Common use of Covered Dental Care Services Clause in Contracts

Covered Dental Care Services. This plan covers dentally necessary services and medically necessary orthodontic services (braces) up to the benefit limit provided below. See the Summary of Medical Benefits for the amount you pay. • Oral Evaluations - two (2) examinations per plan year; examinations include the initial or periodic examination, or an emergency oral evaluation, when performed by a general dentist, including diagnosis and charting. • X-rays - four (4) single x-rays per plan year; two (2) sets of bitewings per plan year; and one full mouth series (FMX) or panorex per 60-month period. • Cleanings (Prophylaxis) - two (2) cleanings per plan year. • Fluoride Treatments - two (2) fluoride treatments per plan year. • Sealants - permanent molars only; one sealant per tooth in a 36-month period. • Space Maintainers. • Palliative Treatment - two (2) visits for minor treatment to relieve sudden, intense pain per plan year. • Fillings. • Simple Extractions - the removal of an erupted tooth (non-surgical). • Denture Repairs and Relines/Rebasing - full or partial denture repairs, relines, and rebasing are limited to once in a 36-month period. • Crowns & Onlays - replacement is limited to once in a 60-month period; predetermination is recommended. • Therapeutic Pulpotomies. • Root Canal Therapy. • Non-Surgical Periodontal Services. • Surgical Periodontal Services - predetermination is recommended. • Periodontal Maintenance - two (2) services in a plan year. • Fixed Bridges and Dentures - replacements are limited to one (per tooth/unit) in a 60-month period; crowns over implants are considered a prosthodontic service; predetermination is recommended. • Dental Implants - replacements are limited to one (1) in a 60-month period; predetermination is recommended. • Oral Surgery Services. • Occlusal (Night) guards - one (1) occlusal (night) guard in a 12-month period; occlusal (night) guard adjustments are covered once in a twenty-four (24) month period. • Orthodontic Services (Braces) - only medically necessary braces are covered; predetermination is recommended. • General Anesthesia or IV Sedation in a Dental Office - covered as a separate benefit when performed in conjunction with covered oral surgery procedure(s) in accordance with our dental policies and related treatment guidelines. • Biopsies - limited to the biopsy and examination of oral tissue, soft or hard. Multi-Stage Procedures This plan covers multi-stage procedures that have a start date before the effective date of this plan if: • the multi-stage procedures have a completion date after the effective date of this plan; and • the multi-stage procedures are covered dental care services. Subject to any plan year or other benefit limits, this plan will pay up to our allowance less any benefits paid or payable under any previous plan for multi- stage procedures. Predeterminations A predetermination is not a requirement in order for planned covered dental care service to be covered. However, if you decide to have the dental service when the predetermination indicates the service is not covered, you will be responsible for the cost of the dental service. Network providers may request predeterminations for covered dental care services such as multiple restorations, periodontics (treatment of gums), prosthodontics (bridges and dentures), and orthodontics.

Covered Dental Care Services. This plan covers dentally necessary services and medically necessary orthodontic services (braces) up to the benefit limit provided below. See the Summary of Medical Benefits for the amount you pay. • Oral Evaluations - two (2) examinations per plan year; examinations include the initial or periodic examination, or an emergency oral evaluation, when performed by a general dentist, including diagnosis and charting. • X-rays - four (4) single x-rays per plan year; two (2) sets of bitewings per plan year; and one full mouth series (FMX) or panorex per 60-month period. • Cleanings (Prophylaxis) - two (2) cleanings per plan year. • Fluoride Treatments - two (2) fluoride treatments per plan year. • Sealants - permanent molars only; one sealant per tooth in a 36-month period. • Space Maintainers. • Palliative Treatment - two (2) visits for minor treatment to relieve sudden, intense pain per plan year. • Fillings. • Simple Extractions - the removal of an erupted tooth (non-surgical). • Denture Repairs and Relines/Rebasing - full or partial denture repairs, relines, and rebasing are limited to once in a 36-month period. • Crowns & Onlays - replacement is limited to once in a 60-month period; predetermination is recommended. • Therapeutic Pulpotomies. • Root Canal Therapy. • Non-Surgical Periodontal Services. • Surgical Periodontal Services - predetermination is recommended. • Periodontal Maintenance - two (2) services in a plan year. • Fixed Bridges and Dentures - replacements are limited to one (per tooth/unit) in a 60-month period; crowns over implants are considered a prosthodontic service; predetermination is recommended. • Dental Implants - replacements are limited to one (1) in a 60-month period; predetermination is recommended. • Oral Surgery Services. • Occlusal (Night) guards - one (1) occlusal (night) guard in a 12-month period; occlusal (night) guard adjustments are covered once in a twenty-four (24) month period. • Orthodontic Services (Braces) - only medically necessary braces are covered; predetermination is recommended. • General Anesthesia or IV Sedation in a Dental Office - covered as a separate benefit when performed in conjunction with covered oral surgery procedure(s) in accordance with our dental policies and related treatment guidelines. • Biopsies - limited to the biopsy and examination of oral tissue, soft or hard. Multi-Stage Procedures This plan covers multi-stage procedures that have a start date before the effective date of this plan if: • the multi-stage procedures have a completion date after the effective date of this plan; and • the multi-stage procedures are covered dental care services. Subject to any plan year or other benefit limits, this plan will pay up to our allowance less any benefits paid or payable under any previous plan for multi- stage procedures. Predeterminations A predetermination is not a requirement in order for planned covered dental care service to be covered. However, if you decide to have the dental service when the predetermination indicates the service is not covered, you will be responsible for the cost of the dental service. This is true whether you have the service rendered by a network provider or non-network provider. Network providers may request predeterminations for covered dental care services such as multiple restorations, periodontics (treatment of gums), prosthodontics (bridges and dentures), and orthodontics. If your dentist is a non-network provider, you or your dentist may request predeterminations for covered dental care services by calling Blue Cross Dental Customer Service listed in the Contact Information section.

Covered Dental Care Services. This plan covers dentally necessary services and medically necessary orthodontic services (braces) up to the benefit limit provided below. See the Summary of Medical Benefits for the amount you pay. •  Oral Evaluations - two (2) examinations per plan year; examinations include the initial or periodic examination, or an emergency oral evaluation, when performed by a general dentist, including diagnosis and charting. •  X-rays - four (4) single x-rays per plan year; two (2) sets of bitewings per plan year; and one full mouth series (FMX) or panorex per 60-month period. •  Cleanings (Prophylaxis) - two (2) cleanings per plan year. •  Fluoride Treatments - two (2) fluoride treatments per plan year. •  Sealants - permanent molars only; one sealant per tooth in a 36-month period. •  Space Maintainers. •  Palliative Treatment - two (2) visits for minor treatment to relieve sudden, intense pain per plan year. •  Fillings. •  Simple Extractions - the removal of an erupted tooth (non-surgical). •  Denture Repairs and Relines/Rebasing - full or partial denture repairs, relines, and rebasing are limited to once in a 36-month period. •  Crowns & Onlays - replacement is limited to once in a 60-month period; predetermination is recommended. •  Therapeutic Pulpotomies. •  Root Canal Therapy. •  Non-Surgical Periodontal Services. •  Surgical Periodontal Services - predetermination is recommended. •  Periodontal Maintenance - two (2) services in a plan year. •  Fixed Bridges and Dentures - replacements are limited to one (per tooth/unit) in a 60-month period; crowns over implants are considered a prosthodontic service; predetermination is recommended. •  Dental Implants - replacements are limited to one (1) in a 60-month period; predetermination is recommended. •  Oral Surgery Services. •  Occlusal (Night) guards - one (1) occlusal (night) guard in a 12-month period; occlusal (night) guard adjustments are covered once in a twenty-four (24) month period. •  Orthodontic Services (Braces) - only medically necessary braces are covered; predetermination is recommended. •  General Anesthesia or IV Sedation in a Dental Office - covered as a separate benefit when performed in conjunction with covered oral surgery procedure(s) in accordance with our dental policies and related treatment guidelines. •  Biopsies - limited to the biopsy and examination of oral tissue, soft or hard. Multi-Stage Procedures This plan covers multi-stage procedures that have a start date before the effective date of this plan if: •  the multi-stage procedures have a completion date after the effective date of this plan; and •  the multi-stage procedures are covered dental care services. Subject to any plan year or other benefit limits, this plan will pay up to our allowance less any benefits paid or payable under any previous plan for multi- stage procedures. Predeterminations A predetermination is not a requirement in order for planned covered dental care service to be covered. However, if you decide to have the dental service when the predetermination indicates the service is not covered, you will be responsible for the cost of the dental service. This is true whether you have the service rendered by a network provider or non-network provider. Network providers may request predeterminations for covered dental care services such as multiple restorations, periodontics (treatment of gums), prosthodontics (bridges and dentures), and orthodontics. If your dentist is a non-network provider, you or your dentist may request predeterminations for covered dental care services by calling Blue Cross Dental Customer Service listed in the Contact Information section.

Covered Dental Care Services. This plan covers dentally necessary services and medically necessary orthodontic services (braces) up to the benefit limit provided below. See the Summary of Medical Benefits for the amount you pay. •  Oral Evaluations - two (2) examinations per plan year; examinations include the initial or periodic examination, or an emergency oral evaluation, when performed by a general dentist, including diagnosis and charting. •  X-rays - four (4) single x-rays per plan year; two (2) sets of bitewings per plan year; and one full mouth series (FMX) or panorex per 60-month period. •  Cleanings (Prophylaxis) - two (2) cleanings per plan year. •  Fluoride Treatments - two (2) fluoride treatments per plan year. •  Sealants - permanent molars only; one sealant per tooth in a 36-month period. •  Space Maintainers. •  Palliative Treatment - two (2) visits for minor treatment to relieve sudden, intense pain per plan year. •  Fillings. •  Simple Extractions - the removal of an erupted tooth (non-surgical). •  Denture Repairs and Relines/Rebasing - full or partial denture repairs, relines, and rebasing are limited to once in a 36-month period. •  Crowns & Onlays - replacement is limited to once in a 60-month period; predetermination is recommended. •  Therapeutic Pulpotomies. •  Root Canal Therapy. •  Non-Surgical Periodontal Services. •  Surgical Periodontal Services - predetermination is recommended. •  Periodontal Maintenance - two (2) services in a plan year. •  Fixed Bridges and Dentures - replacements are limited to one (per tooth/unit) in a 60-month period; crowns over implants are considered a prosthodontic service; predetermination is recommended. •  Dental Implants - replacements are limited to one (1) in a 60-month period; predetermination is recommended. •  Oral Surgery Services. •  Occlusal (Night) guards - one (1) occlusal (night) guard in a 12-month period; occlusal (night) guard adjustments are covered once in a twenty-four (24) month period. •  Orthodontic Services (Braces) - only medically necessary braces are covered; predetermination is recommended. •  General Anesthesia or IV Sedation in a Dental Office - covered as a separate benefit when performed in conjunction with covered oral surgery procedure(s) in accordance with our dental policies and related treatment guidelines. •  Biopsies - limited to the biopsy and examination of oral tissue, soft or hard. Multi-Stage Procedures This plan covers multi-stage procedures that have a start date before the effective date of this plan if: •  the multi-stage procedures have a completion date after the effective date of this plan; and •  the multi-stage procedures are covered dental care services. Subject to any plan year or other benefit limits, this plan will pay up to our allowance less any benefits paid or payable under any previous plan for multi- stage procedures. Predeterminations A predetermination is not a requirement in order for planned covered dental care service to be covered. However, if you decide to have the dental service when the predetermination indicates the service is not covered, you will be responsible for the cost of the dental service. Network providers may request predeterminations for covered dental care services such as multiple restorations, periodontics (treatment of gums), prosthodontics (bridges and dentures), and orthodontics.

Covered Dental Care Services. This plan covers dentally necessary services and medically necessary orthodontic services (braces) up to the benefit limit provided below. See the Summary of Medical Benefits for the amount you pay. •  Oral Evaluations - two (2) examinations per plan year; examinations include the initial or periodic examination, or an emergency oral evaluation, when performed by a general dentist, including diagnosis and charting. •  X-rays - four (4) single x-rays per plan year; two (2) sets of bitewings per plan year; and one full mouth series (FMX) or panorex per 60-month period. •  Cleanings (Prophylaxis) - two (2) cleanings per plan year. •  Fluoride Treatments - two (2) fluoride treatments per plan year. •  Sealants - permanent molars only; one sealant per tooth in a 36-month period. •  Space Maintainers. •  Palliative Treatment - two (2) visits for minor treatment to relieve sudden, intense pain per plan year. •  Fillings. •  Simple Extractions - the removal of an erupted tooth (non-surgical). •  Denture Repairs and Relines/Rebasing - full or partial denture repairs, relines, and rebasing are limited to once in a 36-month period. •  Crowns & Onlays - replacement is limited to once in a 60-month period; predetermination is recommended. •  Therapeutic Pulpotomies. •  Root Canal Therapy. •  Non-Surgical Periodontal Services. •  Surgical Periodontal Services - predetermination is recommended. •  Periodontal Maintenance - two (2) services in a plan year. •  Fixed Bridges and Dentures - replacements are limited to one (per tooth/unit) in a 60-month period; crowns over implants are considered a prosthodontic service; predetermination is recommended. •  Dental Implants - replacements are limited to one (1) in a 60-month period; predetermination is recommended. •  Oral Surgery Services. •  Occlusal (Night) guards - one (1) occlusal (night) guard in a 12-month period; occlusal (night) guard adjustments are covered once in a twenty-four (24) month period. •  Orthodontic Services (Braces) - only medically necessary braces are covered; predetermination is recommended. •  General Anesthesia or IV Sedation in a Dental Office - covered as a separate benefit when performed in conjunction with covered oral surgery procedure(s) in accordance with our dental policies and related treatment guidelines. •  Biopsies - limited to the biopsy and examination of oral tissue, soft or hard. Multi-Stage Procedures This plan covers multi-stage procedures that have a start date before the effective date of this plan if: •  the multi-stage procedures have a completion date after the effective date of this plan; and •  the multi-stage procedures are covered dental care services. Subject to any plan year or other benefit limits, this plan will pay up to our allowance less any benefits paid or payable under any previous plan for multi- multi-stage procedures. Predeterminations A predetermination is not a requirement in order for planned covered dental care service to be covered. However, if you decide to have the dental service when the predetermination indicates the service is not covered, you will be responsible for the cost of the dental service. In-Network providers may request predeterminations for covered dental care services such as multiple restorations, periodontics (treatment of gums), prosthodontics (bridges and dentures), and orthodontics.

Covered Dental Care Services. This plan covers dentally necessary services and medically necessary orthodontic services (braces) up to the benefit limit provided below. See the Summary of Medical Benefits for the amount you pay. • Oral Evaluations - two (2) examinations per plan year; examinations include the initial or periodic examination, or an emergency oral evaluation, when performed by a general dentist, including diagnosis and charting. • X-rays - four (4) single x-rays per plan year; two (2) sets of bitewings per plan year; and one full mouth series (FMX) or panorex per 60-month period. • Cleanings (Prophylaxis) - two (2) cleanings per plan year. • Fluoride Treatments - two (2) fluoride treatments per plan year. • Sealants - permanent molars only; one sealant per tooth in a 36-month period. • Space Maintainers. • Palliative Treatment - two (2) visits for minor treatment to relieve sudden, intense pain per plan year. • Fillings. • Simple Extractions - the removal of an erupted tooth (non-surgical). • Denture Repairs and Relines/Rebasing - full or partial denture repairs, relines, and rebasing are limited to once in a 36-month period. • Crowns & Onlays - replacement is limited to once in a 60-month period; predetermination is recommended. • Therapeutic Pulpotomies. • Root Canal Therapy. • Non-Surgical Periodontal Services. • Surgical Periodontal Services - predetermination is recommended. • Periodontal Maintenance - two (2) services in a plan year. • Fixed Bridges and Dentures - replacements are limited to one (per tooth/unit) in a 60-month period; crowns over implants are considered a prosthodontic service; predetermination is recommended. • Dental Implants - replacements are limited to one (1) in a 60-month period; predetermination is recommended. • Oral Surgery Services. • Occlusal (Night) guards - one (1) occlusal (night) guard in a 12-month period; occlusal (night) guard adjustments are covered once in a twenty-four (24) month period. • Orthodontic Services (Braces) - only medically necessary braces are covered; predetermination is recommended. • General Anesthesia or IV Sedation in a Dental Office - covered as a separate benefit when performed in conjunction with covered oral surgery procedure(s) in accordance with our dental policies and related treatment guidelines. • Biopsies - limited to the biopsy and examination of oral tissue, soft or hard. Multi-Stage Procedures This plan covers multi-stage procedures that have a start date before the effective date of this plan if: • the multi-stage procedures have a completion date after the effective date of this plan; and • the multi-stage procedures are covered dental care services. Subject to any plan year or other benefit limits, this plan will pay up to our allowance less any benefits paid or payable under any previous plan for multi- multi-stage procedures. Predeterminations A predetermination is not a requirement in order for planned covered dental care service to be covered. However, if you decide to have the dental service when the predetermination indicates the service is not covered, you will be responsible for the cost of the dental service. In-Network providers may request predeterminations for covered dental care services such as multiple restorations, periodontics (treatment of gums), prosthodontics (bridges and dentures), and orthodontics.