Welcome to Humana Dental Chicago Transit Authority Two plan options: • PPO • Prestige 75 DHMO Plan

Plan highlights • A larger dental provider network • $3,000 annual maximum for PPO plan • No copayment or deductible for preventive care • Know your costs up front • Check the benefit schedule for your out-of-pocket cost • Pay your copayment at time of service

ILHHQQQEN 1013

Visit HumanaDental.com or call 1-800-837-2341.

Oral health impacts your overall health Dental care is an important part of maintaining good overall health. In fact, research shows that periodontal (gum) disease can be an indicator of other health problems such as heart disease, stroke, and diabetes. Your Humana Dental plan encourages preventive treatment, helping you achieve oral health.

Visit dentists you know and trust You can see any in-network dentist or specialist at any time. It’s easy to find a provider near your home or office who will deliver the quality service you expect. There’s never a need for referrals. Finding a dentist is easy. For the most current provider listing go to HumanaDental.com. You can also go to the website to:

2 - HumanaDental Federal Advantage Plan

We're here to help CALL 1-800-837-2341 FOR CUSTOMER CARE.

Manage your plan at MyHumana If you are a PPO dental member, use MyHumana to manage your plan, understand your benefits, and take charge of your dental health.

As a Humana PPO Dental member, you can: • • • • • • •

Find network dentists Check claims history and status View coverage details Review plan benefit details Order a replacement identification card View estimates for services Exchange secure messages with Humana

Registration is simple

Have your Humana PPO Dental identification card ready and go to Humana.com. Click on “Register,” then follow the instructions.

We’re here to help CALL 1-800-837-2341 FOR CUSTOMER CARE.

Humana.com HumanaDental Federal Advantage Plan - 3

Find a provider at HumanaDental.com If you are a DHMO Humana dental member, use HumanaDental.com to find an in-network provider. Manage your plan at www.MyCompBenefits.com. As a DHMO dental member, you can: • Check claims history and status • Request an identification card • Review plan benefit details • Exchange secure messages with Humana http://www.compbenefits.com/custom/CTA/

We’re here to help CALL 1-800-837-2341 FOR CUSTOMER CARE.

Humana.com HumanaDental Federal Advantage Plan - 3

Chicago Transit Authority PPO Benefit Summary This is a summary of dental services and the allowable levels of coverage. Benefits are paid at the highest levels when services are rendered by a participating preferred dental provider. Preferred dental providers have agreed to a specific fee schedule that will provide savings to you. Claim forms must be submitted to HumanaDental for payment.

PPO Schedule

Percentage Coverage*

Preventive services

100%

Oral Examination (two per benefit period), Prophylaxis (two per benefit period), Topical Fluoride Application-under age 14 (one per benefit period), Sealants-under age 14, Space Maintainers-under age 14, when not part of orthodontic treatment, Emergency oral examinations and palliative emergency treatment for the temporary relief of pain

Primary dental services

90%

Dental X-rays full mouth (one per 36 months), bitewings (one per 12 months), Fillings-Silver, silicate, plastic, porcelain and composite, Extractions-for specific coverage refer to special limitations, Oral Surgery-for specific coverage refer to special limitations, Endodontics/ Root Canal Treatment, Pulp Vitality Tests (once per 12 months), Apicoectomies, Hemisection, Biopsies of Oral Tissue, Periodontics/ Periodontal Therapy, General Anesthesia/Intravenous Sedation, Denture Adjustments, Rebasing and Relining, Recementing of Crowns, Inlays, Onlays, and Bridges, Fixed Bridge Repairs, Repair of Removable Dentures

Major dental services

50%

Inlays, Onlays and Crowns, Full and Partial Dentures, Fixed Bridgework, Veneers

Pre-Estimation of Benefits

For services that will cost more than $125.00, a Pre-Estimation of benefits is recommended.

* The % of coverage will be applied to the reduced fee schedule that preferred providers have agreed to accept for the PPO option. Services rendered by a Non-PPO provider will be paid at usual & customary rates.

Yearly Benefit Maximum (per person) Yearly Deductible

$3,000.00 Single $25.00

Family $50.00 Below is a general outline of services and supplies that are excluded from coverage. SPECIAL LIMITATION No benefits will be provided under this Benefit Section for: 1. Dental services which are performed for cosmetic purposes. 2. Dental services or appliances for the diagnosis and/or treatment ofTemporomandibular Joint Dysfunction and Related Disorders. 3. Oral Surgery for the following procedures: • surgical services related to a congenital malformation; • surgical removal of complete bony impacted teeth, unless covered by a Medical HMO plan; • excision of tumors or cysts of the jaws, cheeks, lips, tongue, roof, and floor of the mouth; • excision of exostoses of the jaws and hard palate (provided that this procedure is not done in preparation for dentures or other prostheses); treatment of fractures facial bone; external incision and drainage of cellulitis; incision of accessory sinuses, salivary glands,

ILHHQMSEN

or ducts; reduction of dislocation, or excision of the temporomandibular joints. 4. Repair of natural teeth due to accidental injury. 5. Hospital and ancillary charges are not covered. 6. Any services, treatments or supplies included as an eligible benefit under any other Benefit Section of this booklet. 7. Any services, treatments or supplies included as an eligible benefit under other group hospital, medical and/or surgical coverage. This summary of benefits is intended only to highlight benefits provided under the dental option of Chicago Transit Authority’s Employee Health Benefit Plan and should not be relied upon to fully determine coverage. This plan may not cover all dental expenses. *Services in progress are excluded. *Missing tooth clause – prosthesis to replace a tooth extracted prior to effective date will be excluded.

Chicago Transit Authority Prestige 75 - DHMO Plan The Prestige 75 dental plans focuses on maintaining oral health, prevention and cost-containment. A member may see a primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet and no waiting periods. Prestige 75 copayments for listed procedures are applicable only at a participating general dentist. Member costs listed here are for services provided by your chosen participating primary care dentist (PCD) only. As your dental professional, your PCD may decide that you need to see a contracted dental specialist. No referral is necessary to see a network specialist.

Summary of services Appointments 9430 9430 9440 0999

Office Visit (normal hours) . . . . . . . . . . . . . . . . . . . . . Emergency visit (regular hours) . . . . . . . . . . . . . . . . Emergency visit (after hours) . . . . . . . . . . . . . . . . . . Broken appointments (without 24 hr notice, per 15 min) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maximum $40 per broken appointment. No charge will be made due to emergencies.

Diagnostic 0110 0120 0130 0140 0150 0160 0210 0220 0230 0240 0250 0260 0270 0272 0274 0275 0330 0340 0415 0425 0460 0470 0471 0501

Member pays $ 5.00 $ 20.00 $ 35.00 $ 10.00

member pays

Initial oral examination . . . . . . . . . . . . . . . . . . . . . . . N/C Periodic oral examination . . . . . . . . . . . . . . . . . . . . . N/C Emergency oral examination . . . . . . . . . . . . . . . . . . N/C Limited oral evaluation - problem focused . . . . . N/C Comprehensive oral evaluation (once every two years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C Detailed and extensive oral evaluation problem focused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C Intraoral - complete series (including bitewings) . N/C Intraoral - periapical - first film. . . . . . . . . . . . . . . . . N/C Intraoral - periapical - each additional film . . . . . N/C Intraoral - occlusal film . . . . . . . . . . . . . . . . . . . . . . . . N/C Extraoral - first film . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C Extraoral - each additional film. . . . . . . . . . . . . . . . . N/C Bitewing - single film . . . . . . . . . . . . . . . . . . . . . . . . . . N/C Bitewings - two films . . . . . . . . . . . . . . . . . . . . . . . . . . N/C Bitewings - four films . . . . . . . . . . . . . . . . . . . . . . . . . N/C Bitewing - each additional film. . . . . . . . . . . . . . . . . N/C Panoramic film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C Cephalometric film . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C Bacteriologic studies for determination of pathologic agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C Caries susceptibility tests . . . . . . . . . . . . . . . . . . . . . . N/C Pulp vitality tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C Diagnostic casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C Diagnostic photographs. . . . . . . . . . . . . . . . . . . . . . . N/C Histopathologic examinations . . . . . . . . . . . . . . . . . N/C

Preventive

member pays

1110 Prophylaxis - adult (once per 6 months/two per year) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C 1120 Prophylaxis - child (once per 6 months/two per year) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C 1203 Topical application of fluoride (excluding prophylaxis) - child (once per year) . . . . . . . . . . . . . N/C 1204 Topical application of fluoride (including prophylaxis) - adult (once per year) . . . . . . . . . . . . N/C 1310 Nutritional counseling for control of dental disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C ILHHQMSEN

1320 Tobacco counseling for the control and prevention of oral disease . . . . . . . . . . . . . . . . . . . . . N/C 1330 Oral hygiene instructions . . . . . . . . . . . . . . . . . . . . . . N/C 1351 Sealant - per tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C Space Maintainers 1510 1515 1520 1525 1550

Space maintainer - fixed - unilateral . . . . . . . . . . . Space maintainer - fixed - bilateral . . . . . . . . . . . . . Space maintainer - removable - unilateral . . . . . Space maintainer - removable - bilateral . . . . . . . Recementation of space maintainer . . . . . . . . . . .

Basic Restorative 2110 2120 2130 2131 2140 2150 2160 2161 2210 2330 2331 2332 2335 2336 2380 2381 2382 2385 2386 2387

$ 35.00 $ 35.00 $ 45.00 $ 45.00 $ 5.00

member pays

Amalgam - one surface, primary . . . . . . . . . . . . . . $ 5.00 Amalgam - two surfaces, primary. . . . . . . . . . . . . . $ 10.00 Amalgam - three surfaces, primary. . . . . . . . . . . . . $ 15.00 Amalgam - four or more surfaces, primary . . . . . $ 20.00 Amalgam - one surface, permanent . . . . . . . . . . . $ 5.00 Amalgam - two surfaces, permanent . . . . . . . . . $ 10.00 Amalgam - three surfaces, permanent . . . . . . . . $ 15.00 Amalgam - four or more surfaces, permanent . $ 20.00 Silicate cement - per restoration . . . . . . . . . . . . . . . $ 10.00 Resin - one surface, anterior . . . . . . . . . . . . . . . . . . . $ 15.00 Resin - two surfaces, anterior . . . . . . . . . . . . . . . . . . $ 20.00 Resin - three surfaces, anterior . . . . . . . . . . . . . . . . $ 25.00 Resin - four or more surfaces or involving incisal angle (anterior) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 30.00 Composite resin crown, anterior-primary . . . . . . $ 20.00 Resin - one surface, posterior, primary . . . . . . . . . $ 10.00 Resin - two surfaces, posterior, primary . . . . . . . . $ 15.00 Resin - three or more surfaces, posterior . . . . . . . $ 15.00 Resin - one surface, posterior, permanent. . . . . . $ 15.00 Resin - two surfaces, posterior, permanent . . . . . $ 20.00 Resin - three or more surfaces, posterior, permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 30.00

Crowns 2510 2520 2530 2543 2544 2610 2620 2630

member pays

member pays

Inlay - metallic - one surface . . . . . . . . . . . . . . . . . . $ 175.00 Inlay - metallic - two surfaces . . . . . . . . . . . . . . . . . $ 200.00 Inlay - metallic - three or more surfaces . . . . . . . $ 200.00 Onlay - metallic - three surfaces . . . . . . . . . . . . . . . $ 200.00 Onlay - metallic - four or more surfaces . . . . . . . . $ 200.00 Inlay - porcelain/ceramic - one surface . . . . . . . . $ 175.00 Inlay - porcelain/ceramic - two surfaces . . . . . . . $ 200.00 Inlay - porcelain/ceramic - three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 200.00 2740 Crown - porcelain/ceramic substrate . . . . . . . . . . $ 225.00 2750 Crown - porcelain fused to high noble metal.. . . $ 225.00 2751 Crown - porcelain fused to predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 225.00

2752 2790 2791 2792 2810 2910 2920 2930 2931 2932 2940 2950 2951 2952 2954 2980

Crown - porcelain fused to noble metal . . . . . . . . $ 225.00 Crown - full cast high noble metal . . . . . . . . . . . . . $ 225.00 Crown - full cast predominantly base metal . . . . $ 225.00 Crown - full cast noble metal . . . . . . . . . . . . . . . . . . $ 225.00 Crown - 3/4 cast metallic . . . . . . . . . . . . . . . . . . . . . . $ 225.00 Recement inlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10.00 Recement crown.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10.00 Prefabricated stainless steel crown - primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00 Prefabricated stainless steel crown - permanent tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00 Prefabricated resin crown. . . . . . . . . . . . . . . . . . . . . . $ 50.00 Sedative filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 15.00 Core buildup, including any pins . . . . . . . . . . . . . . . $ 50.00 Pin retention - per tooth, in addition to restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 15.00 Cast post and core in addition to crown . . . . . . . . $ 75.00 Prefabricated post and core in addition to crown $ 50.00 Crown repair, by report . . . . . . . . . . . . . . . . . . . . . . . . $ 15.00

Root Canals

member pays

3110 Pulp cap - direct (excluding final restoration) . . . $ 5.00 3120 Pulp cap - indirect (excluding final restoration) . $ 5.00 3220 Therapeutic pulpotomy (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 15.00 3230 Pulp therapy - anterior, primary . . . . . . . . . . . . . . . $ 15.00 3240 Pulp therapy - posterior, primary . . . . . . . . . . . . . . . $ 15.00 3310 Endodontic therapy - anterior (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 75.00 3320 Endodontic therapy - bicuspid (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 100.00 3330 Endodontic therapy - molar (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 125.00 3351 Apexification/recalcification - initial visit . . . . . . . $ 45.00 3352 Apexification/recalcification - interim visit . . . . . . $ 45.00 3353 Apexification/recalcification - final visit . . . . . . . . $ 75.00 3410 Apicoectomy/periradicular surgery - anterior. . . $ 75.00 3421 Apicoectomy/periradicular surgery - bicuspid (first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 100.00 3425 Apicoectomy/periradicular surgery - molar (first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 125.00 3426 Apicoectomy/periradicular surgery (each additional root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00 3430 Retrograde filling - per root . . . . . . . . . . . . . . . . . . . . $ 25.00 3450 Root Amputation - per root . . . . . . . . . . . . . . . . . . . $ 50.00 Periodontics (gum treatment)

member pays

4210 Gingivectomy or gingivoplasty - per quadrant . . $ 75.00 4211 Gingivectomy or gingivoplasty - per tooth. . . . . . $ 15.00 4220 Gingival curettage, surgical, per quadrant, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 25.00 4240 Gingival flap procedure, including root planing per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 75.00 4249 Crown lengthening - hard and soft tissue, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 100.00 4250 Mucogingival surgery - per quadrant . . . . . . . . . . . $ 100.00 4260 Osseous Surgery - per quadrant . . . . . . . . . . . . . . . . $ 150.00 4270 Pedicle soft tissue graft procedure . . . . . . . . . . . . . $ 100.00 4271 Free soft tissue graft procedure (including donor site surgery) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 100.00 4273 Subepithelial connective tissue graft . . . . . . . . . . . $ 125.00 4274 Distal or proximal wedge procedure (as separate procedure) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 40.00 4320 Provisional splinting - intracoronal. . . . . . . . . . . . . . $ 50.00 ILHHQMSEN

4321 Provisional splinting - extracoronal . . . . . . . . . . . . . $ 40.00 4341 Periodontal scaling and root planing, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 25.00 4355 Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10.00 4381 Local delivery chemotherapeutic agent - two sites per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20.00 4910 Periodontal maintenance procedures (following active therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20.00 Dentures 5110 5120 5130 5140 5211 5212 5213 5214 5281 5410 5411 5421 5422 5510 5520 5610 5620 5630 5640 5650 5730 5731 5740 5741 5750 5751 5760 5761 5850 5851 5860 5861 5862

Complete denture - upper . . . . . . . . . . . . . . . . . . . . . $ 275.00 Complete denture - lower . . . . . . . . . . . . . . . . . . . . . $ 275.00 Immediate denture - upper . . . . . . . . . . . . . . . . . . . $ 300.00 Immediate denture - lower . . . . . . . . . . . . . . . . . . . $ 300.00 Upper partial denture - resin base (including any conventional clasps, rests, and teeth) . . . . . . . . . . $ 275.00 Lower partial denture - resin base (including any conventional clasps, rests, and teeth) . . . . . . . . . . $ 275.00 Upper partial denture - cast metal base w/resin saddles (including any conventional clasps, rest and teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 325.00 Lower partial denture - cast metal base w/resin saddles (including any conventional clasps, rest and teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 325.00 Removable unilateral partial denture - one piece cast metal (including clasps and teeth) . . . . . . . . $ 175.00 Adjust complete denture - upper . . . . . . . . . . . . . . $ 10.00 Adjust complete denture - lower . . . . . . . . . . . . . . . $ 10.00 Adjust partial denture - upper . . . . . . . . . . . . . . . . . $ 10.00 Adjust partial denture - lower . . . . . . . . . . . . . . . . . $ 10.00 Repair broken complete denture base . . . . . . . . . $ 30.00 Replace missing or broken teeth - complete denture (each tooth) . . . . . . . . . . . . . . . . . . . . . . . . . $ 30.00 Repair resin denture base . . . . . . . . . . . . . . . . . . . . . . $ 30.00 Repair cast framework . . . . . . . . . . . . . . . . . . . . . . . . $ 30.00 Repair or Replace broken clasp . . . . . . . . . . . . . . . . $ 30.00 Replace broken teeth - per tooth . . . . . . . . . . . . . . . $ 30.00 Add tooth to existing partial denture . . . . . . . . . . $ 30.00 Reline complete upper denture (chairside) . . . . . $ 50.00 Reline complete lower denture (chairside) . . . . . $ 50.00 Reline upper partial denture (chairside) . . . . . . . . $ 50.00 Reline lower partial denture (chairside) . . . . . . . . $ 50.00 Reline complete upper denture (laboratory) . . . . $ 100.00 Reline complete lower denture (laboratory) . . . . $ 100.00 Reline upper partial denture (laboratory) . . . . . . $ 100.00 Reline lower partial denture (laboratory) . . . . . . . $ 100.00 Tissue conditioning, upper - per denture unit . . . $ 25.00 Tissue conditioning, lower - per denture unit . . . $ 25.00 Overdenture - complete, by report . . . . . . . . . . . . . $ 300.00 Overdenture - partial, by report . . . . . . . . . . . . . . . . $ 300.00 Precision attachment, by report . . . . . . . . . . . . . . . $ 300.00

Bridges 6210 6211 6212 6240 6241

member pays

member pays

Pontic - cast high noble metal . . . . . . . . . . . . . . . . . Pontic - cast predominantly base metal . . . . . . . Pontic - cast noble metal . . . . . . . . . . . . . . . . . . . . . . Pontic - porcelain fused to high noble metal . . . . Pontic - porcelain fused to predominantly base metal . $ 200.00 6242 Pontic - porcelain fused to noble metal . . . . . . . . 6251 Pontic - resin with predominantly base metal . .

$ 200.00 $ 200.00 $ 200.00 $ 200.00 $ 200.00 $ 200.00

6545 Retainer cast metal for resin bonded fixed prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 150.00 6720 Crown - resin with high noble metal . . . . . . . . . . . . $ 225.00 6721 Crown - resin with predominately base metal . . $ 200.00 6750 Crown - porcelain fused to high noble metal . . . $ 225.00 6751 Crown - porcelain fused to predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 225.00 6752 Crown - porcelain fused to noble metal . . . . . . . . $ 225.00 6780 Crown - ¾ cast high noble (plus gold) . . . . . . . . . . $ 225.00 6790 Crown - full cast high noble metal (plus gold) . . $ 225.00 6791 Crown - full cast predominantly base metal . . . . $ 225.00 6792 Crown - full cast noble metal . . . . . . . . . . . . . . . . . . $ 200.00 6930 Recement fixed partial denture . . . . . . . . . . . . . . . $ 30.00 6940 Stress breaker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 75.00 6950 Precision attachment, by report . . . . . . . . . . . . . . . $ 150.00 6970 Cast post and core in addition to fixed partial denture retainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 75.00 6972 Prefabricated post and core in addition to fixed partial denture retainer . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00 6973 Core build up for retainer, including any pins . . . . $ 50.00 6980 Fixed partial denture repair, by report . . . . . . . . . . $ 30.00 Oral surgery 7110 7120 7130 7210 7220 7230 7240 7241 7250 7270 7280 7281 7286 7310 7320 7510 7960 7970 7971

member pays

Routine extraction - single tooth . . . . . . . . . . . . . . . $ 10.00 Routine extraction - each additional tooth . . . . . $ 10.00 Root removal - exposed roots . . . . . . . . . . . . . . . . . $ 20.00 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth . . . . . . . . . . . . . . . . . . $ 20.00 Removal of impacted tooth - soft tissue . . . . . . . $ 30.00 Removal of impacted tooth - partially bony . . . . $ 50.00 Removal of impacted tooth - completely bony . $ 50.00 Removal of impacted tooth - completely bony w/complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00 Surgical removal of residual tooth roots (cutting procedure) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 25.00 Tooth reimplantation and/or stabilization of accidentally evulsed of displaced tooth and/or alveolus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 40.00 Surgical exposure of impacted or erupted tooth for orthodontic reasons (including orthodontic attachments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 75.00 Surgical exposure of impacted/unerupted tooth to aid eruption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 75.00 Biopsy of oral tissue - soft . . . . . . . . . . . . . . . . . . . . . $ 75.00 Alveoloplasty in conjunction with extractions per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00 Alveoloplasty not in conjunction with extractions - per quadrant . . . . . . . . . . . . . . . . . . . . . $ 50.00 Incision and drainage of abscess - intraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 25.00 Frenulectomy (frenectomy or frenotomy) separate procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00 Excision of hyperplastic tissue - per arch . . . . . . . $ 100.00 Excision of pericoronal gingival . . . . . . . . . . . . . . . . $ 50.00

ILHHQMSEN

Other services

member pays

9110 Palliative (emergency) treatment of dental pain - minor procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C 9210 Local anesthesia not in conjunction with operative or surgical procedures . . . . . . . . . . . . . . . N/C 9215 Local anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/C 9220 General anesthesia - first 30 minutes . . . . . . . . . . $ 100.00 9230 Analgesia (per visit if available) . . . . . . . . . . . . . . . . $ 10.00 9240 Intravenous sedation . . . . . . . . . . . . . . . . . . . . . . . . . $ 100.00 9310 Consultation (per visit by another plan dentist) . $ 25.00 9910 Application of desensitizing medicament . . . . . . $ 10.00 9940 Occlusal guard, by report . . . . . . . . . . . . . . . . . . . . . . $ 100.00 9951 Occlusal adjustment - limited . . . . . . . . . . . . . . . . . $ 50.00 9952 Occlusal adjustment - complete . . . . . . . . . . . . . . . $ 100.00 Cosmetic 2960 2961 2962 2999

member pays

Labial veneer laminate - chairside . . . . . . . . . . . . . $ 250.00 Labial veneer (resin laminate) - laboratory . . . . . $ 300.00 Labial veneer (porcelain laminate) - laboratory . $ 325.00 Bleach - per arch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 100.00

Orthodontics

member pays

8070/8080 Comprehensive orthodontic treatment of the transitional/adolescent dentition Children up to 19 years of age Up to 24 months of routine orthodontic treatment for Class I and Class II cases Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Records/Treatment Planning . . . . . . . . . . . . . . . . . . Orthodontic Treatment . . . . . . . . . . . . . . . . . . . . . . . . 8090 Comprehensive orthodontic treatment of the adult dentition Adults 19 years of age and over Up to 24 months of routine orthodontic treatment for Class I and Class II cases Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Records/Treatment Planning . . . . . . . . . . . . . . . . . . Orthodontic Treatment . . . . . . . . . . . . . . . . . . . . . . .

N/C $ 35.00 $ 250.00 $ 1,800.00

N/C $ 35.00 $ 250.00 $ 2,200.00

THE PRECEDING COPAYMENTS DO NOT INCLUDE THE ADDITIONAL COST OF PRECIOUS AND SEMI-PRECIOUS METAL. When crown and or bridgework exceeds six consecutive units, the patient may be charged an additional $25.00 per unit. All procedures listed might not be performed by the Participating General Dentist you select. The copayments shown apply to those General Dentists who do perform those services and are not applicable for services performed by a specialist. Therefore, you are encouraged to discuss availability of the scheduled services with your Participating General Dentist. Procedures not listed on the schedule of benefits, that are performed by the selected Participating General Dentist will be charged at that Participating General Dentist’s usual and customary fee less 25%. SPECIALISTS Should you need a specialist (i.e., Endodontist, Oral Surgeon, Periodontist, Prosthodontist, Pediatric Dentist, you may be referred by your Participating General Dentist. Copayment amounts are applicable when treatment is performed by selected Participating General Dentist or by Participating Specialists. Benefits for procedures not listed on the schedule of benefits, that are performed by a Participating Specialist are available at the Participating Specialist’s usual and customary fee less 25%.

Limitations and Exclusions 1. No service of any dentist other than a Participating General Dentist or Participating Specialist will be covered by Company, except out-of-area emergency care as provided in Section VIII, Paragraph C of the Certificate of Benefits. 2. Whenever any Contributions or Copayments are delinquent, Member will not be entitled to receive Benefits, transfer Dental Facilities, or enjoy any of the other privileges of Member in good standing. 3. Company does not provide coverage for the following services: a Cost of hospitalization and pharmaceuticals, drugs or medications. b Services which in the opinion of the Participating General Dentist or Participating Specialist are not Necessary Treatment to establish and/or maintain the Member’s oral health. c Any service that is not consistent with the normal and or usual services provided by the Participating General Dentist or Participating Specialist or which in the opinion of the Participating General Dentist or Participating Specialist would endanger the health of the Member. d Any service or procedure which the Participating General Dentist or Participating Specialist is unable to perform because of the general health or physical limitations of the Member. e Any dental treatment started prior to the Member’s effective date for eligibility of benefits. f Services for injuries and conditions which are paid or payable under Workers’ Compensation or Employers’ Liability laws. g Treatment for cysts, neoplasms and malignancies. h General anesthesia. *Services in progress are excluded.

Humana.com ILHHQMSEN