Common use of Supplemental Dental Expense Benefits Clause in Contracts

Supplemental Dental Expense Benefits. We Cover the following dental care services for members 19 years of age and older. Please refer to the Schedule of Benefits for Cost-Sharing requirements. Prophylaxis: Limited to a total of one prophylaxis or periodontal maintenance procedures (considered under Periodontal Services) in any six consecutive month period. Allowance includes scaling and polishing procedures to remove coronal plaque, calculus and stains. Also see Periodontal Maintenance under Group III Services. Additional prophylaxis when needed as a result of a medical (i.e., a non-dental) condition: Covered once in any 12 consecutive month period, and only when the additional prophylaxis is recommended by the Dentist and is a result of a medical condition as verified in writing by the Member's medical physician. This does not include a condition which could be resolved by proper oral hygiene or that is the result of patient neglect. Comprehensive oral evaluation – limited to once every 36 consecutive months per Dentist. All office visits, oral evaluations, examinations or limited problem focused re- evaluations: Limited to a total of one in any six consecutive month period. Detailed and extensive oral evaluations are not covered. Limited oral evaluation – problem focused or emergency oral evaluation: Limited to a total of one in any six consecutive month period. After-hours office visit or emergency palliative treatment. Allowance includes evaluation and diagnosis. Full mouth, complete series or panoramic radiograph: Either but not both of the following procedures, limited to one in any 60 consecutive month period. • Full mouth series, of at least 14 images including bitewings. • Panoramic image, maxilla and mandible, with or without bitewing radiographs. Bitewing images: Limited to either a maximum of four bitewing images or a set (seven - eight images) of vertical bitewings, in one visit, once in any 12 consecutive month period. Intraoral periapical or occlusal images- single images. Multiple restorations on one surface will be considered one restoration. Replacement of existing amalgam and resin restorations will only be covered if 36 months has passed since the previous restoration was placed if the member is age 19 or older. Amalgam restorations: Allowance includes bonding agents, liners, bases, polishing and local anesthetic. Resin restorations: Limited to Anterior Teeth only. Coverage for resins on Posterior Teeth is limited to the corresponding amalgam benefit. Allowance includes light curing, acid etching, adhesives, including resin bonding agents, and local anesthetic. Prefabricated stainless steel crown, prefabricated resin crown and resin composite crown: Limited to once per tooth in any 24 consecutive month period. Prefabricated stainless steel crowns, prefabricated resin crowns and resin based composite crowns are considered to be a temporary or provisional procedure when done within 24 months of a permanent crown. Temporary and provisional crowns are considered to be part of the permanent restoration. Pin retention, per tooth: Covered only in conjunction with a permanent amalgam or composite restoration, exclusive of restorative material. Allowance includes examination and diagnosis. Consultations: Diagnostic consultation with a Dentist other than the one providing treatment, limited to one consultation for each Covered Dental Specialty in any 12 consecutive month period. This dental Policy covers a consultation only when no other treatment, other than radiographs, is performed during the visit. Diagnostic casts when needed to prepare a treatment plan for three or more of the following performed at the same time in more than one arch: (1) dentures; (2) crowns;

Supplemental Dental Expense Benefits. We Cover the following dental care services for members 19 years of age and older. Please refer to the Schedule of Benefits for Cost-Sharing requirements. Prophylaxis: Limited to a total of one prophylaxis or periodontal maintenance procedures (considered under Periodontal Services) in any six consecutive month period. Allowance includes scaling and polishing procedures to remove coronal plaque, calculus and stains. Also see Periodontal Maintenance under Group III II Services. Additional prophylaxis when needed as a result of a medical (i.e., a non-dental) condition: Covered once in any 12 consecutive month period, and only when the additional prophylaxis is recommended by the Dentist and is a result of a medical condition as verified in writing by the Member's medical physician. This does not include a condition which could be resolved by proper oral hygiene or that is the result of patient neglect. Comprehensive oral evaluation – limited to once every 36 consecutive months per Dentist. All office visits, oral evaluations, examinations or limited problem focused re- evaluations: Limited to a total of one in any six consecutive month period. Detailed and extensive oral evaluations are not covered. Limited oral evaluation – problem focused or emergency oral evaluation: Limited to a total of one in any six consecutive month period. After-hours office visit or emergency palliative treatment. Allowance includes evaluation and diagnosis. Full mouth, complete series or panoramic radiograph: Either but not both of the following procedures, limited to one in any 60 consecutive month period. • Full mouth series, of at least 14 images including bitewings. • Panoramic image, maxilla and mandible, with or without bitewing radiographs. Bitewing images: Limited to either a maximum of four bitewing images or a set (seven - eight images) of vertical bitewings, in one visit, once in any 12 consecutive month period. Intraoral periapical or occlusal images- single images. Multiple restorations on one surface will be considered one restoration. Replacement of existing amalgam and resin restorations will only be covered if 36 months has passed since the previous restoration was placed if the member is age 19 or older. Amalgam restorations: Allowance includes bonding agents, liners, bases, polishing and local anesthetic. Resin restorations: Limited to Anterior Teeth only. Coverage for resins on Posterior Teeth is limited to the corresponding amalgam benefit. Allowance includes light curing, acid etching, adhesives, including resin bonding agents, and local anesthetic. Prefabricated stainless steel crown, prefabricated resin crown and resin composite crown: Limited to once per tooth in any 24 consecutive month period. Prefabricated stainless steel crowns, prefabricated resin crowns and resin based composite crowns are considered to be a temporary or provisional procedure when done within 24 months of a permanent crown. Temporary and provisional crowns are considered to be part of the permanent restoration. Pin retention, per tooth: Covered only in conjunction with a permanent amalgam or composite restoration, exclusive of restorative material. Allowance includes examination and diagnosis. Consultations: Diagnostic consultation with a Dentist other than the one providing treatment, limited to one consultation for each Covered Dental Specialty in any 12 consecutive month period. This dental Policy covers a consultation only when no other treatment, other than radiographs, is performed during the visit. Diagnostic casts when needed to prepare a treatment plan for three or more of the following performed at the same time in more than one arch: (1) dentures; (2) crowns;