DENTAL BENEFIT RIDER This Rider is part of the policy/certificate to which it is attached. The consideration for this Rider is the application for the Rider and payment of any applicable premium. The effective date of this Rider is shown on the Schedule of Benefits. BENEFIT WAITING PERIOD: There is no waiting period required for a covered person to receive the benefits under the Preventive Dental Services section of the Dental Plan Schedule. Each covered person must be insured under this Rider for a minimum period of 6 consecutive months to be eligible to receive any of the benefits provided under the Basic Dental Services section of the Dental Plan Schedule. Each covered person must be insured under this Rider for a minimum period of 12 consecutive months to be eligible to receive any of the benefits provided under Major Dental Services section of the Dental Plan Schedule. DEDUCTIBLE: No deductible shall apply against any benefits payable under the Preventive Dental Services section of the Dental Plan Schedule. Benefits will be payable after an annual deductible, as stated on the Schedule of Benefits page, has been satisfied by a covered person during a calendar year for any benefits payable under either the Basic Dental Services or Major Dental Services section of the Dental Plan Schedule. If three (3) covered persons of any one family have met the annual deductible requirement, no further annual deductible will be required for any other covered persons of the family during the same calendar year. The deductible shall consist of charges for the Basic Dental Services and/or Major Dental Services. BENEFITS: Subject to the exclusions and limitations contained herein, benefits shall be provided for the dental procedures as shown below and are payable at the lesser of: the actual cost level of the service, or the benefit amount stated below for each procedure:
DENTAL PLAN SCHEDULE BENEFIT FOR EACH COVERED PERSON
ADA
CODE
PLAN BENEFITS
PREVENTIVE DENTAL SERVICES 9110 110 120 130 110 1120 1201 1203 1204 1205
PALL-EMER TREAT DENT PAIN - MINOR.............................................................................. $ 39 1 INITIAL ORAL EXAM .................................................................................................................... 24 1 PERIODIC ORAL EXAM ............................................................................................................... 18 1 EMERGENCY ORAL EXAM ......................................................................................................... 24 1 PROPHYLAXIS-ADULT ................................................................................................................ 36 1 PROPHYLAXIS-CHILD ................................................................................................................. 26 2 TOP APPL FLUOR INCL PROPHY-CHILD ................................................................................. 31 2 TOP APPL FLUOR EXCL PROPHY-CHILD ................................................................................ 13 2 TOP APPL FLUOR EXCL PROPHY-ADULT .............................................................................. 13 2 TOP APPL FLUOR INCL PROPHY-ADULT ................................................................................ 37
PAL697GMM-DENT-FL
-1-
1
2
Note that benefits for any one or more of these five procedures are payable only once in any continuous period of 6 months. Note that benefits for any one or more of these four procedures are payable only once in any continuous period of 12 months. BASIC DENTAL SERVICES
210 220 230 240 270 272 274 330 460 470 2110 2120 2130 2131 2140 2150 2160 2161 2190 2330 2331 2332 2337 2338 2339 7110 7120
3
4
3
INTRAORAL-COMPL SER INC BITEWINGS ............................................................................ $44 3 INTRAORAL-PERIAPICAL-FIRST FILM ........................................................................................ 8 3 INTRAORAL-PERIAPICAL-EACH ADD FILM ............................................................................... 7 3 INTRAORAL OCCLUSAL FILM ................................................................................................... 13 4 X-RAYS-BITEWING SINGLE FILM .............................................................................................. 11 4 X-RAYS-BITEWING TWO FILMS ................................................................................................ 14 4 X-RAYS-BITEWING FOUR FILMS ............................................................................................... 19 4 X-RAYS-PANORAMIC FILM ......................................................................................................... 39 PULP VITALITY TESTS................................................................................................................. 18 DIAGNOSTIC CASTS .................................................................................................................... 46 AMALGAM-ONE SURFACE PRIMARY ........................................................................................ 32 AMALGAM-TWO SURFACES PRIMARY ..................................................................................... 41 AMALGAM-THREE SURFACES PRIMARY ................................................................................. 50 AMALGAM-FOUR+ SURFACES PRIMARY ................................................................................. 61 AMALGAM-ONE SURFACE PERMANENT.................................................................................. 36 AMALGAM-TWO SURFACES PERMANENT .............................................................................. 47 AMALGAM-THREE SURFACES PERMANENT........................................................................... 57 AMALGAM-FOUR+ SURFACES PERMANENT........................................................................... 68 PIN RETENTION EXCLUSIVE OF AMALGAM............................................................................. 16 RESIN-ONE SURFACE ................................................................................................................. 40 RESIN-TWO SURFACES.............................................................................................................. 52 RESIN-THREE SURFACES .......................................................................................................... 82 COMPOS W/ULTRA VIOLET-1 SURFACE.................................................................................. 45 COMPOS W/ULTRA VIOLET-2 SURFACES ............................................................................... 66 COMPOS W/ULTRA VIOLET-3 SURFACES ............................................................................... 80 ORAL SURGERY-SINGLE TOOTH .............................................................................................. 36 ORAL SURGERY-EACH ADDITIONAL TOOTH.......................................................................... 34
Note that benefits for any one or more of these four procedures are payable only once in any continuous period of 60 months. Note that benefits for any one or more of these four procedures are payable only once in any continuous period of 6 months.
PAL697GMM-DENT-FL
-2-
MAJOR DENTAL SERVICES 1510 1515 1520 1525 1550 2334 2335 3110 3120 3220 3310 3320 3330 3340 3350 3410 3420 3430 3440 3450 3920 3940 3960 4210 4211 4240 4250 4260 4261 4262 4270 4271 4272 4320 4321 4330 4331 4341 4360 4910 7130 7210 7220 7230
SPACE MAINTAINER-FIXED UNILATERAL ............................................................................$154 SPACE MAINTAINER-FIXED BILATERAL ................................................................................. 184 SPACE MAINTAINER-REMOV UNILATERAL............................................................................ 190 SPACE MAINTAINER-REMOV BILATERAL............................................................................... 221 RECEMENTATION OF SPACE MAINTAINER............................................................................. 31 PIN RETENTION-EXCLUSIVE OF COMPOST............................................................................ 18 REX-3+ SURF OR INV INCISAL ANGLE...................................................................................... 97 PULP CAP-DIRECT EXCL FINAL REST...................................................................................... 12 PULP CAP-INDIRECT EXCL FINAL REST .................................................................................. 10 THERAPEUTIC PULPOTOMY EXCL FINAL REST..................................................................... 26 ONE CANAL EXCL FINAL REST................................................................................................ 115 TWO CANALS EXCL FINAL REST............................................................................................. 139 THREE CANALS EXCL FINAL REST......................................................................................... 197 FOUR OR MORE CANALS EXCL FINAL REST ........................................................................ 196 APEXIFICATION PER TREATMENT VISIT .................................................................................. 51 APICOECTOMY PER TOOTH-FIRST ROOT............................................................................. 129 APICO PERFMD IN CON WITH ENDO MANI ............................................................................ 180 RETROGRADE FILLING-PER ROOT .......................................................................................... 47 APICAL CURETTAGE ................................................................................................................... 50 ROOT AMPUTATION-PER ROOT................................................................................................ 62 HEMISECT W RT REM-W/O CANAL THER ................................................................................ 55 RECALC/REPAIR-PERF/ROOT RESOR/ETC............................................................................. 28 BLEACH NON-VITAL DISCOLORED TOOTH ............................................................................. 38 GINGIVECTOMY/GINGIVOPLASTY-PER QUAD ...................................................................... 120 GINGIVECTOMY/GINGIVOPLASTY-PER TOOTH...................................................................... 32 GINGIVAL FLAP INCL RT PLAN-PER QUAD ............................................................................ 151 MUCO-GINGIVAL SURGERY-PER QUAD................................................................................. 173 OSS SURG & FLAP ENT/CLOS-PER QUAD............................................................................. 221 OSS GFT-SGL SITE & FLAP ENT/CLOS/DNR.......................................................................... 158 OSS GFT-MULTI SI & FLAP ENT/CLOS/DNR........................................................................... 204 PEDICLE SOFT TISSUE GRAFT PROCEDURE....................................................................... 166 FREE SOFT TISSUE GFT & DONOR SITE ............................................................................... 164 APICALLY POSITIONING FLAP PROCEDURE......................................................................... 120 PROVISIONAL SPLINTING-INTRACORONAL ............................................................................ 78 PROVISIONAL SPLINTING-EXTRACORONAL........................................................................... 73 OCCLUSAL ADJUSTMENT LIMITED........................................................................................... 38 OCCLUSAL ADJUSTMENT COMPLETE................................................................................... 103 ROOT PLANNING-PER QUAD ..................................................................................................... 53 SPEC PERIO APPL INCLUD OCCL GUARDS ............................................................................ 99 PERIODONTAL PROPHY ............................................................................................................. 22 ROOT REMOVAL-EXPOSED ROOTS ......................................................................................... 44 SURGICAL REMOVAL OF ERUPTED TOOTH ........................................................................... 59 REM IMPACTED TOOTH-SOFT TISSUE .................................................................................... 83 REM IMPACTED TOOTH-PART BONY ..................................................................................... 111
PAL697GMM-DENT-FL
-3-
MAJOR DENTAL SERVICES (Continued) 7240 7250 7260 7270 7280 7281 7290 7310 7320 7470 7510 7960 7970 9220 9230 9240 9310 9910 2410 2420 2430 2510 2520 2530 2540 2610 2710 2720 2721 2722 2740 2750 2751 2752 2790 2791 2792 2810 2910 2920 2930 2931
REM IMPACTED TOOTH-COMPL BONY .................................................................................. 135 SURG REM RESID T ROOTS-CUTTING PROC......................................................................... 71 OROANTRAL FISTULA CLOSURE ............................................................................................ 254 TOOTH REPLANTATION............................................................................................................ 154 SURG EXPOS IMP/UNERUPT-ORTHO..................................................................................... 148 SURG EXPOS IMP/UNERUPT-AID ERUP................................................................................. 123 SURGICAL REPOSITIONING OF TEETH.................................................................................. 121 ALVEOPL IN CONJ W/EXTRACT-PER QUAD............................................................................ 78 ALVEOPLASTY NO EXTRACT-PER QUAD .............................................................................. 127 REM EXOSTOSIS-MAXILLA OR MANDIBLE............................................................................. 241 I&D ABSCESS-INTRAORAL SOFT TISSUE ................................................................................ 54 FRENECTOMY FRENEC/FRENOT-SEP PROC ....................................................................... 132 EXC OF HYPERPLASTIC TISSUE-PER ARCH......................................................................... 235 GENERAL ANESTHESIA ............................................................................................................ 147 ANALGESIA (NITROUS OXIDE)................................................................................................... 25 INTRAVENOUS SEDATION........................................................................................................ 155 CONSULTATION-PER SESSION ................................................................................................. 49 APPL OF DESENSITIZING MED................................................................................................... 18 GOLD FOIL-ONE SURFACE......................................................................................................... 55 GOLD FOIL-TWO SURFACES ..................................................................................................... 85 GOLD FOIL-THREE SURFACES................................................................................................ 116 INLAY-METALLIC-ONE SURFACE............................................................................................. 116 INLAY-METALLIC-TWO SURFACES ......................................................................................... 140 INLAY-METALLIC-THREE SURFACES ..................................................................................... 164 ONLAY-METALLIC-PER T IN ADD TO INLAY ............................................................................. 41 INLAY-PORCELAIN/CERAMIC-ONE SURFACE ....................................................................... 152 CROWN-RESIN-LABORATORY................................................................................................... 99 CROWN-RESIN WITH HIGH NOBLE METAL ........................................................................... 169 CROWN-RESIN WITH PREDOM BASE METAL ....................................................................... 138 CROWN-RESIN WITH NOBLE METAL...................................................................................... 149 CROWN-PORCELAIN/CERAMIC SUBSTRATE........................................................................ 180 CROWN-PORC FUSED TO HIGH NOBLE METAL................................................................... 188 CROWN-PORC FUSED TO PREDOM BASE MTL ................................................................... 222 CROWN-PORC FUSED TO NOBLE METAL ............................................................................. 192 CROWN-FULL CAST HIGH NOBLE METAL ............................................................................. 210 CROWN-FULL CAST PREDOM BASE METAL ......................................................................... 173 CROWN-FULL CAST NOBLE METAL ....................................................................................... 167 CROWN-3/4 CAST METALLIC ................................................................................................... 180 RECEMENT INLAY ........................................................................................................................ 16 RECEMENT CROWN .................................................................................................................... 16 PREFAB STAINLESS STL CROWN-PRIM TOOTH .................................................................... 44 PREFAB STAINLESS STL CROWN-PERM TOOTH................................................................... 49
PAL697GMM-DENT-FL
-4-
MAJOR DENTAL SERVICES (Continued) 2940 2950 2951 2952 2954 5110 5120 5130 5140 5211 5212 5213 5214 5215 5216 5280 5281 5610 5620 5630 5640 5650 5660 5850 6210 6211 6212 6240 6241 6242 6250 6251 6252 6520 6530 6540 6545 6720 6721 6722 6740 6750
SEDATIVE FILLINGS ..................................................................................................................... 17 CROWN BUILDUP-INCLUDING ANY PINS ................................................................................. 44 PIN RETEN-PER TOOTH IN ADD TO REST................................................................................. 9 CAST POST & CORE IN ADD TO CROWN................................................................................. 67 PREFAB POST & CORE IN ADD TO CROWN............................................................................ 48 COMPLETE UPPER DENTURE ................................................................................................. 273 COMPLETE LOWER DENTURE ................................................................................................ 273 IMMEDIATE UPPER DENTURE ................................................................................................. 289 IMMEDIATE LOWER DENTURE ................................................................................................ 289 U PAR-ACRY BS & CONV CLSPS & RSTS ............................................................................... 232 L PAR-ACRY BS & CONV CLSPS & RSTS................................................................................ 276 U PAR BS CST BS W ACRY SDLS & C&R ................................................................................ 273 L PAR BS CST BS W ACRY SDLS & C&R................................................................................. 318 U PAR HI NBL CST BS-ACR SDLS & C&R................................................................................ 446 L PAR HI NBL CST BS-ACR SDLS & C&R ................................................................................ 446 RM UNI PAR D-1 PC-HI NBL-CLSP-PER UN ............................................................................ 210 RM UNI PAR D-1 PC-BS CST-CLSP-PER UN........................................................................... 171 REPAIR ACRYLIC SADDLE OR BASE......................................................................................... 35 REPAIR CAST FRAMEWORK ...................................................................................................... 37 REPAIR OR REPLACE BROKEN CLASP .................................................................................... 46 REPLACE BROKEN TEETH-PER TOOTH .................................................................................. 26 ADD TOOTH TO EXISTING PART DENTURE............................................................................ 41 ADD CLASP TO EXISTING PART DENTURE ............................................................................. 47 TISSUE CONDITIONING-PER DENT UNIT ................................................................................. 24 PONTIC-CAST HIGH NOBLE METAL ........................................................................................ 205 PONTIC-CAST PREDOM BASE METAL.................................................................................... 176 PONTIC-CAST NOBLE METAL .................................................................................................. 188 PONTIC-PORC FUSED TO HI NOBLE METAL......................................................................... 206 PONTIC-PORC FUSED TO PREDOM BS METAL .................................................................... 189 PONTIC-PORC FUSED TO NOBLE METAL.............................................................................. 194 PONTIC-RESIN W HI NOBLE METAL........................................................................................ 201 PONTIC-RESIN W PREDOM BASE METAL.............................................................................. 189 PONTIC-RESIN W NOBLE METAL ............................................................................................ 199 INLAY-METALLIC-TWO SURFACES ......................................................................................... 150 INLAY-METALLIC-3 OR MORE SURFACES ............................................................................. 177 INLAY-METALLIC-ONLAYING CUSPS......................................................................................... 48 CAST METAL RET FOR ACID ETCH BRIDGE............................................................................ 94 CROWN-RESIN W HI NOBLE METAL ....................................................................................... 207 CROWN-RESIN W PREDOM BASE METAL ............................................................................. 191 CROWN-RESIN W NOBLE METAL............................................................................................ 194 CROWN-PORCELAIN ................................................................................................................. 200 CROWN-PORC FUSED TO HI NOBLE METAL ........................................................................ 206
PAL697GMM-DENT-FL
-5-
MAJOR DENTAL SERVICES (Continued) 6751 6752 6780 6790 6791 6792 6930 6950 6970
CROWN-PORC FUSED TO PREDOM BS METAL ................................................................... 201 CROWN-PORC FUSED TO NOBLE METAL ............................................................................. 196 CROWN-3/4 CAST HIGH NOBLE METAL ................................................................................. 200 CROWN-FULL CAST HI NOBLE METAL................................................................................... 205 CROWN-FULL CAST PREDOM BS METAL.............................................................................. 186 CROWN-FULL CAST NOBLE METAL ....................................................................................... 194 RECEMENT BRIDGE..................................................................................................................... 24 PRECISION ATTACHMENT........................................................................................................ 127 CAST POST & CORE IN ADD TO BRDG RET ............................................................................ 80
EXCLUSIONS AND LIMITATIONS No benefits will be payable (nor will such benefits count toward meeting the deductible) for: 1.
any procedure, service or supplies which are included as covered medical expenses under any medical care plan;
2.
any treatment which is for cosmetic purposes or for the correction of congenital malformations, unless the treatment is performed on a covered dependent who is 19 years of age or less because of congenital disease or anomaly that resulted in a functional defect as determined by the attending physician or dentist so long as the covered dependent was covered continuously under the policy from birth;
3.
the replacement of lost or stolen appliances;
4.
initial placement of any prosthetic appliance or fixed bridge unless such placement is necessitated by the extraction of one or more natural teeth while insured under this Rider. Any such appliance or fixed bridge must include the replacement of the extracted tooth or teeth;
5.
replacement of any prosthetic appliance or fixed bridge, inlays, crowns or orthodontic appliances which were not placed while insured under this Rider, unless the replacement has been in place at least five (5) years;
6.
any procedure begun after the covered person's insurance under this Rider terminates, or for any prosthetic dental appliance finally installed or delivered more than thirty (30) days after the covered person's insurance under this Rider terminates;
7.
any procedure begun or appliance installed before a covered person became insured under this Rider;
PAL697GMM-DENT-FL
-6-
8.
analysis, appliances, restorations, or surgery necessary to alter vertical dimension or restore occlusion or for the purpose of splinting;
9.
services provided for any type of temporomandibular joint (TMJ) dysfunctions, myofacial pain or orthognathic surgery;
10. general anesthesia, unless administered in conjunction with bony impaction, prescribed drugs, premedication or analgesia; 11. failure to keep a scheduled visit or charges for the completion of any claim forms; 12. expenses provided or paid for by any governmental program or law, except as to charges which the covered person is legally obligated to pay; 13. service or supply not listed in the Dental Plan Schedule; 14. charges for: implants of any type, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments; 15. services or supplies rendered by a person who is an immediate family member of the covered member; 16. services or supplies provided by the covered member's employer; 17. any charges due to accidental injury or illness that arises out of or in the course of employment. COORDINATION OF BENEFITS: The Coordination of Benefits provision, outlined in the policy to which this Rider is attached, is amended to also apply when the covered person entitled to dental benefits under this Rider is also covered by another insurance policy which provides dental benefits. EXTENSION OF BENEFITS: If a covered person’s dental benefits under this Rider end, coverage will be extended for a course of treatment or a dental procedure in connection with a specific injury or illness which occurred while coverage under this Rider was in effect, which was recommended in writing by the attending physician or dentist to the covered person, and which commenced while the person was covered under this Rider. The dental procedures provided to the covered person must be those other than routine examinations, prophylaxis, x-rays, sealants or other orthodontic services. The dental procedures must be performed within 90 days after coverage under this Rider ends, and termination of coverage must not have occurred as a result of the covered member’s voluntary termination of coverage.
PAL697GMM-DENT-FL
-7-
All limitations, exclusions or reductions under this Rider that would have applied to the specific dental procedures had the coverage on the patient not terminated apply during the extension of benefits. The benefit extension will terminate on the earlier of: •
90 days from the date the covered person’s insurance ends; or
•
the date the person becomes covered under another plan which provides similar coverage.
With respect to other covered persons who have not sustained an injury or illness that would qualify under this provision, dental benefits will not be extended past the date of termination of coverage. TERMINATION: A covered person’s coverage under this Rider will end on the earliest of: • •
• •
the date the covered member or covered spouse reaches age 65; or the date the covered dependent reaches age 19 (or 25 if the covered dependent is enrolled in a full-time course of study at an accredited 2 year or 4 year college or university); or the date coverage under the policy ends; or the premium due date following the date we receive a request to terminate the Rider.
Nothing in this Rider shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, provisions or limitations of the policy, other than as stated above. PROVIDENT AMERICAN LIFE & HEALTH INSURANCE COMPANY
President
PAL697GMM-DENT-FL
-8-
