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Item 4H ITEM 4H M E M O R A N D U M July 29, 2015 TO: Shana Yelverton, City Manager FROM: Stacey Black, Director of Human Resources SUBJECT:Approve a contract renewal with United Healthcareto provide employee dentalbenefits for Plan Year October 1, 2015to September 30, 2016. Action Requested: Approve a contract renewal with United Healthcare to provide employee dental benefits for Plan Year October 1, 2015to September 30, 2016. Background Information: The City’s current dental insurance carrier is United Healthcare. United Healthcare(UHC)has been the City’s dentalcarrier since October 1, 2010and dentalinsurance was last competitively bid in 2010. Employeesare offered two plan options: a traditionalDental PPO(DPPO)plan and a Dental HMO(DHMO)plan. The plan is fully insured; the City pays a monthly per employee premium and UHC assumes the risk and accepts the financial responsibility for dental claims and administrative costs. The City currently pays the entire premium for employee only dental coverage and the employee pays the entire dependent cost. For new plan year, UHC has proposed no rate increase and no plan design changes to the DPPOplan and minor plan improvements to the DHMO plan. The currentDHMOplan is no longer being offered by UHC and they have recommended a similarDHMOplan that includes more robust benefits. In addition, UHC has offered a 24 month rate guaranteefor both plans. Financial Considerations: The estimated cost of dental insurance premiums is $18,320per month, or $219,843annually(combined City and employee premium contributions). The City’s annual estimated cost is $127,724. There is noannual estimated increase in the City’s portion of dental insurance premiums for FY 2016. The proposed dental insurance plan costs will be included in the proposed budget for Fiscal Year 2016. Shana Yelverton, City ManagerITEM 4H July 29, 2015 Page 2 Strategic Link: Performance Management and Service Delivery: attract, develop and retain a skilled workforce.CBO2: Become an employer of choice by developing a plan to recruit, develop and retain employees committed to excellence. Citizen Input/ Board Review: N/A Legal Review: N/A Alternatives: Deny the contract renewal with United Healthcareand seek alternative options. Supporting Documents: The following supporting documents are attached: United Healthcare Dental Renewal Staff Recommendation: Approve a contract renewal with United Healthcareto provide employee dentalbenefits for Plan Year October 1, 2015to September 30, 2016. dental plan D096N/D097N MEMBERSMEMBERS ADADESCRIPTIONCOPAYMENTADADESCRIPTIONCOPAYMENT DIAGNOSTIC SERVICES RESTORATIVE SERVICES* D0120PERIODIC ORAL EVALUATION EST PT $0 D2335RSN COMPOS-4/> SURF/W/INCISAL ANG $38 D0140LTD ORAL EVALUATION - PROBLEM FOCUS$0 D2390RESIN COMPOS CROWN ANTERIOR $45 D0150COMP ORAL EVALUATION - NEW/EST PT $0 D2391RESIN COMPOS - 1 SURFACE POSTERIOR $50 D0160DTL&EXT ORAL EVAL - PROB FOCUS RPT $0 D2392RESIN COMPOS - 2 SURFACES POSTERIOR$55 D0170RE-EVALUATION - LTD PROBLEM FOCUSED$0 D2393RESIN COMPOS - 3 SURFACES POSTERIOR$85 D0180COMP PERIODONTAL EVAL - NEW/EST PT $0 D2394RESIN COMPOS - 4/MORE SURFACES POST$95 D0210INTRAORAL-COMPLETE SERIES $0 D2510INLAY - METALLIC - ONE SURFACE $185 D0220INTRAORAL PERIAPICAL FIRST FILM $0 D2520INLAY - METALLIC - TWO SURFACES $185 D0230INTRAORL PERIAPICAL EA ADD FILM $0 D2530INLAY - METALLIC - 3/MORE SURFACES $185 D0240INTRAORAL - OCCLUSAL FILM $0 D2542ONLAY - METALLIC - TWO SURFACES $225 D0250EXTRAORAL - FIRST FILM $0 D2543ONLAY METALLIC THREE SURFACES $225 D0260EXTRAORAL - EACH ADDITIONAL FILM $0 D2544ONLAY METALLIC FOUR OR MORE SURF $225 D0270BITEWING - SINGLE FILM $0 D2610INLAY - PORCELN/CERAMIC - 1 SURFACE$250 D0272BITEWINGS - TWO FILMS $0 D2620INLAY - PORCELN/CERAMIC - 2 SURF $250 D0273BITEWINGS - THREE FILMS $0 D2630INLAY - PORCELN/CERAM - 3/MORE SURF$250 D0274BITEWINGS - FOUR FILMS $0 D2642ONLAY - PORCELN/CERAMIC - 2 SURF $250 D0277VERTICAL BITEWINGS - 7 TO 8 FILMS $0 D2643ONLAY - PORCELN/CERAMIC - 3 SURF $250 D0330PANORAMIC FILM $0 D2644ONLAY - PORCELN/CERAM - 4/MORE SURF$250 D0415COLLECT MICROORAGNISMS CULT & SENS $0 D2650INLAY-RSN COMPOS COMPOS/RSN-1 SURF $250 D0425CARIES SUSCEPTIBILITY TESTS $0 D2651INLAY-RSN COMPOS COMPOS/RSN-2 SURF $250 D0431ADJUNCT PREDX TST NO CYTOL/BX PROC $20 D2652INLAY-RSN COMPOS COMPOS/RSN-3/>SURF$250 D0460PULP VITALITY TESTS $0 D2662ONLAY-RSN COMPOS COMPOS/RSN-2 SURF $250 D0470DIAGNOSTIC CASTS $0 D2663ONLAY-RSN COMPOS COMPOS/RSN-3 SURF $250 D0472ACCESS TISS-GROSS EXAM-PREP & REPRT$0 D2664ONLAY-RSN COMPOS COMPOS/RSN-4/> $250 D0473ACCESS TISS-GROSS/MICRO-PREP/REPRT $0 D2710CROWN RESINBASED COMPOSITE INDIRECT$150 D0474ACSS TISS GR&MIC SURG MARG PREP/RPT$0 D2712CROWN 3/4 RESNBASED COMPOS INDIRECT$150 D0999OFFICE VISIT FEE - PER VISIT$0 D2720CROWN - RESIN WITH HIGH NOBLE METAL*$250 PREVENTIVE SERVICES D2721CROWN - RESIN W/PREDOM BASE METAL $250 1 D1110PROPHYLAXIS - ADULT $0 D2722CROWN - RESIN WITH NOBLE METAL* $250 1 --------PROPHYLAXIS - ADULT Add. Prophy within 6 months $25 D2740CROWN - PORCELAIN/CERAMIC SUBSTRATE $300 1 D1120PROPHYLAXIS - CHILD $0 D2750CROWN - PORCELN FUSED HI NOBLE METL*$250 1 --------PROPHYLAXIS - CHILD Add. Prophy within 6 months $25 D2751CROWN-PORCELN FUSD PREDOM BASE METL$250 D1203TOP FLUORIDE - CHILD $0 D2752CROWN - PORCELAIN FUSED NOBLE METAL *$250 D1204TOP FLUORIDE - ADULT $0 D2780CROWN - 3/4 CAST HIGH NOBLE METAL* $250 D1206TOP FLUORIDE; TX APPL MOD-HI RISK $0 D2781CROWN - 3/4 CAST PREDOM BASE METL $250 D1310NUTRIT CNSL CONTROL DENTAL DISEASE $0 D2782CROWN - 3/4 CAST NOBLE METAL * $250 D1320TOBACCO CNSL CNTRL&PREVION ORL DZ $0 D2783CROWN - 3/4 PORCELAIN/CERAMIC $250 D1330ORAL HYGIENE INSTRUCTIONS $0 D2790CROWN - FULL CAST HIGH NOBLE METAL* $250 D1351SEALANT - PER TOOTH $8 D2791CROWN - FULL CAST PREDOM BASE METL $250 D1510SPACE MAINTAINER - FIXED-UNILATERAL$25 D2792CROWN - FULL CAST NOBLE METAL * $250 D1515SPACE MAINTAINER - FIXED-BILATERAL $25 D2794CROWN TITANIUM * $250 D1520SPACE MAINTAINER - REMOVABLE-UNI $40 D2910RECEMENT INLAY ONLAY/PART COV REST $0 D1525SPACE MAINTAINER - REMOVABLE-BIL $40 D2915RECEMENT CAST/PREFAB POST & CORE $0 D1550RECEMENTATION OF SPACE MAINTAINER $15 D2920RECEMENT CROWN $0 D1555REMOVAL OF FIXED SPACE MAINTAINER $15 D2930PRFABR STAINLESS STEEL CROWN-PRIM $25 RESTORATIVE SERVICES* D2931PRFABR STAINLESS STEEL CROWN-PERM $25 D2140AMALGAM-ONE SURFACE PRIMARY/PERM $8 D2932PREFABRICATED RESIN CROWN $40 D2150AMALGAM-TWO SURFACES PRIMARY/PERM $15 D2933PRFABR STNLSS STEEL CROWN RSN WNDOW$40 D2160AMALGAM-3 SURFACES PRIMARY/PERM $22 D2940PROTECTIVE RESTORATION $0 D2161AMALGAM-FOUR/MORE SURF PRIM/PERM $28 D2950CORE BUILDUP INCLUDING ANY PINS $50 D2330RESIN COMPOS - ONE SURFACE ANTERIOR$10 D2951PIN RETN - PER TOOTH ADDITION REST $10 D2331RESIN COMPOS - 2 SURFACES ANTERIOR$20 D2952POST & CORE ADD CROWN INDIRECT FAB $50 D2332RESIN COMPOS - 3 SURFACES ANTERIOR$30 D2953EA ADD INDIRECT FAB POST SAME TOOTH$50 1 MEMBERSMEMBERS ADADESCRIPTIONCOPAYMENTADADESCRIPTIONCOPAYMENT D2954PREFABR POST&CORE ADDITION CROWN $30REMOVEABLE PROSTHODONTICS SERVICES* D2955POST REMOVAL $10D5211MAX PARTIAL DENTURE - RESIN BASE $325 D2957EA ADD PREFABR POST - SAME TOOTH $30D5212MAND PARTIAL DENTUR - RESIN BASE $325 D2970TEMPORARY CROWN $0D5213MAX PART DENTUR-CAST METL W/RSN $425 D2971ADD PROC NEW CROWN XST PART DENTURE$50D5214MAND PART DENTUR- CAST METL W/RSN $425 ENDODONTIC SERVICESD5225MAXILLARY PARTIAL DENTURE FLEX BASE$425 D3110PULP CAP - DIRECT $5D5226MANDIBULAR PART DENTURE FLEX BASE $425 D3120PULP CAP - INDIRECT $5D5281REMV UNI PART DENTUR-1 PC CAST METL$300 D3220TX PULPOT-CORONL DENTNOCEMENTL JUNC$5D5410ADJUST COMPLETE DENTURE - MAXILLARY$10 D3221PULPAL DEBRID PRIMARY&PERM TEETH $30D5411ADJUST COMPLETE DENTUR - MANDIBULAR$10 D3230PULPAL THERAPY - ANT PRIMARY TOOTH $40D5421ADJUST PARTIAL DENTURE - MAXILLARY $10 D3240PULPAL THERAPY - POST PRIMARY TOOTH$40D5422ADJUST PARTIAL DENTURE - MANDIBULAR$10 D3310ENDODONTIC THERAPY, ANTERIOR TOOTH(XCLD FINL REST) $125D5510REPAIR BROKEN COMPLETE DENTURE BASE$35 D3320ENDODONTIC THERAPY, BICUSPID TOOTH(XCLD FINL REST) $175D5520REPL MISS/BROKEN TEETH-CMPL DENTUR $35 D3330ENDODONTIC THERAPY, MOLAR(XCLD FINAL RESTORATION) $325D5610REPAIR RESIN DENTURE BASE $35 D3331TX RC OBSTRUCTION; NON-SURG ACCESS $85D5620REPAIR CAST FRAMEWORK $35 D3332INCMPL ENDO TX;INOP UNRSTR/FX TOOTH$85D5630REPAIR OR REPLACE BROKEN CLASP $35 D3333INTRL ROOT REPAIR PERFORATION DEFEC$85D5640REPLACE BROKEN TEETH - PER TOOTH $35 D3346RETX PREVIOUS RC THERAPY - ANTERIOR$145D5650ADD TOOTH EXISTING PARTIAL DENTURE $40 D3347RETX PREVIOUS RC THERAPY - BICUSPID$195D5660ADD CLASP EXISTING PARTIAL DENTURE $40 D3348RETX PREVIOUS RC THERAPY - MOLAR $345D5670REPL ALL TEETH&ACRYLC FRMEWRK MAX $150 D3351APEXIFICAT/RECALCIFICAT/PULPAL REGENERTN - INTIAL VST $70D5671REPL ALL TEETH&ACRYLC FRMEWRK MAND $150 D3352APEXIFICAT/RECALC/PULP REGEN-INTRM MED REPLACMNT $70D5710REBASE COMPLETE MAXILLARY DENTURE $75 D3353APEXIFICAT/RECALCIFICAT-FINAL VISIT$70D5711REBASE COMPLETE MANDIBULAR DENTURE $75 D3410APICOECT/PERIRADICULAR SURG - ANT $95D5720REBASE MAXILLARY PARTIAL DENTURE $75 D3421APICOECT/PERIRADICULR SURG-BICUSPID$95D5721REBASE MANDIBULAR PARTIAL DENTURE $75 D3425APICOECT/PERIRADICULAR SURG - MOLAR$95D5730RELINE CMPL MAXIL DENTURE CHAIRSIDE$55 D3426APICOECTOMY/PERIRADICULAR SURGERY $55D5731RELINE CMPL MAND DENTURE CHAIRSIDE $55 D3430RETROGRADE FILLING - PER ROOT $55D5740RELINE MAXIL PART DENTURE CHAIRSIDE$55 D3450ROOT AMPUTATION - PER ROOT $95D5741RELINE MAND PART DENTURE CHAIRSIDE $55 D3910SURG PROC ISOLAT TOOTH W/RUBBER DAM$15D5750RELINE CMPL MAXIL DENTURE LAB $75 D3920HEMISECTION NOT INCL RC THERAPY $90D5751RELINE CMPL MAND DENTRUE LABORATORY$75 D3950CANAL PREP&FIT PREFORMED DOWEL/POST$15D5760RELINE MAXIL PART DENTURE LAB $75 PERIODONTIC SERVICESD5761RELINE MAND PART DENTURE LABORATORY$75 D4210GINGIVECT/PLSTY 4/>CNTIG TEETH QUAD$130D5820INTERIM PARTIAL DENTURE MAXILLARY $145 D4211GINGIVECT/PLSTY 1-3CNTIG TEETH QUAD$85D5821INTERIM PARTIAL DENTURE MANDIBULAR $155 D4240GINGL FLP 4/>CNTIG/BOUND TEETH QUAD$150D5850TISSUE CONDITIONING MAXILLARY $20 D4241GINGL FLP 1-3 CNTIG/BND TEETH QUAD $110D5851TISSUE CONDITIONING MANDIBULAR $20 D4245APICALLY POSITIONED FLAP $165FIXED PROSTHODONTICS SERVICES* D4249CLIN CROWN LEN - HARD TISSUE $150D6210PONTIC - CAST HIGH NOBLE METAL* $250 D4260OSSEOUS SURG 4/> CNTIG TEETH QUAD $355D6211PONTIC - CAST PREDOM BASE METAL $250 D4261OSSEOUS SURG 1-3 CNTIG TEETH QUAD $275D6212PONTIC - CAST NOBLE METAL * $250 D4263BONE REPLCMT GRAFT - 1 SITE QUAD $205D6214PONTIC TITANIUM * $250 D4264BN REPLCMT GRAFT - EA ADD SITE QUAD$90D6240PONTIC-PORCELN FUSED HI NOBLE METL *$250 D4270PEDICLE SOFT TISSUE GRAFT PROCEDURE$235D6241PONTIC-PORCLN FUSD PREDOM BASE METL$250 D4271FREE SOFT TISSUE GRAFT PROCEDURE $235D6242PONTIC - PORCELN FUSED NOBLE METAL *$250 D4274DISTAL OR PROXIMAL WEDGE PROCEDURE $90D6245PONTIC - PORCELAIN/CERAMIC $300 D4341PRDNTL SCAL&ROOT PLAN 4/>TEETH-QUAD$55D6250PONTIC - RESIN W/HIGH NOBLE METAL * $250 D4342PRDONTAL SCAL&ROOT PLAN 1-3 TEETH $50D6251PONTIC RESIN W/PREDOM BASE METAL $250 D4355FULL MOUTH DEBRID COMP EVAL&DX $55D6252PONTIC RESIN W/NOBLE METAL * $250 D4381LOC DEL ANTIMICROBIAL AGT TOOTH BR $65D6600INLAY-PORCELAIN/CERAMIC 2 SURFACES $270 D4910PERIODONTAL MAINTENANCE $40D6601INLAY - PORCELN/CERAMIC 3/MORE SURF$270 D4920UNSCHEDULED DRESSING CHANGE $0D6602INLAY - CAST HI NOBLE METAL 2 SURF $185 REMOVEABLE PROSTHODONTICS SERVICES*D6603INLAY-CAST HI NOBLE METL 3/> SURF $185 D5110COMPLETE DENTURE - MAXILLARY $350D6604INLAY-CAST PREDOM BASE METL 2 SURF $185 D5120COMPLETE DENTURE - MANDIBULAR $350D6605INLAY-CAST PREDOM BASE METL 3/>SURF$185 D5130IMMEDIATE DENTURE - MAXILLARY $400D6606INLAY - CAST NOBLE METAL 2 SURFACES $185 D5140IMMEDIATE DENTURE - MANDIBULAR $400D6607INLAY - CAST NOBLE METL 3/MORE SURF $185 2 MEMBERSMEMBERS ADADESCRIPTIONCOPAYMENTADADESCRIPTIONCOPAYMENT FIXED PROSTHODONTICS SERVICES* ORAL SURGERY SERVICES D6608ONLAY - PORCELN/CERAMIC 2 SURFACES $280 D7473REMOVAL OF TORUS MANDIBULARIS $65 D6609ONLAY - PORCELN/CERAMIC 3/MORE SURF$280 D7485SURGICAL RDUC OSSEOUS TUBEROSITY $65 D6610ONLAY - CAST HI NOBLE METAL 2 SURF $185 D7510I&D ABSCESS-INTRAORAL SOFT TISS $35 D6611ONLAY-CAST HI NOBLE METL 3/> SURF $175 D7511I & D ABSC INTRAORAL SOFT TISS COMP$35 D6612ONLAY-CAST PREDOM BASE METL 2 SURF $175 D7910SUTURE RECENT SMALL WOUNDS UP 5 CM $25 D6613ONLAY-CAST PREDOM BASE METL 3/>SURF$175 D7960FRENULECTOMY-ALSO KNOWN AS FRENECTOMY OR FRE-$45 NOTOMY-SEPAR PROCED NOT INCIDENTAL TO ANOTHER D6614ONLAY - CAST NOBLE METAL 2 SURFACES$175 D7963FRENULOPLASTY $45 D6615ONLAY - CAST NOBLE METL 3/MORE SURF$175 D7970EXC HYPERPLASTIC TISSUE-PER ARCH $55 D6624INLAY TITANIUM $250 D7971EXCISION OF PERICORONAL GINGIVA $40 D6634ONLAY TITANIUM $250 D7972SURGICAL RDUC FIBROUS TUBEROSITY $100 D6720CROWN - RESIN WITH HIGH NOBLE METAL *$250 ADJUNCTIVE GENERAL SERVICES D6721CROWN RESIN PREDOM BASE METL-DENTUR$250 D9110PALLIATVE TX DENTAL PAIN-MINOR PROC$10 D6722CROWN - RESIN WITH NOBLE METAL * $250 D9211REGIONAL BLOCK ANESTHESIA $0 D6740CROWN - PORCELAIN/CERAMIC $300 D9212TRIGEMINAL DIVISION BLOCK ANES $0 D6750CRWN PORCLN FUSD HI NOBL MTL-DENTUR *$250 D9215LOCAL ANESTHESIA $0 D6751CROWN-PORCELN FUSD PREDOM BASE METL$250 D9220DP SEDATION/GEN ANES-1ST 30 MIN $155 D6752CROWN - PORCELAIN FUSED NOBLE METAL *$250 D9221DP SEDAT/GEN ANES-EA ADD 15 MIN $75 D6780CROWN - 3/4 CAST HIGH NOBLE METAL *$250 D9241IV CONSC SEDAT/ANALG -1ST 30 MIN $155 D6781CROWN-3/4 CAST PREDOM BASED METAL $250 D9242IV CONSC SEDAT/ANALG-EA ADD 15 MIN $70 D6782CROWN 3/4 CAST NOBLE METAL-DENTURE *$250 D9310CNSLT DX DENT/PHY NOT REQ DENT/PHY$0 D6783CROWN 3/4 PORCELAIN/CERAMIC-DENTURE$300 D9430OV OBS - NO OTH SERVICES PERFORMED $5 D6790CROWN FULL CAST HI NOBL METL-DENTUR *$250 D9440OV-AFTER REGULARLY SCHEDULED HRS $35 D6791CROWN FULL CAST BASE METAL-DENTURE $250 D9450CASE PRSATION DTL&EXT TX PLANNING $0 D6792CROWN FULL CAST NOBLE METAL-DENTURE *$250 D9930TREATMENT OF COMPLICATIONS - POST SURG.$0 D6794CROWN TITANIUM * $250 D9940OCCLUSAL GUARD BY REPORT $100 D6930RECEMENT FIXED PARTIAL DENTURE $0 D9951OCCLUSAL ADJUSTMENT - LIMITED $35 D6940STRESS BREAKER $125 D9952OCCLUSAL ADJUSTMENT - COMPLETE $90 D6970POST&CORE ADD FIX PART DENTURE RET $50 D9972EXTERNAL BLEACHING - PER ARCH $125 D6972PRFAB POST&COR ADD PART DENTUR RETN$30 D9999BROKEN APPOINTMENT$20 D6973CORE BUILD UP RETAIN INCL ANY PINS $20 ORTHODONTIC SERVICES D6976EA ADD INDIRECT FAB POST SAME TOOTH$50 D8070COMPREHENSIVE ORTHODONTIC TREATMENT TRANSI-$1,895 D6977EACH ADD PRFAB POST SAME TOOTH $50 TIONAL DENTITION ORAL SURGERY SERVICES D8080COMPREHENSIVE ORTHODONTIC TREATMENT ADOLES-$1,895 D7111XTRCT CORONL RMNNTS DECIDUOUS TOOTH$10 CENT DENTITION D7140EXTRAC ERUPTED TOOTH/EXPOSED ROOT $10 D8090COMPREHENSIVE ORTHODONTIC TREATMENT ADULT $1,895 D7210SURG REMOVAL ERUPTED TOOTH $30 DENTITION D7220REMOVAL IMPACT TOOTH - SOFT TISSUE $65 D8680ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, $300 D7230REMOVAL IMPACT TOOTH - PARTLY BONY $85 CONSTRUCTION, AND PLACEMENT OF RETAINERS) D7240REMOVAL IMPACTED TOOTH - CMPL BONY $125 D8999START-UP FEE (INCLUDING EXAM, BEGINNING RECORDS, $250 D7241REMV IMP TOOTH-CMPL BNY W/SURG COMP$150X-RAYS, TRACING, PHOTOS, AND MODELS D7250SURG REMOVAL RESIDUAL TOOTH ROOTS $40D8999POST TREATMENT RECORDS$150 D7270TOOTH REIMPL&/STBL ACC DISPLCD $50 D7280SURGICAL ACCESS AN UNERUPTED TOOTH $85 D7282MOBILZ ERUPT/MALPSTN TOOTH AID ERUP$90 D7285BIOPSY OF ORAL TISSUE HARD $150 D7286BIOPSY OF ORAL TISSUE SOFT $60 D7288BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION $0 D7310ALVEOLOPLASTY W/EXT 4/> TEETH/SPACE$40 D7311ALVEOLOPLSTY CONJNC XTRCT 1-3 TEETH$15 D7320ALVEOLOPLASTY NO EXT 4/> TEETH/SPAC$60 D7321ALVEOLOPLSTY NOT W/XTRCT 1-3 TEETH $25 D7471REMOVAL OF LATERAL EXOSTOSIS $85 D7472REMOVAL OF TORUS PALATINUS $65 1. Additional Prophy within 6 months will be based upon the necessity recommended by the provider. ce. xed bridges. When high noble metal is used, the Covered Person must pay: (a) the xed bridge; and (b) an added charge equal to the actual laboratory cost of the high noble metal, not to exceed $150. 3 All Specialty Referral Services Must Be: (A) Pre-Authorized by us; and Limitations of Bene Ð ts (B) Coordinated by a Covered Person’s PCD. Any Covered Person who elects specialist care without prior referral by his or her PCD and The following are the limitation of bene Ð ts, unless otherwise approval by us is responsible for all charges incurred speci Ð cally listed as a covered bene Ð t on this Plans Schedule of In order for specialty services to be Covered by this plan, the Bene Ð ts: following referral process must be followed: A Covered Person’s PCD must coordinate all Dental Services. Dental Prophylaxis - Limited to 1 time per 6 months When the care of a Network Specialist Dentist is required, Intraoral -Complete Series (including bitewings) - Limited to 1 time in any the Covered Person’s PCD must contact us and request 2 year period. authorization... Intraoral Bitewing Radiographs – Limited to 1 series of 4 ﬁ lms in any 6 If the PCD’s request for specialist referral is denied, the PCD month period and the Covered Person will be notiﬁ ed of the reason for the denial. If the service in question is a Covered service, and Fluoride Treatments – Limited to one time per calendar year no limitations or exclusions apply, the PCD may be asked to Scaling and Root Planing - Limited to 4 quadrants per calendar year. perform the service. Periodontal Maintenance - Limited to once every 6 months, following Covered Person who receives authorized specialty services active therapy, exclusive of gross debridement must pay all applicable Copayments associated with the Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays services provided. When we authorize specialty dental care, a (Major Restorative Services) - Replacement of complete dentures, Covered Person will be referred to a Network Specialist Dentist ﬁ xed or removable partial dentures, crowns, inlays or onlays previously for treatment. The Network includes Network Specialist Dentists submitted for payment under the plan is limited to 1 time per 5 years from in: (a) endodontics; (b) oral surgery; (c) pediatric dentistry; and initial or supplemental placement (d) orthodontics; and (e) periodontics, located in the Covered Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays Person’s Service Area. If there is no Network Specialist Dentist (Major Restorative Services) - Replacement of complete dentures, and in the Covered Person’s Service Area, we will refer the Covered ﬁ xed and removable partial dentures or crowns if damage or breakage Person to a Non-Participating Specialist of our choice. Except was directly related to provider error. This type of replacement is the for Emergency Dental Services, in no event will we cover dental responsibility of the Dentist. If replacement is Necessary because of care provided to a Covered Person by a specialist not pre- patient non-compliance, the patient is liable for the cost of replacement. authorized by us to provide such services. Crowns - Retainers/Abutments - Limited to 1 time per tooth per 5 years. Covered Person’s ﬁnancial responsibility is limited to applicable Copayments. Copayments are listed in the Covered Person’s Crowns – Restorations - Limited to 1 time per tooth per 5 years. Covered Schedule of Covered Dental Services. only when a ﬁ lling cannot restore the tooth. Temporary Crowns – Restorations - Limited to 1 time per tooth per 5 years. Covered only when a ﬁ lling cannot restore the tooth. Inlays/Onlays - Retainers/Abutments - Limited to 1 time per tooth per 5 years Inlays/Onlays – Restorations - Limited to 1 time per tooth per 5 years. Covered only when a ﬁ lling cannot restore the tooth... Stainless Steel Crowns - Limited to 1 time per tooth per 5 years. Covered only when a ﬁ lling cannot restore the tooth. Prefabricated esthetic coated stainless steel crown -primary tooth, are limited to primary anterior teeth. Crowns and ﬁ xed bridges, the maximum beneﬁ t within a 12-month period is any combination of 7 crowns or pontics (artiﬁ cial teeth that are part of a ﬁ xed bridge). If more than 7 crowns and/or pontics are done for a Member within a 12-month period, the dentist’s fee for any additional crowns within that period would not be limited to the listed Copayment, but instead can reﬂ ect the Dentist’s Billed Charges... Post and Cores - Covered only for teeth that have had root canal therapy. Adjustments to Full Dentures, Partial Dentures, Bridges or Crowns Limited to repairs or adjustments performed more than 6 months after the initial insertion. Intravenous Sedation or General Anesthesia - Administration of I.V. sedation or general anesthesia is limited to covered oral surgical procedures involving 1 or more impacted teeth (soft tissue, partial bony or complete bony impactions). Adjunctive Pre-Diagnostic Test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures - Limited to 1 time per year, to Covered Persons over the age of 30. 4 Dental Services received as a result of war or any act of war, whether Exclusion of Bene Ð ts declared or undeclared or caused during service in the armed forces of any country. The following procedures and services are excluded and not Relative analgesia (N2O2 - nitrous oxide) is not covered. Covered Services, unless otherwise speci Ð cally listed as a covered bene Ð t on this Plans Schedule of Bene Ð ts: Dental Services that are not Necessary Any Dental Services or Procedures not listed in the Schedule of Covered Dental Services Any Dental Procedure not performed in a participating dental setting. An exception is made for Emergency Dental Care, as deﬁ ned in this Evidence of Coverage. Any Dental Procedure not directly associated with dental disease. Procedures related to the reconstruction of a patient’s correct vertical dimension of occlusion (VDO) Any service done for cosmetic purposes that is not listed as a Covered cosmetic service in the Schedule of Covered Dental Services Costs for non-dental services related to the provision of dental services in hospitals, extended care facilities, or Member’s home are not covered. When deemed necessary by the Primary Care Dentist, the Member’s physician, and authorized by the Plan, covered dental services that are delivered in an inpatient or outpatient hospital setting are covered as indicated in the Schedule of Beneﬁ ts Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue. Replacement of a lost, missing or stolen appliance or prosthesis or the fabrication of a spare appliance or prosthesis Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays (Major Restorative Services) - The plan provides for the use of noble metals for inlays, onlays, crowns and ﬁ xed bridges. When high noble metal is used, the Covered Person must pay: (a) the Copayment for the inlay, onlay, crown or ﬁ xed bridge; and (b) an added charge equal to the actual laboratory cost of the high noble metal. Placement of ﬁ xed partial dentures solely for the purpose of achieving periodontal stability Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction Services for injuries or conditions covered by Worker’s Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare Dental Services otherwise Covered under the Contract, but rendered after the date individual Coverage under the Contract terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Contract terminates Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision. Any Covered Person request for: (a) specialist services or treatment which can be routinely provided by the PCD; or (b) treatment by a specialist without referral from the PCD and our approval Placement of dental implants, implant-supported abutments and prostheses Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental ofﬁ ce during the patient visit. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment. Any endodontic, periodontal, crown or bridge abutment procedure or appliance requested, recommended or performed for a tooth or teeth with a guarded, questionable or poor prognosis 5 Orthodontic Exclusions & Limitations If you require the services of an orthodontist, a referral must Ð rst be obtained. If a referral is not obtained prior to the commencement of orthodontic treatment, the member will be responsible for all costs associated with any orthodontic treatment. If you terminate coverage after the start of orthodontic treatment, you will be responsible for any additional charges incurred for the remaining orthodontic treatment. The following are not Covered orthodontic beneﬁ ts: Extractions required for orthodontic purposes Surgical orthodontics or jaw repositioning Myofunctional therapy Cleft palate Micrognathia Macroglossia Hormonal imbalances Orthodontic retreatment when initial treatment was rendered under this plan or for changes in orthodontic treatment necessitated by any kind of accident Palatal expansion appliances Replacement or repair of lost, stolen or broken appliances or appliances damaged due to the neglect of the Covered Person If a treatment plan is for less than 24 months, then a prorated portion of the full Copayment shall apply. If Covered Person’s dental eligibility ends, for whatever reason, and the Covered Person is receiving orthodontic treatment under the plan, the remaining cost for that treatment will be prorated at the orthodontist’s usual fees over the number of months of treatment remaining. The Covered Person will be responsible for the payment of this balance under the terms and conditions pre-arranged with the orthodontist. If the Covered Person has the orthodontist perform a “diagnostic work-up” (a consultation and diagnosis) and then decides to forgo the treatment program, the Covered Person will be charged a $50 consultation fee, plus any lab costs incurred by the orthodontist. One orthodontic beneﬁ t under this plan is available per lifetime, per Covered Person. A Covered Person may access this beneﬁ t for either Interceptive Orthodontic Treatment or Comprehensive Orthodontic Treatment, or both. If both interceptive treatment and comprehensive treatment are necessary, and both are completed within a 24 month period, the Copayments listed will apply. If both are necessary and active treatment for both extends beyond 24 months, the provider is obligated to accept the plan Copayment only for the ﬁ rst 24 months of active therapy. The provider may charge usual and customary fees for active treatment extending beyond the 24 month beneﬁ t period. 6