternate benefit of a D0120/D0145 and count towards this frequency. ORAL PATHOLOGY/LABORATORY D0472 Accession of tissue, gross examination, preparation and transmission of written report. D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report. D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report. ORAL PATHOLOGY LABORATORY: D0472, D0473, D0474 • Coverage is limited to 1 of any of these procedures per 12 month(s). • Coverage is limited to 1 examination per biopsy/excision. SPACE MAINTAINERS D1510 Space maintainer - fixed - unilateral. D1515 Space maintainer - fixed - bilateral. D1520 Space maintainer - removable - unilateral. D1525 Space maintainer - removable - bilateral. D1550 Re -cementation of space maintainer. D1555 Removal of fixed space maintainer. SPACE MAINTAINER: D1510, D1515, D1520, D1525 • Coverage is limited to space maintenance for unerupted teeth,. following extraction of primary teeth. Allowances include all adjustments within 6 months of placement date. AMALGAM RESTORATIONS (FILLINGS) D2140 Amalgam - one surface, primary or permanent. D2150 Amalgam - two surfaces, primary or permanent. D2160 Amalgam - three surfaces, primary or permanent. D2161 Amalgam - four or more surfaces, primary or permanent. AMALGAM RESTORATIONS: D2140, D2150, D2160, D2161 • Coverage is limited to 1 of any of these procedures per 6 month(s). • D2330, D2331, D2332, D2335, D2391, D2392. D2393, D2394, D9911, also contribute(s) to this limitation. RESIN RESTORATIONS (FILLINGS) D2330 Resin -based composite - one surface, anterior. D2331 Resin -based composite - two surfaces, anterior. D2332 D2335 D2391 D2392 D2393 D2394 D2410 D2420 D2430 Resin -based composite Resin -based composite Resin -based composite Resin -based composite Resin -based composite Resin -based composite Gold foil - one surface. Gold foil - two surfaces. Gold foil - three surfaces three surfaces, anterior. four or more surfaces or involving incisal angle (anterior). one surface, posterior. two surfaces, posterior. three surfaces, posterior. four or more surfaces, posterior. • COMPOSITE RESTORATIONS: D2330, D2331, D2332, D2335. D2391, D2392, D2393. D2394 TYPE 2 PROCEDURES • Coverage is limited to 1 of any of these procedures per 6 month(s). • D2140, D2150, D2160, D2161, D9911, also contributes) to this limitation. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable restorations. GOLD FOIL RESTORATIONS: D2410, D2420, D2430 • Gold foils are considered at an alternate benefit of an amalgamlcomposite restoration. ENDODONTICS MISCELLANEOUS D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp corona' to the dentinocemental junction and application of medicament. D3221 Pulpal debridement, primary and permanent teeth. D3222 Partial Pulpotomy for apexogenesis - permanent tooth with incomplete root development. D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration). D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration). D3333 Internal root repair of perforation defects. D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352 Apexication/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.). D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.). D3430 Retrograde filling - per root. D3450 Root amputation - per root. D3920 Hemisection (including any root removal), not including root canal therapy. ENDODONTICS MISCELLANEOUS: D3333, D3430, D3450, D3920 • Procedure D3333 is limited to permanent teeth only. ENDODONTIC THERAPY (ROOT CANALS) D3310 Endodontic therapy, anterior tooth. D3320 Endodontic therapy, bicuspid tooth. D3330 Endodontic therapy, molar. D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth. D3346 Retreatment of previous root canal therapy - anterior. D3347 Retreatment of previous root canal therapy - bicuspid. D3348 Retreatment of previous root canal therapy - molar. ROOT CANALS: D3310, D3320. D3330, D3332 • Benefits are considered on permanent teeth only. • Allowances include intraoperative films and cultures but exclude final restoration. RETREATMENT OF ROOT CANAL: D3346, D3347. D3348 • Coverage is limited to 1 of any of these procedures per 12 month(s). • D3310, D3320, D3330, also contribute(s) to this limitation. • Benefits are considered on permanent teeth only. • Coverage is limited to service dates more than 12 months after root canal therapy. Allowances include intraoperative films and cultures but exclude final restoration. SURGICAL ENDODONTICS D3410 Apicoectomy/periradicular surgery - anterior. D3421 Apicoectomy/periradicular surgery - bicuspid (first root). D3425 Apicoectomy/periradicular surgery - molar (first root). D3426 Apicoectomy/periradicular surgery (each additional root). SURGICAL PERIODONTICS D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant. TYPE 2 PROCEDURES D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant. D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant. D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant. D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant. D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant. D4263 Bone replacement graft - first site in quadrant. D4264 Bone replacement graft - each additional site in quadrant. D4265 Biologic materials to aid in soft and osseous tissue regeneration. D4270 Pedicle soft tissue graft procedure. D4271 Free soft tissue graft procedure (including donor site surgery). D4273 Subepithelial connective tissue graft procedures, per tooth. D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area). D4275 Soft tissue allograft. D4276 Combined connective tissue and double pedicle graft, per tooth. BONE GRAFTS: D4263, D4264, D4265 • Each quadrant is limited to 1 of each of these procedures per 3 years) • Coverage is limited to treatment of periodontal disease. GINGIVECTOMY: D4210, D4211 • Each quadrant is limited to 1 of each of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. OSSEOUS SURGERY: D4240, D4241, D4260, D4261 • Each quadrant is limited to I of each of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. TISSUE GRAFTS: D4270, D4271, D4273, D4275, D4276 • Each quadrant is limited to 2 of any of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. NON -SURGICAL PERIODONTICS D4341 Periodontal scaling and root planing - four or more teeth per quadrant. D4342 Periodontal scaling and root planing - one to three teeth, per quadrant. D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report. CHEMOTHERAPEUTIC AGENTS: D4381 • Each quadrant is limited to 2 of any of these procedures per 2 year(s). PERIODONTAL SCALING & ROOT PLANING: D4341, D4342 • Each quadrant is limited to 1 of each of these procedures per 2 year( s). FULL MOUTH DEBRIDEMENT D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis. FULL MOUTH DEBRIDEMENT: D4355 • Coverage is limited to 1 of any of these procedures per 5 year(s). PERIODONTAL MAINTENANCE D4910 Periodontal maintenance. PERIODONTAL MAINTENANCE: D4910 • Coverage is limited to 2 of any of these procedures per I benefit period. • D1110, D1120, also contribute(s) to this limitation. • Coverage is contingent upon evidence of full mouth active periodontal therapy. Benefits are not available if perfonned on the same date as any other periodontal procedure. NON -SURGICAL EXTRACTIONS D7111 Extraction, coronal remnants - deciduous tooth. D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal). TYPE 2 PROCEDURES SURGICAL EXTRACTIONS D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. D7220 Removal of impacted tooth - soft tissue. D7230 Removal of impacted tooth - partially bony. D7240 Removal of impacted tooth - completely bony. D7241 Removal of impacted tooth - completely bony, with unusual surgical complications. D7250 Surgical removal of residual tooth roots (cutting procedure). OTHER ORAL SURGERY D7260 Oroantral fistula closure. D7261 Primary closure of a sinus perforation. D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth. D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization). D7280 Surgical access of an unerupted tooth. D7282 Mobilization of erupted or malpositioned tooth to aid eruption. D7283 Placement of device to facilitate eruption of impacted tooth. D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant. D7311 Alveoplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant. D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant. D7321 Alveoplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant. D7340 Vestibuloplasty - ridge extension (secondary epithelialization). D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue). D7410 Excision of benign lesion up to 1.25 cm. D7411 Excision of benign lesion greater than 1.25 cm. D7412 Excision of benign lesion, complicated. D7413 Excision of malignant lesion up to 1.25 cm. D7414 Excision of malignant lesion greater than 1.25 cm. D7415 Excision of malignant lesion, complicated. D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm. D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm. D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm. D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm. D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm. D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm. D7465 Destruction of lesion(s) by physical or chemical method, by report. D7471 Removal of lateral exostosis (maxilla or mandible). D7472 Removal of torus palatinus. D7473 Removal of torus mandibularis. D7485 Surgical reduction of osseous tuberosity. D7490 Radical resection of maxilla or mandible. D7510 Incision and drainage of abscess - intraoral soft tissue. D7520 Incision and drainage of abscess - extraoral soft tissue. D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue. TYPE 2 PROCEDURES D7540 Removal of reaction producing foreign bodies, musculoskeletal system. D7550 Partial ostectomy/sequestrectomy for removal of non -vital bone. D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body. D7910 Suture of recent small wounds up to 5 cm. D7911 Complicated suture - up to 5 cm. D7912 Complicated suture - greater than 5 cm. D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure. D7963 Frenuloplasty. D7970 Excision of hyperplastic tissue - per arch. D7972 Surgical reduction of fibrous tuberosity. D7980 Sialolithotomy. D7983 Closure of salivary fistula. REMOVAL OF BONE TISSUE: D7471, D7472. D7473 • Coverage is limited to 5 of any of these procedures per 1 lifetime. BIOPSY OF ORAL TISSUE D7285 Biopsy of oral tissue - hard (bone, tooth). D7286 Biopsy of oral tissue - soft. D7287 Exfoliative cytological sample collection. D7288 Brush biopsy - transepithelial sample collection. PALLIATIVE D91 10 Palliative (emergency) treatment of dental pain - minor procedure. PALLIATIVE TREATMENT: D91 10 • Not covered in conjunction with other procedures, except diagnostic x-ray films. ANESTHESIA-GENERAL/IV D9220 Deep sedation/general anesthesia - first 30 minutes. D9221 Deep sedation/general anesthesia - each additional 15 minutes. D9241 Intravenous conscious sedation/analgesia - first 30 minutes. D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes. GENERAL ANESTHESIA: D9220, D9221, D9241, D9242 • Coverage is only available with a cutting procedure. Verification of the dentist's anesthesia pennit and a copy of the anesthesia report is required. A maximum of two additional units (09221 or D9242) will be considered. PROFESSIONAL CONSULT/VISIT/SERVICES D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician. D9430 Office visit for observation (during regularly scheduled hours) - no other services performed. D9440 Office visit - after regularly scheduled hours. D9930 Treatment of complications (post -surgical) - unusual circumstances, by report. CONSULTATION: D9310 • Coverage is limited to 1 of any of these procedures per 1 provider. OFFICE VISIT: D9430, D9440 • Procedure D9430 is allowed for accidental injury only. Procedure D9440 will be allowed on the basis of services rendered or visit, whichever is greater. OCCLUSAL ADJUSTMENT D9951 Occlusal adjustment - limited. D9952 Occlusal adjustment - complete. OCCLUSAL ADJUSTMENT: D9951, D9952 • Coverage is considered only when performed in conjunction with periodontal procedures for the treatment of periodontal disease. MISCELLANEOUS TYPE 2 PROCEDURES D0486 Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report. D2951 Pin retention - per tooth, in addition to restoration. D9911 Application of desensitizing resin for cervical and/or root surfaces, per tooth. DESENSITIZATION: D9911 a Coverage is limited to l of any of these procedures per 6 month(s). D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394, also contributes) to this limitation. Porcelain and resin benefits are considered for anterior and bicuspid teeth only. Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable restorations. TYPE 3 PROCEDURES PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations STAINLESS STEEL CROWN (PREFABRICATED CROWN) D2390 Resin -based composite crown, anterior. D2930 Prefabricated stainless steel crown - primary tooth. D2931 Prefabricated stainless steel crown - permanent tooth. D2932 Prefabricated resin crown. D2933 Prefabricated stainless steel crown with resin window. D2934 Prefabricated esthetic coated stainless steel crown - primary tooth. STAINLESS STEEL CROWN: D2390, D2930, D2931, D2932, D2933, D2934 • Replacement is limited to 1 of any of these procedures per 12 month(s). • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. INLAY RESTORATIONS D2510 Inlay - metallic - one surface. D2520 Inlay - metallic - two surfaces. D2530 Inlay - metallic - three or more surfaces. D2610 Inlay - porcelain/ceramic - one surface. D2620 Inlay - porcelain/ceramic - two surfaces. D2630 Inlay - porcelain/ceramic - three or more surfaces. D2650 Inlay - resin -based composite - one surface. D2651 Inlay - resin -based composite - two surfaces. D2652 Inlay - resin -based composite - three or more surfaces. INLAY: D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652 • Inlays will be considered at an alternate benefit of an amalgam/composite restoration and only when resulting from caries (tooth decay) or traumatic injury. ONLAY RESTORATIONS D2542 Onlay - metallic - two surfaces. D2543 Onlay - metallic - three surfaces. D2544 Onlay - metallic - four or more surfaces. D2642 Onlay - porcelain/ceramic - two surfaces. D2643 Onlay - porcelain/ceramic - three surfaces. D2644 Onlay - porcelain/ceramic - four or more surfaces. D2662 Onlay - resin -based composite - two surfaces. D2663 Onlay - resin -based composite - three surfaces. D2664 Onlay - resin -based composite - four or more surfaces. ONLAY: D2542, D2543, D2544, D2642, D2643, D2644, D2662, D2663, D2664 • Replacement is limited to 1 of any of these procedures per 5 year(s). D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651. D2652, D2710. D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615. D6624, D6634, D6710, D6720. D6721, D6722, D6740, D6750. D6751, D6752, D6780, D6781, D6782, D6783. D6790, D6791, D6792, D6794, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury. • Benefits will not be considered if procedure D2390, D2930, D2931. D2932, D2933 or D2934 has been performed within 12 months. CROWNS SINGLE RESTORATIONS D2710 Crown - resin -based composite (indirect). D2712 Crown - 3/4 resin -based composite (indirect). D2720 Crown - resin with high noble metal. D2721 Crown - resin with predominantly base metal. TYPE 3 PROCEDURES D2722 Crown - resin with noble metal. D2740 Crown - porcelain/ceramic substrate. D2750 Crown - porcelain fused to high noble metal. D2751 Crown - porcelain fused to predominantly base metal. D2752 Crown - porcelain fused to noble metal. D2780 Crown - 3/4 cast high noble metal. D2781 Crown - 3/4 cast predominantly base metal. D2782 Crown - 3/4 cast noble metal. D2783 Crown - 3/4 porcelain/ceramic. D2790 Crown - full cast high noble metal. D2791 Crown - full cast predominantly base metal. D2792 Crown - full cast noble metal. D2794 Crown - titanium. CROWN: D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D278I, D2782, D2783, D2790, D2791, D2792, D2794 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, 02642, 02643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D66I4, D6615, D6624, D6634, D6710, 06720, 06721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury. • Benefits will not be considered if procedure D2390, D2930, 02931, D2932, D2933 or D2934 has been performed within 12 months. RECEMENT D2910 Recement inlay, onlay, or partial coverage restoration. D2915 Recement cast or prefabricated post and core. D2920 Recement crown. D6092 Recement implant/abutment supported crown. D6093 Recement implant/abutment supported fixed partial denture. D6930 Recement fixed partial denture. SEDATIVE FILLING D2940 Sedative filling. CORE BUILD-UP D2950 Core buildup, including any pins. D6973 Core build up for retainer, including any pins. POST AND CORE D2952 Post and core in addition to crown, indirectly fabricated. D2954 Prefabricated post and core in addition to crown. FIXED CROWN AND PARTIAL DENTURE REPAIR D2980 Crown repair, by report. D6980 Fixed partial denture repair, by report. D9120 Fixed partial denture sectioning. CROWN LENGTHENING D4249 Clinical crown lengthening - hard tissue. PROSTHODONTICS - FIXED/REMOVABLE (DENTURES) D51 10 Complete denture - maxillary. D5120 Complete denture - mandibular. TYPE 3 PROCEDURES D5130 Immediate denture - maxillary. D5140 Immediate denture - mandibular. D521 1 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth). D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth). D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth). D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth). D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth). D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth). D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth). D5670 Replace all teeth and acrylic on cast metal framework (maxillary). D5671 Replace all teeth and acrylic on cast metal framework (mandibular). D5810 Interim complete denture (maxillary). D5811 Interim complete denture (mandibular). D5820 Interim partial denture (maxillary). D5821 Interim partial denture (mandibular). D5860 Overdenture - complete, by report. D5861 Overdenture - partial, by report. D6053 Implant/abutment supported removable denture for completely edentulous arch. D6054 Implant/abutment supported removable denture for partially edentulous arch. D6078 Implant/abutment supported fixed denture for completely edentulous arch. D6079 Implant/abutment supported fixed denture for partially edentulous arch. COMPLETE DENTURE: D5110, D5120, D5130, D5140, D5860. D6053, D6078 • Replacement is limited to 1 of any of these procedures per 5 year(s). • Frequency is waived for accidental injury. • Allowances include adjustments within 6 months after placement date. Procedures D5860, D6053. and D6078 are considered at an alternate benefit of a 05110/D5120. PARTIAL DENTURE: D521 I, D5212, D5213, D5214, D5225, D5226, D5281, D5670, D5671, D5861, D6054, D6079 • Replacement is limited to 1 of any of these procedures per 5 year(s). • Frequency is waived for accidental injury. • Allowances include adjustments within 6 months of placement date. Procedures D5861, D6054. and D6079 are considered at an alternate benefit of a D5213/1)5214. DENTURE ADJUSTMENTS D5410 Adjust complete denture - maxillary. D5411 Adjust complete denture - mandibular. D5421 Adjust partial denture - maxillary. D5422 Adjust partial denture - mandibular. DENTURE ADJUSTMENT: D5410. D5411, D5421, D5422 • Coverage is limited to dates of service more than 6 months after placement date. DENTURE REPAIR D5510 Repair broken complete denture base. D5520 Replace missing or broken teeth - complete denture (each tooth). D5610 Repair resin denture base. D5620 Repair cast framework. D5630 Repair or replace broken clasp. D5640 Replace broken teeth - per tooth. ADD TOOTH/CLASP TO EXISTING PARTIAL D5650 Add tooth to existing partial denture. D5660 Add clasp to existing partial denture. TYPE 3 PROCEDURES DENTURE REBASES D5710 Rebase complete maxillary denture. D5711 Rebase complete mandibular denture. D5720 Rebase maxillary partial denture. D5721 Rebase mandibular partial denture. DENTURE RELINES D5730 Reline complete maxillary denture (chairside). D5731 Reline complete mandibular denture (chairside). D5740 Reline maxillary partial denture (chairside). D5741 Reline mandibular partial denture (chairside). D5750 Reline complete maxillary denture (laboratory). D5751 Reline complete mandibular denture (laboratory). D5760 Reline maxillary partial denture (laboratory). D5761 Reline mandibular partial denture (laboratory). DENTURE RELINE: D5730, D5731, D5740, D5741, D5750, D5751, D5760. D5761 • Coverage is limited to service dates more than 6 months after placement date. TISSUE CONDITIONING D5850 Tissue conditioning, maxillary. D5851 Tissue conditioning, mandibular. PROSTHODONTICS - FIXED D6058 Abutment supported porcelain/ceramic crown. D6059 Abutment supported porcelain fused to metal crown (high noble metal). D6060 Abutment supported porcelain fused to metal crown (predominantly base metal). D6061 Abutment supported porcelain fused to metal crown (noble metal). D6062 Abutment supported cast metal crown (high noble metal). D6063 Abutment supported cast metal crown (predominantly base metal). D6064 Abutment supported cast metal crown (noble metal). D6065 Implant supported porcelain/ceramic crown. D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal). D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal). D6068 Abutment supported retainer for porcelain/ceramic FPD. D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal). D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal). D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal). D6072 Abutment supported retainer for cast metal FPD (high noble metal). D6073 Abutment supported retainer for cast metal FPD (predominantly base metal). D6074 Abutment supported retainer for cast metal FPD (noble metal). D6075 Implant supported retainer for ceramic FPD. D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal). D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble metal). D6094 Abutment supported crown - (titanium). D6194 Abutment supported retainer crown for FPD - (titanium). D6205 Pontic - indirect resin based composite. D6210 Pontic - cast high noble metal. D6211 Pontic - cast predominantly base metal. D6212 Pontic - cast noble metal. TYPE 3 PROCEDURES D6214 Pontic - titanium. D6240 Pontic - porcelain fused to high noble metal. D6241 Pontic - porcelain fused to predominantly base metal. D6242 Pontic - porcelain fused to noble metal. D6245 Pontic - porcelain/ceramic. D6250 Pontic - resin with high noble metal. D6251 Pontic - resin with predominantly base metal. D6252 Pontic - resin with noble metal. D6545 Retainer - cast metal for resin bonded fixed prosthesis. D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis. D6600 Inlay - porcelain/ceramic, two surfaces. D6601 Inlay - porcelain/ceramic, three or more surfaces. D6602 Inlay - cast high noble metal, two surfaces. D6603 Inlay - cast high noble metal, three or more surfaces. D6604 Inlay - cast predominantly base metal, two surfaces. D6605 Inlay - cast predominantly base metal, three or more surfaces. D6606 Inlay - cast noble metal, two surfaces. D6607 Inlay - cast noble metal, three or more surfaces. D6608 Onlay - porcelain/ceramic, two surfaces. D6609 Onlay - porcelain/ceramic, three or more surfaces. D6610 Onlay - cast high noble metal, two surfaces. D6611 Onlay - cast high noble metal, three or more surfaces. D6612 Onlay - cast predominantly base metal, two surfaces. D6613 Onlay - cast predominantly base metal, three or more surfaces. D6614 Onlay - cast noble metal, two surfaces. D6615 Onlay - cast noble metal, three or more surfaces. D6624 Inlay - titanium. D6634 Onlay - titanium. D6710 Crown - indirect resin based composite. D6720 Crown - resin with high noble metal. D6721 Crown - resin with predominantly base metal. D6722 Crown - resin with noble metal. D6740 Crown - porcelain/ceramic. D6750 Crown - porcelain fused to high noble metal. D6751 Crown - porcelain fused to predominantly base metal. D6752 Crown - porcelain fused to noble metal. D6780 Crown - 3/4 cast high noble metal. D6781 Crown - 3/4 cast predominantly base metal. D6782 Crown - 3/4 cast noble metal. D6783 Crown - 3/4 porcelain/ceramic. D6790 Crown - full cast high noble metal. D6791 Crown - full cast predominantly base metal. D6792 Crown - full cast noble metal. D6794 Crown - titanium. D6940 Stress breaker. FIXED PARTIAL CROWN: D6710, D6720, D6721, D6722. D6740, D6750, D6751, D6752. D6780. D6781, 06782, D6783, D6790. D6791, D6792, D6794 Replacement is limited to l of any of these procedures per 5 years). D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, 02651, D2652, D2662, D2663, D2664, D2710. D2712, D2720, 02721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602. D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610. D6611, D6612. 06613, D6614, D6615, D6624. D6634, also contribute(s) to this limitation. Frequency is waived for accidental injury. Porcelain and resin benefits are considered for anterior and bicuspid teeth only. Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. TYPE 3 PROCEDURES Benefits will not be considered if procedure D2390, D2930, D293I, D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL INLAY: D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6624 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D27I2, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791. D2792, D2794, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL ONLAY: D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6634 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6624, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782. D6783, D6790, D6791, D6792, D6794, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL PONTIC: D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6094, D6194, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. IMPLANT SUPPORTED CROWN: D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6094 • Replacement is limited to I of any of these procedures per 5 year(s). • D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6194, D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252, also contribute(s) to this limitation. Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. IMPLANT SUPPORTED RETAINER: D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6194 • Replacement is limited to 1 of any of these procedures per 5 year(s). • D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6094, D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252, also contribute(s) to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. CAST POST AND CORE FOR PARTIALS D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated. D6972 Prefabricated post and core in addition to fixed partial denture retainer. ORTHODONTIC EXPENSE BENEFITS We will determine orthodontic expense benefits according to the terms of the group policy for orthodontic expenses incurred by an Insured. DETERMINING BENEFITS. The benefits payable will be determined by totaling all of the Covered Expenses submitted. This amount is reduced by the Deductible, if any. The result is then multiplied by the Coinsurance Percentage shown in the Schedule of Benefits. Benefits are subject to the Maximum Amount shown in the Schedule of Benefits. DEDUCTIBLE. The Deductible is shown on the Schedule of Benefits and is a specified amount of Covered Expenses that must be incurred and paid by each Insured person prior to any benefits being paid. MAXIMUM AMOUNT. The Maximum Benefit During Lifetime shown in the Schedule of Benefits is the maximum amount that may be paid for the Covered Expenses incurred by an Insured during his or her lifetime. COVERED EXPENSES. Covered Expenses refer to the usual and customary charges made by a provider for necessary orthodontic treatment rendered while the person is insured under this section. Expenses are limited to the Maximum Amount shown in the Schedule of Benefits and Limitations. Usual and Customary ("U&C") describes those dental charges that we have determined to be the usual and customary charge for a given dental procedure within a particular ZIP code area. The U&C is based upon a combination of dental charge information taken from our own database as well as from data received from nationally recognized industry databases. From the array of charges ranked by amount, your Policyholder (in most cases your employer) has selected a percentile that will be used to determine the maximum U&C for your plan. The U&C is reviewed and updated periodically. The U&C can differ from the actual fee charged by your provider and is not indicative of the appropriateness of the provider's fee. Instead, the U&C is simply a plan provision used to determine the extent of benefit coverage purchased by your Policyholder. ORTHODONTIC TREATMENT. Orthodontic Treatment refers to the movement of teeth by means of active appliances to correct the position of maloccluded or malpositioned teeth. TREATMENT PROGRAM. Treatment Program ("Program") means an interdependent series of orthodontic services prescribed by a provider to correct a specific dental condition. A Program will start when the active appliances are inserted. A Program will end when the services are done, or after eight calendar quarters starting with the day the appliances were inserted, whichever is earlier. EXPENSES INCURRED. Benefits will be payable when a Covered Expense is incurred: a. at the end of every quarter (three-month period) of a Program for an Insured who pursues a Program, but not beyond the date the Program ends; or b. at the time the service is rendered for an Insured who incurs Covered Expenses but does not pursue a Program. The Covered Expenses for a Program are based on the estimated cost of the Insured's Program. They are pro- rated by quarter (three-month periods) over the estimated length of the Program, up to a maximum of eight quarters. The last quarterly payment for a Program may be changed if the estimated and actual cost of the Program differ. BENEFITS PAYABLE UPON TERMINATION. If coverage terminates during a Program quarter, the quarterly benefit payable for that quarter will be pro -rated by day for the period of time that coverage was in -force and premium was received. LIMITATIONS. Covered Expenses will not include and benefits will not be payable for expenses incurred: 1. for a Program begun before the Insured became covered under this section, unless the Insured was covered for Orthodontic Expense Benefits under the prior carrier on January 31, 2010 and are both: a. insured under this policy; and b. currently undergoing a Treatment Program on February 1, 2010. 2. in the first 12 months that a person is insured if the person is a Late Entrant. 3. if the Insured's insurance under this section terminates. 4. for which the Insured is entitled to benefits under any workmen's compensation or similar law, or for charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit. 5. for charges the Insured is not legally required to pay or would not have been made had no insurance been in force. 6. for services not required for necessary care and treatment or not within the generally accepted parameters of care. 7. because of war or any act of war, declared or not. 8. To replace lost or stolen appliances. COORDINATION OF BENEFITS This section applies if an Insured person has dental coverage under more than one Plan definition below. All benefits provided under this policy are subject to this section. EFFECT ON BENEFITS. The Order of Benefit Determination rules below determine which Plan will pay as the primary Plan. If all or any part of an Allowable Expense under this Plan is an Allowable Expense under any other Plan, then benefits will be reduced so that, when they are added to benefits payable under any other Plan for the same service or supply, the total does not exceed 1 00% of the total Allowable Expense. If another Plan is primary and this Plan is considered secondary, the amount by which benefits have been reduced during the Claim Determination Period will be used by us to pay the Allowable Expenses not otherwise paid which were incurred by you in the same Claim Determination Period. We will determine our obligation to pay for Allowable Expenses as each claim is submitted, based on all claims submitted in the current Claim Determination Period. DEFINITIONS. The following apply only to this provision of the policy. 1. "Plan" refers to the group policy and any of the following plans, whether insured or uninsured, providing benefits for dental services or supplies: a. Any group or blanket insurance policy. b. Any group Blue Cross, group Blue Shield, or group prepayment arrangement. c. Any labor/management, trusteed plan, labor organization, employer organization, or employee organization plan, whether on an insured or uninsured basis. d. Any coverage under a governmental plan that allows coordination of benefits, or any coverage required or provided by law. This does not include a state plan under Medicaid (TitleXVIII and XIX of the Social Security Act as enacted or amended). It also does not include any plan whose benefits by law are excess to those of any private insurance program or other non-govenimental program. 2. "Plan" does not include the following: a. Individual or family benefits provided through insurance contracts, subscriber contracts, coverage through individual HMOs or other prepayment arrangements. b. Coverages for school type accidents only, including athletic injuries. 3. "Allowable Expense" refers to any necessary, reasonable and customary item of expense at least a portion of which is covered under at least one of the Plans covering the Insured person for whom that claim is made. When a Plan provides services rather than cash payments, the reasonable cash value of each service will be both an Allowable Expense and a benefit paid. Benefits payable under another Plan include benefits that would have been payable had a claim been made for them. 4. "Claim Determination Period" refers to a Benefit Period, but does not include any time during which a person has no coverage under this Plan. 5. "Custodial Parent" refers to a parent awarded custody of a minor child by a court decree. 111 the absence of a court decree, it is the parent with whom the child resides more than half of the calendar year without regard to any temporary visitation. ORDER OF BENEFIT DETERMINATION. When two or more Plans pay benefits, the rules for determining the order of payment are as follows: 1. A Plan that does not have a coordination of benefits provision is always considered primary and will pay benefits first. 2. If a Plan also has a coordination of benefits provision, the first of the following rules that describe which Plan pays its benefits before another Plan is the rule to use: a. The benefits of a Plan that covers a person as an employee, member or subscriber are determined before those of a Plan that covers the person as a dependent. b. If a Dependent child is covered by more than one Plan, then the primary Plan is the Plan of the parent whose birthday is earlier in the year if: i. the parents are married; ii. the parents are not separated (whether or not they ever have been married); or iii. a court decree awards joint custody without specifying that one party has the responsibility to provide Dental coverage. If both parents have the same birthday, the Plan that covered either of the parents longer is primary. c. If the Dependent child is covered by divorced or separated parents under two or more Plans, benefits for that Dependent child will be determined in the following order: i. the Plan of the Custodial Parent; ii. the Plan of the spouse of the Custodial Parent; iii. the Plan of the non -Custodial Parent; and then iv. the Plan of the spouse of the non -Custodial Parent. However, if the specific terns of a court decree establish a parent's responsibility for the child's Dental expenses and the Plan of that parent has actual knowledge of those terns, that Plan is primary. This rule applies to Claim Determination Periods or Benefit Periods commencing after the Plan is given notice of the court decree. d. The benefits of a Plan that cover a person as an employee who is neither laid -off nor retired (or as that employee's dependent) are determined before those of a Plan that covers that person as a laid -off or retired employee (or as that employee's dependent). If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule will be ignored. e. If a person whose coverage is provided under a right of continuation provided by a federal or state law also is covered under another Plan, the Plan covering the person as an employee, member, subscriber or retiree (or as that person's dependent) is primary, and the continuation coverage is secondary. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule will be ignored. The benefits of a Plan that has covered a person for a longer period will be determined first. If the preceding rules do not determine the primary Plan, the allowable expenses shall be shared equally between the Plans meeting the definition of Plan under this provision. In addition, this Plan will not pay more than what it would have paid had it been primary. RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION. We may without your consent and notice to you: 1. Release any information with respect to your coverage and benefits under the policy; and 2. Obtain from any other insurance company, organization or person any information with respect to your coverage and benefits under another Plan. You must provide us with any information necessary to coordinate benefits. FACILITY OF PAYMENT. When other Plans make payments that should have been made under this Plan according to the above terms, we will, at our discretion, pay to any organizations making these payments any amounts that we decide will satisfy the intent of the above terms. Amounts paid in this way will be benefits paid under this Plan. We will not be liable to the extent of these payments. RIGHT OF RECOVERY. When we make payments for Allowable Expenses in excess of the amount that will satisfy the intent of the above terms, we will recover these payments, to the extent of the excess, from any persons or organizations to or for whom these payments were made. The request will not be made more than twelve months after a claim has been paid except in cases of fraud or misrepresentation by the provider. The amount of the payments made includes the reasonable cash value of any benefits provided in the foam of services. GENERAL PROVISIONS NOTICE OF CLAIM. Written notice of a claim must be given to us within 30 days after the incurred date of the services provided for which benefits are payable. Notice must be given to us at our Home Office, or to one of our agents. Notice should include the Policyholder's name, Insured's name, and policy number. If it was not reasonably possible to give written notice within the 30 day period stated above, we will not reduce or deny a claim for this reason if notice is filed as soon as is reasonably possible. CLAIM FORMS. When we receive the notice of a claim, we will send the claimant forms for filing proof of loss. If these forms are not furnished within 15 days after the giving of such notice, the claimant will meet our proof of loss requirements by giving us a written statement of the nature and extent of loss within the time limit for filing proofs of loss. PROOF OF LOSS. Written proof of loss must be given to us within 90 days after the incurred date of the services provided for which benefits are payable. If it is impossible to give written proof within the 90 -day period, we will not reduce or deny a claim for this reason if the proof is filed as soon as is reasonably possible. TIME OF PAYMENT. We will pay all benefits within 30 days of when we receive due proof. Any balance remaining unpaid at the end of any period for which we are liable will be paid at that time. PAYMENT OF BENEFITS. All benefits will be paid to the Insured unless otherwise agreed upon through your authorization or provider contracts. FACILITY OF PAYMENT. If an Insured or beneficiary is not capable of giving us a valid receipt for any payment or if benefits are payable to the estate of the Insured, then we may, at our option, pay the benefit up to an amount not to exceed $2,000, to any relative by blood or connection by marriage of the Insured who is considered by us to be equitably entitled to the benefit. Any equitable payment made in good faith will release us from liability to the extent of payment. PROVIDER -PATIENT RELATIONSHIP. The Insured may choose any Provider who is licensed by the law of the state in which treatment is provided within the scope of their license. We will in no way disturb the provider -patient relationship. LEGAL PROCEEDINGS. No legal action can be brought against us until 60 days after the Insured sends us the required proof of loss. No legal action against us can start more than five years after proof of loss is required. INCONTESTABILITY. Any statement made by the Policyholder to obtain the Policy is a representation and not a warranty. No misrepresentation by the Policyholder will be used to deny a claim or to deny the validity of the Policy unless: 1. The Policy would not have been issued if we had known the truth; and 2. We have given the Policyholder a copy of a written instrument signed by the Policyholder that contains the misrepresentation. The validity of the Policy will not be contested after it has been in force for one year, except for nonpayment of premiums or fraudulent misrepresentations. WORKER'S COMPENSATION. The coverage provided under the Policy is not a substitute for coverage under a workmen's compensation or state disability income benefit law and does not relieve the Policyholder of any obligation to provide such coverage. ERISA INFORMATION AND NOTICE OF YOUR RIGHTS A. Eligibility and Benefits Provided Under the Group Policy Please refer to the Conditions for Insurance within the Group Policy and Certificate of Coverage for a detailed description of the eligibility for participation under the plan as well as the benefits provided. If this plan includes a participating provider (PPO) option, provider lists are furnished without charge, as a separate document. If you have any questions about your benefits or concerns about our services related to this Group Policy, you may call Customer Service Toll Free at 1-800-487-5553. B. Qualified Medical Child Support Order ("QMCSO") QMCSO Determinations. A Plan participant or beneficiary can obtain, without charge, a copy of the Plan's procedures governing Qualified Medical Child Support Order determinations from the Plan Administrator. C. Termination Of The Group Policy The Group Policy which provides benefits for this plan may be terminated by the Policyholder at any time with prior written notice to Ameritas Life Insurance Corp. It will terminate automatically if the Policyholder fails to pay the required premium. Ameritas Life Insurance Corp. may terminate the Group Policy on any Premium Due Date if the number of persons insured is less than the required minimum, or if Ameritas Life Insurance Corp. believes the Policyholder has failed to perform its obligations relating to the Group Policy. After the first policy year, Ameritas Life Insurance Corp. may also terminate the Group Policy on any Premium Due Date for any reason by providing a 60 -day advance written notice to the Policyholder. The Group Policy may be changed in whole or in part. No change or amendment will be valid unless it is approved in writing by a Ameritas Life Insurance Corp. executive officer. D. Claims For Benefits Claims procedures are furnished automatically, without charge, as a separate document. E. Continuation of Coverage Provisions (COBRA) COBRA (Consolidation Omnibus Budget Reconciliation Act of 1985) gives Qualified Beneficiaries the right to elect COBRA continuation after insurance ends because of a Qualifying Event. The law generally covers group health plans maintained by employers with 20 or more employees in the prior year. The law does not, however, apply to plans sponsored by the Federal government and certain church -related organizations. Definitions For This Section Qualified Beneficiary means an Insured Person who is covered by the plan on the day before a qualifying event. Any child born to or placed for adoption with a covered employee during the period of COBRA coverage is considered a qualified beneficiary. A Qualifying Event occurs when: 1. The Member dies (hereinafter referred to as Qualifying Event 1); The Member's employment terminates for reasons other than gross misconduct as determined by the Employer (hereinafter referred to as Qualifying Event 2); 3. The Member's work hours fall below the minimum number required to be a Member (hereinafter referred to as Qualifying Event 3); 4. The Member becomes divorced or legally separated from a Spouse (hereinafter refenTed to as Qualifying Event 4); 5. The Member becomes entitled to receive Medicare benefits under Title XVII of the Social Security Act (hereinafter referred to as Qualifying Event 5); 6. The Child of a Member ceases to be a Dependent (hereinafter referred to as Qualifying Event 6); 7. The Employer files a petition for reorganization under Title 11 of the U.S. Bankruptcy Code, provided the Member is retired from the Employer and is insured on the date the petition is filed (hereinafter referred to as Qualifying Event 7). ii. Electing COBRA Continuation A. Each Qualified Beneficiary has the right to elect to continue coverage that was in effect on the day before the Qualifying Event. The Qualified Beneficiary must apply in writing within 60 days of the later of: 1. The date on which Insurance would otherwise end; and 2. The date on which the Employer or Plan Administrator gave the Qualified Beneficiary notice of the right to COBRA continuation. B. A Qualified Beneficiary who does not elect COBRA Continuation coverage during their original election period may be entitled to a second election period if the following requirements are satisfied: 1. The Member's Insurance ended because of a trade related termination of their employment, which resulted in being certified eligible for trade adjustment assistance; 2. The Member is certified eligible for trade adjustment assistance (as determined by the appropriate governmental agency) within 6 months of the date Insurance ended due to the trade related termination of their employment; and 3. The Qualified Beneficiary must apply in writing within 60 days after the first day of the month in which they are certified eligible for trade adjustment assistance. iii. Notice Requirements 1. When the Member becomes insured, the Plan Administrator must inform the Member and Spouse in writing of the right to COBRA continuation. 2. The Qualified Beneficiary must notify the Plan Administrator in writing of Qualifying Event 4 or 6 above within 60 days of the later of: a. The date of the Qualifying Event; or b. The date the Qualified Beneficiary loses coverage due to the Qualifying Event. 3. A Qualified Beneficiary, who is entitled to COBRA continuation due to the occurrence of Qualifying Event 2 or 3 and who is disabled at any time during the first 60 days of continuation coverage as determined by the Social Security Administration pursuant to Title II or XVI of the Social Security Act, must notify the Plan Administrator of the disability in writing within 60 days of the later of: a. The date of the disability determination; b. The date of the Qualifying Event; or c. The date on the Qualified Beneficiary loses coverage due to the Qualifying Event. 4. Each Qualified Beneficiary who has become entitled to COBRA continuation with a maximum duration of 18 or 29 months must notify the Plan Administrator of the occurrence of a second Qualifying Event within 60 days of the later of: a. The date of the Qualifying Event; or b. The date the Qualified Beneficiary loses coverage due to the Qualifying Event. 5. The Employer must give the Plan Administrator written notice within 30 days of the occurrence of Qualifying Event 1, 2, 3, 5, or 7. 6. Within 14 days of receipt of the Employer's notice, the Plan Administrator must notify each Qualified Beneficiary in writing of the right to elect COBRA continuation. In order to protect your rights, Members and Qualified Beneficiaries should inform the Plan Administrator in writing of any change of address. iv. COBRA Continuation Period 1. 18 -month COBRA Continuation Each Qualified Beneficiary may continue Insurance for up to 18 months after the date of Qualifying Event 2 or 3. 2. 29 -month COBRA Continuation Each Qualified Beneficiary, who is entitled to COBRA continuation due to the occun-ence of Qualifying Event 2 or 3 and who is disabled at any time during the first 60 days of continuation coverage as determined by the Social Security Administration pursuant to Title II or XVI of the Social Security Act, may continue coverage for up to 29 months after the date of the Qualifying Event. All Insured Persons in the Qualified Beneficiary's family may also continue coverage for up to 29 months. 3. 36 -Month COBRA Continuation If you are a Dependent, you may continue Coverage for up to 36 months after the date of Qualifying Event 1, 4, 5, or 6. Each Qualified Beneficiary who is entitled to continue Insurance for 18 or 29 months may be eligible to continue coverage for up to 36 months after the date of their original Qualifying Event if a second Qualifying Event occurs while they are on continuation coverage. Note: The total period of COBRA continuation available in 1 through 3 will not exceed 36 months. 4. COBRA Continuation For Certain Bankruptcy Proceedings If the Qualifying Event is 7, the COBRA continuation period for a retiree or retiree's Spouse is the lifetime of the retiree. Upon the retiree's death, the COBRA continuation period for the surviving Dependents is 36 months from the date of the retiree's death. v. Premium Requirements Insurance continued under this provision will be retroactive to the date insurance would have ended because of a Qualifying Event. The Qualified Beneficiary must pay the initial required premium not later than 45 days after electing COBRA continuation, and monthly premium on or before the Premium Due Date thereafter. The monthly premium is a percentage of the total premium (both the portion paid by the employee and any portion paid by the employer) currently in effect on each Premium Due Date. The premium rate may change after you cease to be Actively at Work. The percentage is as follows: 18 month continuation - 102% 29 month continuation - 102% during the first 18 months, 150% during the next 11 months 36 month continuation - 102% vi. When COBRA Continuation Ends COBRA continuation ends on the earliest of: 1. The date the Group Policy terminates; 2. 31 days after the date the last period ends for which a required premium payment was made; 3. The last day of the COBRA continuation period. 4. The date the Qualified Beneficiary first becomes entitled to Medicare coverage under Title XVII of the Social Security Act; 5. The first date on which the Qualified Beneficiary is: (a) covered under another group Dental policy and (b) not subject to any preexisting condition limitation in that policy. F. Your Rights under ERISA As a participant in this Plan, you are entitled to certain rights and protections under the Employment Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Plan Administrator's office and at other specified locations, such as work -sites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies. Receive a summary of the plan's annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Plan Coverage Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights. Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the plan, have a duty to operate and administer this plan prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. If it should happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance with Your Rights If you have any questions about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling those publications hotline of the Employee Benefits Security Administration. CLAIMS REVIEW PROCEDURES AS REQUIRED UNDER EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA) The following provides information regarding the claims review process and your rights to request a review of any part of a claim that is denied. Please note that certain state laws may also require specified claims payment procedures as well as internal appeal procedures and/or independent external review processes. Therefore, in addition to the review procedures defined below, you may also have additional rights provided to you under state law. If your state has specific grievance procedures, an additional notice specific to your state will also be included within the group policy and your certificate. CLAIMS FOR BENEFITS Claims may be submitted by mailing the completed claim form along with any requested information to: Ameritas Life Insurance Corp. PO Box 82520 Lincoln, NE 68501 NOTICE OF DECISION OF CLAIM We will evaluate your claim promptly after we receive it. Utilization Review Program. Generally, utilization review means a set of criteria designed to monitor the use of, or evaluate the medical necessity, appropriateness, or efficiency of health care services. We have established a utilization review program to ensure that any guidelines and criteria used to evaluate the medical necessity of a health care service are clearly documented and include procedures for applying such criteria based on the needs of the individual patients. The program was developed in conjunction with licensed dentists and is reviewed at least annually to ensure that criteria are applied consistently and are current with dental technology, evidence -based research and any dental trends. We will provide you written notice regarding the payment under the claim within 30 calendar days following receipt of the claim. This period may be extended for an additional 15 days, provided that we have determined that an extension is necessary due to matters beyond our control, and notify you, prior to the expiration of the initial 30 -day period, of the circumstances requiring the extension of time and the date by which we expect to render a decision. If the extension is due to your failure to provide information necessary to decide the claim, the notice of extension shall specifically describe the required infoi oration we need to decide the claim. If we request additional information, you will have 45 days to provide the information. If you do not provide the requested information within 45 days, we may decide your claim based on the information we have received. If we deny any part of your claim, you will receive a written notice of denial containing: a. The reasons for our decision. b. Reference to the parts of the Group Policy on which our decision is based. c. Reference to any internal rule or guideline relied upon in making our decision, along with your right to receive a copy of these guidelines, free of charge, upon request. d. A statement that you may request an explanation of the scientific or clinical judgment we relied upon to exclude expenses that are experimental or investigational, or are not necessary or accepted according to generally accepted standards of Dental practice. e. A description of any additional information needed to support your claim and why such information is necessary. f. Information concerning your right to a review of our decision. g. Information concerning your right to bring a civil action for benefits under section 502(a) of ERISA following an adverse benefit determination on review. APPEAL PROCEDURE If all or part of a claim is denied, you may request a review in writing within 180 days after receiving notice of the benefit denial. You may send us written comments or other items to support your claim. You may review and receive copies of any non -privileged infomation that is relevant to your appeal. There will be no charge for such copies. You may request the names of the experts we consulted who provided advice to us about your claim. The appeal review will be conducted by the Plan's named fiduciary and will be someone other than the person who denied the initial claim and will not be subordinate to that person. The person conducting the review will not give deference to the initial denial decision. If the denial was based in whole or in part on a medical judgment, including determinations with regard to whether a service was considered experimental, investigational, and/or not medically necessary, the person conducting the review will consult with a qualified health care professional. This health care professional will be someone other than the person who made the original judgment and will not be subordinate to that person. Our review will include any written comments or other items you submit to support your claim. We will review your claim promptly after we receive your request. If your appeal is about urgent care, you may call Toll Free at 877-897-4328, and an Expedited Review will be conducted. Verbal notification of our decision will be made within 72 hours, followed by written notice within 3 calendar days after that. If your appeal is about benefit decisions related to clinical or medical necessity, a Standard Consultant Review will be conducted. A written decision will be provided within 30 calendar days of the receipt of the request for appeal. If your appeal is about benefit decisions related to coverage, a Standard Administrative Review will be conducted. A written decision will be provided within 60 calendar days of the receipt of the request for appeal. If we deny any part of your claim on review, you will receive a written notice of denial containing: a. The reasons for our decision. b. Reference to the parts of the Group Policy on which our decision is based. c. Reference to any internal rule or guideline relied upon in making our decision along with your right to receive a copy of these guidelines, free of charge, upon request. d. Information concerning your right to receive, free of charge, copies of non -privileged documents and records relevant to your claim. e. A statement that you may request an explanation of the scientific or clinical judgment we relied upon to exclude expenses that are experimental or investigational, or are not necessary or accepted according to generally accepted standards of Dental practice. f Information concerning your right to bring a civil action for benefits under section 502(a) of ERISA. Certain state laws also require specified internal appeal procedures and/or external review processes. In addition to the review procedures defined above, you may also have additional rights provided to you under state law. Please review your certificate for such information, call us, or contact your state insurance regulatory agency for assistance. In any event, you need not exhaust such state law procedures prior to bringing civil action under Section 502(a) of ERISA. Any request for appeal should be directed to: Quality Control, P.O. Box 82657, Lincoln, NE 68501-2657. NOTICE OF PROTECTED HEALTH INFORMATION PRIVACY PRACTICES We are required by law to maintain the privacy of our insured members' and their dependents' personal health information and to provide notice of our legal duties and privacy practices with respect to your personal health information. We are required to abide by the terms of this Notice as long as it remains in effect. We reserve the right to change the terns of this Notice as necessary and to make the new Notice effective for all personal health information maintained by us. Copies of revised Notices will be provided to you directly or to your group's Plan Sponsor (usually your employer) by regular mail or e-mail with instructions to deliver a paper copy to each certificate holder. THIS NOTICE DESCRIBES OUR PRACTICES REGARDING YOUR PROTECTED HEALTH INFORMATION MAINTAINED BY THE GROUP DENTAL LINE OF BUSINESS WITHIN THE UNIFI COMPANIES. THIS NOTICE MORE PARTICULARLY DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Contact Information All of the entities affiliated under the common control of the UNIFI Mutual Holding Company that pay for the cost of healthcare, including Ameritas Life Insurance Corp. and First Ameritas Life Insurance Corp. of New York, are required by federal law to maintain the privacy of your protected health information and to provide notice of the legal duties and privacy practices with respect to your protected health information. This Notice fulfills the "Notice" requirements of the Final Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If you have any questions -about any part of this Notice of Protected Health Information Privacy Practices or desire to have further information concerning the information practices at the UNIFI Companies, please direct your inquiries to: The Privacy Office, Attn. HIPAA Privacy, P.O. Box 81889, Lincoln, NE 68501-1889, or e-mail us at privacy@ameritas.com. THIS NOTICE IS PUBLISHED AND BECOMES EFFECTIVE: APRIL 14, 2003 OUR PLEDGE REGARDING YOUR PROTECTED HEALTH INFORMATION We understand that information about you and your family is personal and we are committed to protecting your privacy and the security of your protected health information. This Notice explains the ways in which we use and disclose protected health information about you and your covered dependents and details certain obligations we have in connection with such use and disclosure. It also describes your rights with regard to your protected health information. We are required by both law and internal policy to: make sure that protected health information that identifies you and/or your covered dependents is kept private; give you notice of our legal duties and privacy practices and your rights with respect to your protected health information; and follow the practices outlined in this Notice. WHO WILL FOLLOW THE PRIVACY PRACTICES DESCRIBED IN THIS NOTICE The Protected Health Information Privacy Practices described in this Notice have been adopted and implemented by all of the divisions and associates who work directly or indirectly with your protected health information within the following UNIFI Companies: Ameritas Life Insurance Corp.; and First Ameritas Life Insurance Corp. of New York. All of the associates who need access to your protected health information in order to service your products and administer your claims have received proper training about how to protect your privacy, secure your protected health information and adhere to our Privacy of Protected Health Information Policies, Practices and Procedures. In order to keep costs of your coverage down and provide you with the best customer service, we may contract with outside carriers and/or vendors; known as "business associates," to assist us with the administration of your policy. For example, we may contract with third party administrators who process claims and collect premium payments; or paper -shredding companies who destroy records when they are no longer needed. Because these business associates need access to your protected health information in order to fulfill their obligations to us, we require them to agree in writing to keep your protected health information confidential in the same manner that we do as described in this Notice. TYPES OF PROTECTED HEALTH INFORMATION WE MAY HAVE AND HOW WE OBTAIN IT Protected Health Information is: Any information that identifies you that we obtain from you or others that relates to your past, present or future healthcare including the payment for such healthcare. In the regular course of business we receive protected health infonnation about you in order to provide you with our products and services. Some of this protected health information comes directly from you. For example, when you purchase one of our health insurance products for you and your family, you provide us with information about you and your covered dependents such as name, address, phone number, social security number, etc. Some of the protected health information we obtain about you comes from your provider. For example, as you and your covered dependents utilize your coverage, your healthcare provider sends us infonnation about services and treatments perfoimed so that we can process and pay your claims. All of this information we receive about you and your covered dependents is necessary in order for us to provide you and your covered dependents with quality health insurance products and to comply with legal requirements. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION The following categories describe different ways we may use and disclose your protected health infonnation without your authorization. For each category of uses and disclosures, we will explain what we mean and give an example. Not every use or disclosure in a category will be listed. All of the ways we are permitted to use and disclose information will fall within one of the identified categories. For Payment: We may use and disclose protected health information about you and your covered dependents in order to verify your coverage to your provider, process payment for claims filed under your policy or coordinate benefits with another carrier. For example, we may need to disclose your protected health infonnation to a provider whom you have seen or are planning to see in order to pre -approve that a particular treatment you are seeking is covered under your plan. It is also necessary for us to use the information received from your medical provider concerning the services rendered to you so the health plan can pay the provider or reimburse you for the cost of the treatment under the terms of your plan. Finally, when you have more than one insurance policy that covers some of the same procedures as your plan with us, it may be necessary for us to exchange payment infonnation with the carrier of your other insurance plan in order to coordinate the payment of your claim with that other carrier. For Health Care Operations: We may use and disclose protected health information about you and your covered dependents as necessary to operate your health insurance plan and promote quality service. For example, we may use or disclose your personal health infonnation for quality assessment and quality improvement, credentialing health care providers, conducting or arranging for medical review or compliance. We may also disclose your personal health information to another health plan, health care facility or health care provider for activities such as quality assurance or case management. Business Associates: We may disclose protected health information to other persons or organizations, known as business associates, who provide services on our behalf under contract. However, in order to assure the protection of your private information, we require our business associates to adhere to our Privacy Policies concerning the use and disclosure of your protected health information and appropriately safeguard the infonnation we disclose to them. We prohibit our business associates from using and disclosing any of your protected health information in any manner except for the purpose intended by the contract. Business associates are expressly prohibited from using your protected health infonnation to create any marketing target lists. Plan Sponsors: We may disclose your protected health information to your plan sponsor (usually your employer). It is our policy not to disclose your protected health information to your Plan's sponsor. There may by exceptional occasions that your Plan Sponsor requests protected health information. We will only disclose your protected health information to your Plan Sponsor if we have your authorization to do so, or if the plan sponsor certifies that the information will be maintained in a confidential manner and will not be utilized or disclosed for employment -related actions and decisions or in connection with any other benefit or employee benefit plan of the plan sponsor. Public policy uses and disclosures of your protected health information We may use and disclose your protected health information for public policy purposes. For example: As Required By Law: We will disclose protected health information about you or your covered dependent when required to do so by federal, state or local law. For example, we may be required by law to disclose certain protected health information about you pursuant to a court order or subpoena served upon us. About Victims of Abuse, Neglect or Domestic Violence: For example, if we believe that you have been a victim of abuse, neglect or domestic violence, we may disclose your protected health information to the govemmnental entity or agency authorized to receive such information. In this case the disclosure will be made consistent with the requirements of applicable federal and state laws. Workers' Compensation: We may release your protected health information for workers' compensation or similar programs that provide benefits to you for work -related injuries or illness but only in a manner consistent with applicable laws. Public Health: We may have an occasion to disclose protected health information about you or your covered dependent for public health activities to a public health authority that is permitted by law to collect or receive the information. A public health activity would be, for example, an activity conducted by a public health authority in the furtherance of preventing or controlling disease, injury or disability; reporting births, deaths or reactions to medications; or notifying people of recalls of products they may be using. AUTHORIZED USES AND DISCLOSURES From time to time you may request that we disclose your protected health information to other individuals or entities. For example, you may request that we disclose your claims history to an attorney that you have hired to assist you in a civil matter. Likewise, we may ask your permission to use or disclose your protected health information. Any disclosures, such as these that do not fit into one of the categories in the previous section require us to obtain your written authorization prior to making such disclosure. In the event that you do provide us with written authorization to use or disclose your information, you may revoke such authorization at any time by writing to the Privacy Officer at the address indicated in the "Contact" section of this Notice below. YOUR RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION You have the following rights regarding protected health information that we maintain about you. All requests must be made in writing. Your Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice. You have a right to receive this Notice because you are insured by a health plan offered by Ameritas Life Insurance Corp. or First Arneritas Life Insurance Corp. of New York. You may ask us to give you a copy of this Notice at any time and we will comply. Even if you have agreed to receive this Notice electronically, you are entitled to a paper copy of this Notice if you so request. Your Right to an Accounting of Disclosures: You have the right to request a listing of any disclosures of your protected health information that we have made that are required by law. This listing would exclude disclosures we made to you, or pursuant to your authorization or request, or for payment of your claims as described above, or for health care operations as described above. Your request must state a time period that may not be longer than six years and may not include dates prior to April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically, fax etc.). The first accounting of disclosures you request within a 12 -month period will be free. We may charge for the costs of providing additional lists during that same 12 -month period. In the event that you may incur a charge, we will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred. Your Right to Request an Amendment: You have the light to request an amendment to the protected health information that we maintain about you if you believe that our information is incorrect or incomplete. You maintain the right to request an amendment for as long as the information is kept by or for the UNIFI Companies. You must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that: 1) was not created by us; 2) is not part of the medical information kept by or for a UNIFI Company; 3) is not part of the information which you would be permitted to inspect and copy under the law; or 4) is accurate and complete. Your Right to Request a Restriction: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for, payment or health plan operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for care, like a family member or friend. We are not required to agree to your request. If we do agree to a requested restriction, we will comply with your request unless the information is needed to facilitate emergency treatment. To request restrictions, you must make your request in writing. In your request, you must tell us (1) what infornation you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. Your Right to Request Confidential Communications: You have the right to request that we communicate with you about payment for your medical matters in an alternative means (such as by fax) or at an alternative location (such as to your office). To request confidential communications, you must make your request in writing. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Your Rights to Inspect and Copy: You have the right to inspect and copy protected health information that we maintain about you that may be used to make decisions about payment for your care. To inspect this protected health information you may contact the Privacy Officer. To obtain copies of such protected health information, you must submit your request in writing as indicated below. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your protected health information, in most situations you may request that the denial be reviewed by a licensed health care professional who did not take part in the decision to deny access. We will comply with the outcome of the review. Your Right to Make Complaints: If you believe that your privacy rights have been violated you may make a complaint to the UNIFI Companies Privacy Office or to the Secretary of Health and Human Resources as follows: UNIFI Privacy Office Attn. HIPAA Privacy P.O. Box 81889 Lincoln, NE 68510 Secretary, Health and Human Services, Office of Civil Rights United States Department of Health and Human Services 200 Independence Avenue, SW Room 509F HHH Building Washington D.C. 20201 Any complaint you file will not cause you to suffer retaliation from our company. We will promptly investigate your complaint as soon as we receive it. When we have completed our investigation, we will notify you of our findings. If the investigation reveals that your privacy rights have indeed been violated, we will immediately take the appropriate measures to correct the violation pursuant to our Privacy Practices and Procedures. Individual Rights Contact To assert any of your rights with respect to this Notice, or to obtain an authorization form, please call 1-800-487- 5553 and request the appropriate form. Effective Date This Notice will become effective as of April 14, 2003.