State of Arizona



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Prepaid Dental


Good news about dental benefits for employees of

State of Arizona


A Dental Plan Means Healthy Smiles

Because you are a valued employee, Assurant Employee Benefits* is pleased to offer you the opportunity to enroll in a dental benefit plan provided by United Dental Care of Arizona, Inc. and administered by Union Security Insurance Company. This prepaid dental plan offers benefits through a network of Plan Dentists. When you enroll for benefits, treatments you receive from your selected Plan Dentist will be provided at reduced fees called copayments. For your information, a partial list of frequently used dental treatments is included.

Plan Features


  • No Deductibles

  • No Waiting Periods

  • Coverage for Pre-existing Conditions

  • No Claim Forms to File for Plan Dentist and Plan Specialist Services

  • No Referrals Required for Specialist Services

  • No Annual Maximum for Plan Dentist and Plan Specialist Services

Important Enrollment Information

To enroll, just follow three simple steps:



  1. Select a general dentist from the Directory of Dentists for yourself and every eligible member of your family. Each family member may choose a different Plan Dentist. You must select a Plan Dentist to receive services. Except for certain specialist services, all services must be performed by this selected Plan Dentist. You may change your Plan Dentist(s) throughout the Plan Year in accordance with the provisions of the group agreement. However, all services must be performed by a Plan Provider.

  2. Complete the enclosed enrollment form, being sure to include the Dental Facility Number of each Plan Dentist selected.

  3. Return your completed enrollment form to your Personnel Department or Benefits Manager authorizing payroll deductions for your coverage.

Finding a Provider

You can find a dental provider in the Heritage Series Provider Network by visiting the Assurant Employee Benefits web site at www.assurantemployeebenefits.com, clicking on the “Provider Search” link, and then selecting Heritage Series. Availability of Plan Dentists and Plan Specialists varies depending on location.





If you have any questions, call Customer Service at 800.443.2995.

*
Prepaid - page 1


Benefits are provided by United Dental Care of Arizona, Inc., marketed by Assurant Employee Benefits, and administered by Union Security Insurance Company.

Savings You Can See



The following is a list of commonly used dental treatments. It is not the Evidence of Coverage. After you enroll, a complete list of copayments will be provided to you along with your Evidence of Coverage.




Plus Plan

1. Plan Dentist Services


The dental services listed in the following schedule are covered only when provided by the Member's selected Plan Dentist. The Member will be responsible for paying the amount listed in the "Member Copayment" column (plus any applicable lab fees*) at the time the service is received, or in accordance with the selected Plan Dentist's billing procedures. To fully understand the benefits, exclusions and limitations of this plan, the Member should consult the Evidence of Coverage.

Services marked with a single asterisk (*) below also require separate payment of laboratory charges. The laboratory charges must be paid to the Plan Dentist in addition to any applicable copayment for the service.



Payment for each service of a Non-Plan Dentist (at that dentist's normal retail charge) is the responsibility of the Member, except for limited Plan Benefits for covered dental Emergency Services for temporary pain relief.

2. Plan Specialist Services


See the enclosed Specialty Benefit Amendment Copayment Schedule.







ADA
Code** Service Description**


Member
Copayment


Appointments

None Office visit - during regularly scheduled hours*** 10.00

D0120 Periodic oral evaluation No Charge

(may only be obtained once in any six calendar months, except for medically necessary more frequent prophylaxis as determined by Member's Plan Dentist)

D0140 Limited oral evaluation - problem focused 20.00

D0150 Comprehensive oral evaluation - new or established patient No Charge

(may only be obtained once in any six calendar months, except for medically necessary more frequent prophylaxis as determined by Member's Plan Dentist)

D0160 Detailed and extensive oral evaluation - problem focused, by report 15.00

D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) 15.00

D0180 Comprehensive periodontal evaluation - new or established patient 15.00

None Missed appointment without 24 hour notice*** 20.00

D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) 55.00

D9440 Office visit - after regularly scheduled hours 40.00

Diagnostic Dentistry

D0210 Intraoral - complete series (including bitewings) No Charge

(once in any 3 calendar years)

D0220 Intraoral - periapical first film No Charge

D0230 Intraoral - periapical each additional film No Charge

D0240 Intraoral - occlusal film No Charge

D0250 Extraoral - first film No Charge

D0260 Extraoral - each additional film No Charge

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0270 Bitewing - single film No Charge

D0272 Bitewings - two films No Charge

(may only be obtained once in any six calendar months, except for medically necessary more frequent prophylaxis as determined by Member's Plan Dentist)

D0274 Bitewings - four films No Charge

(may only be obtained once in any six calendar months, except for medically necessary more frequent prophylaxis as determined by Member's Plan Dentist)

D0277 Vertical bitewings - 7 to 8 films No Charge

D0330 Panoramic film 5.00

(once in any 3 calendar years)

D0415 Collection of microorganisms for culture and sensitivity No Charge

D0425 Caries susceptibility tests No Charge

D0460 Pulp vitality tests No Charge

Preventive Dentistry

D1110 Prophylaxis - adult 5.00

(may only be obtained once in any six calendar months, except for medically necessary more frequent prophylaxis as determined by Member's Plan Dentist)

D1120 Prophylaxis - child 5.00

(may only be obtained once in any six calendar months, except for medically necessary more frequent prophylaxis as determined by Member's Plan Dentist)

D1203 Topical application of fluoride (prophylaxis not included) - child No Charge

D1310 Nutritional counseling for control of dental disease No Charge

D1330 Oral hygiene instructions No Charge

D1351 Sealant - per tooth 15.00

D1510 Space maintainer - fixed - unilateral* 70.00

D1515 Space maintainer - fixed - bilateral* 70.00

D1520 Space maintainer - removable - unilateral* 90.00

D1525 Space maintainer - removable - bilateral* 105.00

D1550 Re-cementation of space maintainer 15.00

None Additional prophylaxis (D1110 or D1120 service does not apply to patients with periodontal disease)*** 30.00

Restorative Dentistry

D2140 Amalgam - one surface, primary or permanent 20.00

D2150 Amalgam - two surfaces, primary or permanent 25.00

D2160 Amalgam - three surfaces, primary or permanent 35.00

D2161 Amalgam - four or more surfaces, primary or permanent 45.00

D2330 Resin-based composite - one surface, anterior 35.00

D2331 Resin-based composite - two surfaces, anterior 45.00

D2332 Resin-based composite - three surfaces, anterior 55.00

D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) 70.00

D2391 Resin-based composite - one surface, posterior 75.00

D2392 Resin-based composite - two surfaces, posterior 80.00

D2393 Resin-based composite - three surfaces, posterior 95.00

D2394 Resin-based composite - four or more surfaces, posterior 110.00

D2510 Inlay - metallic - one surface* 230.00

D2520 Inlay - metallic - two surfaces* 255.00

D2530 Inlay - metallic - three or more surfaces* 285.00

D2542 Onlay - metallic - two surfaces* 280.00

D2543 Onlay - metallic - three surfaces* 295.00

D2544 Onlay - metallic - four or more surfaces* 320.00

D2610 Inlay - porcelain/ceramic one surface* 265.00

D2620 Inlay - porcelain/ceramic two surfaces* 285.00

D2630 Inlay - porcelain/ceramic three or more surfaces* 305.00

D2740 Crown - porcelain/ceramic substrate* 265.00

D2750 Crown - porcelain fused to high noble metal* 265.00

D2751 Crown - porcelain fused to predominantly base metal* 265.00

D2752 Crown - porcelain fused to noble metal* 265.00

D2790 Crown - full cast high noble metal* 265.00

D2791 Crown - full cast predominantly base metal* 265.00

D2792 Crown - full cast noble metal* 265.00

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2910 Recement inlay, onlay, or partial coverage restoration 20.00

D2920 Recement crown 20.00

D2930 Prefabricated stainless steel crown - primary tooth 80.00

D2940 Sedative filling 25.00

D2950 Core buildup, including any pins 50.00

D2951 Pin retention - per tooth, in addition to restoration 20.00

D2952 Cast post and core in addition to crown* 110.00

D2954 Prefabricated post and core in addition to crown 80.00

D2962 Labial veneer (porcelain laminate) - laboratory* 320.00

D2980 Crown repair, by report* 25.00

None Temporary filling*** 20.00

Endodontics

D3110 Pulp cap - direct (excluding final restoration) 15.00

D3120 Pulp cap - indirect (excluding final restoration) 10.00

D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application
of medicament 40.00

D3310 Anterior (excluding final restoration) 125.00

D3320 Bicuspid (excluding final restoration) 220.00

D3330 Molar (excluding final restoration) 275.00

D3346 Retreatment of previous root canal therapy - anterior 325.00

D3347 Retreatment of previous root canal therapy - bicuspid 385.00

D3348 Retreatment of previous root canal therapy - molar 465.00

D3410 Apicoectomy/periradicular surgery - anterior 150.00

D3421 Apicoectomy/periradicular surgery - bicuspid (first root) 180.00

D3425 Apicoectomy/periradicular surgery - molar (first root) 220.00

D3426 Apicoectomy/periradicular surgery - (each additional root) 100.00

D3430 Retrograde filling - per root 55.00

D3450 Root amputation - per root 100.00

D3920 Hemisection (including any root removal), not including root canal therapy 100.00

Periodontics

D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant 150.00

D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant 65.00

D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant 140.00

D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant 100.00

D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant 350.00

D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant 203.00

D4320 Provisional splinting - intracoronal 125.00

D4321 Provisional splinting - extracoronal 95.00

D4341 Periodontal scaling and root planing - four or more teeth per quadrant 65.00

D4342 Periodontal scaling and root planing - one to three teeth per quadrant 39.00

D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis 75.00

D4910 Periodontal maintenance 45.00

None Periodontal hygiene instructions*** No Charge

Prosthodontics, removable

D5110 Complete denture - maxillary* 365.00

D5120 Complete denture - mandibular* 365.00

D5130 Immediate denture - maxillary* 400.00

D5140 Immediate denture - mandibular* 400.00

D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth)* 375.00

D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth)* 375.00

D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and
teeth)* 465.00

D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and
teeth)* 465.00

D5410 Adjust complete denture - maxillary 30.00

D5411 Adjust complete denture - mandibular 30.00

D5421 Adjust partial denture - maxillary 30.00

D5422 Adjust partial denture - mandibular 30.00

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5510 Repair broken complete denture base* 40.00

D5610 Repair resin denture base* 40.00

D5620 Repair cast framework* 70.00

D5630 Repair or replace broken clasp* 40.00

D5640 Replace broken teeth - per tooth* 40.00

D5650 Add tooth to existing partial denture* 40.00

D5730 Reline complete maxillary denture (chairside) 75.00

D5731 Reline complete mandibular denture (chairside) 75.00

D5740 Reline maxillary partial denture (chairside) 75.00

D5741 Reline mandibular partial denture (chairside) 75.00

D5750 Reline complete maxillary denture (laboratory)* 110.00

D5751 Reline complete mandibular denture (laboratory)* 110.00

D5760 Reline maxillary partial denture (laboratory)* 110.00

D5761 Reline mandibular partial denture (laboratory)* 110.00

D5850 Tissue conditioning, maxillary 50.00

D5851 Tissue conditioning, mandibular 50.00

D5862 Precision attachment, by report* 150.00

Prosthodontics, fixed

D6210 Pontic - cast high noble metal* 305.00

D6211 Pontic - cast predominantly base metal* 305.00

D6212 Pontic - cast noble metal* 305.00

D6240 Pontic - porcelain fused to high noble metal* 305.00

D6241 Pontic - porcelain fused to predominantly base metal* 305.00

D6242 Pontic - porcelain fused to noble metal* 305.00

D6251 Pontic - resin with predominantly base metal* 305.00

D6545 Retainer - cast metal for resin bonded fixed prosthesis* 140.00

D6721 Crown - resin with predominantly base metal* 305.00

D6750 Crown - porcelain fused to high noble metal* 305.00

D6751 Crown - porcelain fused to predominantly base metal* 305.00

D6752 Crown - porcelain fused to noble metal* 305.00

D6780 Crown - 3/4 cast high noble metal* 265.00

D6790 Crown - full cast high noble metal* 265.00

D6791 Crown - full cast predominantly base metal* 265.00

D6792 Crown - full cast noble metal* 265.00

D6930 Recement fixed partial denture 45.00

D6940 Stress breaker 150.00

D6950 Precision attachment 195.00

D6980 Fixed partial denture repair, by report* 50.00

None Resin bonded bridge pontic, per unit***(*) 235.00

Oral Surgery

D7111 Extraction, coronal remnants - deciduous tooth 20.00

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) 20.00

D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth 55.00

D7220 Removal of impacted tooth - soft tissue 65.00

D7230 Removal of impacted tooth - partially bony 80.00

D7240 Removal of impacted tooth - completely bony 100.00

D7241 Removal of impacted tooth - completely bony, with unusual surgical complications 135.00

D7250 Surgical removal of residual tooth roots (cutting procedure) 50.00

D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth 105.00

D7280 Surgical access of an unerupted tooth 100.00

D7310 Alveoloplasty in conjunction with extractions - per quadrant 100.00

D7320 Alveoloplasty not in conjunction with extractions - per quadrant 100.00

D7510 Incision and drainage of abscess - intraoral soft tissue 100.00

D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure 125.00

Other Services

D9220 Deep sedation/general anesthesia - first 30 minutes 185.00

D9230 Analgesia, anxiolysis, inhalation of nitrous oxide 15.00

D9241 Intravenous conscious sedation/analgesia - first 30 minutes 170.00

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9242 Intravenous conscious sedation/analgesia - each additional 15 minutes 30.00

D9940 Occlusal guard, by report* 85.00

D9951 Occlusal adjustment - limited 35.00

D9952 Occlusal adjustment - complete 170.00

Bleaching

D9972 External bleaching - per arch 155.00

This is a sample Member Copayment Schedule only. It is not an Evidence of Coverage. Please see the Group Dental Service Agreement, Evidence of Coverage, and Copayment Schedule, which determine all rights, benefits, and applicable limitations and exclusions.

Listed copayments apply only to Plan Dentists who perform the corresponding listed services. The Plan Dentist selected by the Member may not perform all listed services. Plan Specialists may not perform or offer all services listed. Availability and participation of Plan Dentists and Plan Specialists are subject to change.

**Current and prior versions of the Current Dental Terminology (CDT) codes (in the ADA Code column) and descriptors (in the Service Description column) are copyrighted by the American Dental Association (ADA) and are used by permission. Current Dental Terminology © American Dental Association.

***Service does not have an American Dental Association Current Dental Terminology code or descriptor.


Prepaid - page 6

Specialty Benefit Amendment

Copayment Schedule for the Heritage Series





How Your Specialty Benefit Amendment (SBA) Works


Should you need the services of a dental care specialist, you may receive those services without a referral from your Plan Dentist.
To find a Plan Specialist (SBA or Non-SBA), refer to the provider directory. SBA Plan Specialists are indicated with an "S". All other listed specialists are Non-SBA Plan Specialists. Or, you may visit the web site at www.assurantemployeebenefits.com (click on Provider Search, and then on Heritage Series). For more information about the SBA plan or for assistance in finding a Plan Specialist, call Customer Service at 800.443.2995.
If you use an SBA Plan Specialist (a specialist who is a part of the plan provider network and accepts SBA copayments) for a service listed on the schedule below, you will pay the corresponding Member Copayment shown in the “SBA Plan Specialist Copayment” column at the time of service.
All other services obtained from an SBA Plan Specialist, and all services obtained from a Non-SBA Plan Specialist (a specialist who is a part of the plan provider network but does not accept SBA copayments), will be provided to you at a reduction in that Plan Specialist’s normal retail charges. A 15% reduction applies if that Plan Specialist is an endodontist. A 25% reduction applies if that Plan Specialist is any other type of specialist, including but not limited to an orthodontist. You will be responsible for paying the entire reduced charge at the time of service or in accordance with that Plan Specialist’s billing procedures.
Payment for each service of a Non-Plan Specialist (a specialist who is not a part of the plan provider network), at that specialist’s normal retail charge, is your responsibility, except for limited Plan Benefits for covered dental emergency services for temporary pain relief.









ADA
Code** Service Description**


SBA Plan
Specialist Copayment


Appointments

D0140 Limited oral evaluation - problem focused 35.00

D0150 Comprehensive oral evaluation - new or established patient 45.00

(may only be obtained once in any six calendar months, except for medically necessary more frequent prophylaxis as determined by Member's Plan Dentist)

D0160 Detailed and extensive oral evaluation - problem focused, by report 67.00

D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) 35.00

D0180 Comprehensive periodontal evaluation - new or established patient 80.00

Endodontics

D3320 Bicuspid (excluding final restoration) 280.00

D3330 Molar (excluding final restoration) 395.00

D3346 Retreatment of previous root canal therapy - anterior 360.00

D3347 Retreatment of previous root canal therapy - bicuspid 525.00

D3348 Retreatment of previous root canal therapy - molar 545.00

D3410 Apicoectomy/periradicular surgery - anterior 265.00

D3421 Apicoectomy/periradicular surgery - bicuspid (first root) 280.00

D3425 Apicoectomy/periradicular surgery - molar (first root) 310.00

D3430 Retrograde filling - per root 90.00

Periodontics

D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant 355.00

D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant 100.00

D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant 495.00

D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant 215.00

D4341 Periodontal scaling and root planing - four or more teeth per quadrant 100.00

D4342 Periodontal scaling and root planing - one to three teeth per quadrant 70.00

D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis 80.00

Oral Surgery

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7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth 80.00

D7220 Removal of impacted tooth - soft tissue 105.00

D7230 Removal of impacted tooth - partially bony 135.00

D7240 Removal of impacted tooth - completely bony 200.00

D7241 Removal of impacted tooth - completely bony, with unusual surgical complications 220.00

D7250 Surgical removal of residual tooth roots (cutting procedure) 75.00

D7310 Alveoloplasty in conjunction with extractions - per quadrant 180.00

D7320 Alveoloplasty not in conjunction with extractions - per quadrant 130.00

D7510 Incision and drainage of abscess - intraoral soft tissue 105.00

D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure 185.00

Other Services

D9241 Intravenous conscious sedation/analgesia - first 30 minutes 170.00



This is a sample schedule only. It is not an Evidence of Coverage. Please see the Group Dental Service Agreement, Evidence of Coverage, and Copayment Schedule, which determine all rights, benefits, and applicable limitations and exclusions.


Listed copayments apply only to SBA Specialists who perform the corresponding listed services. Plan Specialists may not perform or offer all services listed. Availability and participation of SBA and Non-SBA Plan Specialists are subject to change.
**Current and prior versions of the Current Dental Terminology (CDT) codes (in the ADA Code column) and descriptors (in the Service Description column) are copyrighted by the American Dental Association (ADA) and are used by permission. Current Dental Terminology © American Dental Association.


Prepaid - page 8



Learn more about the prepaid

dental plan being offered to you!





Your employer is offering you an attractive prepaid dental plan. This Q&A will help provide you more information about the plan being offered to you.

What is a prepaid plan?

With a prepaid plan you pay a monthly prepayment fee plus you pay reduced fees called “copayments” for dental services provided. To receive the reduced fees you must use a Plan Dentist selected at the time of enrollment.
What are copayments and where can I locate the copayment schedule?

A copayment is the set fee that you pay to the Plan Dentist at the time of treatment for covered services that are being performed.


The copayment schedule is a listing of covered services and copayments for your plan. The schedule is included in the Evidence of Coverage. It is helpful to bring your copayment schedule to your dental appointment.
How do I select a Plan Dentist?

You should select your Plan Dentist when you enroll. You can visit www.assurantemployeebenefits.com and go to Provider Search or refer to your plan network directory for a listing of Plan Dentists. On the web site please choose the Heritage Series network listed on the Provider Search page for provider look-up. Note that your Plan Dentist must be a general dentist, not a specialist.


How long does it take to appear on the patient list/roster of my Plan Dentist that I select at time of enrollment?

If Assurant Employee Benefits receives your Plan Dentist selection by the 20th of the month, you will appear on the roster the 1st of the next month. If we receive the selection after the 20th, you will appear on the roster the 1st day of the second following month. If you are not listed on the roster, please contact us at 800.443.2995.

How will the Plan Dentist know I am a patient?

The Plan Dentist receives a patient listing, called a roster, from Assurant Employee Benefits each month that includes all members who have chosen that individual as their dentist.


Please confirm at the time of making your appointment with the Plan Dentist that you are on the provider’s roster.

Can I change my Plan Dentist?

Yes, you can. To change your Plan Dentist, contact Customer Service at 800.443.2995.
What if I choose to see a dentist other than my selected Plan Dentist?

The costs will not be covered by your dental plan and you will be responsible for the full payment to the dentist. This is why it is important for you to seek treatment from your selected Plan Dentist.


If I have a dental emergency, do I need to see my Plan Dentist?

First, contact your Plan Dentist to make an appointment. If your Plan Dentist is unable to see you, you may seek treatment from any licensed dentist in the United States.


Please be informed that the emergency benefit in your plan is limited to the temporary relief of pain and has limited benefits.
If I need to see a specialist, how do I go about finding a Plan Specialist in my area?

You may find a list of Plan Specialists by looking in the plan network directory, visiting the web site at www.assurantemployeebenefits.com or calling 800.443.2995 for assistance. No referrals are necessary from your Plan Dentist to seek treatment from a Plan Specialist.


What if I lose my Dental ID card or have a question about my plan?

Contact Customer Service by calling 800.443.2995.





Prepaid - page 9



Limitations & Exclusions

Termination






Pre-existing Conditions

Limitations and exclusions apply with respect to the Member’s oral conditions without regard to whether or not such conditions existed before the effective date of the Member’s enrollment.


Limitations and Exclusions

Plan Benefits are not available for:



  1. Any services not specifically described in the Copayment Schedule (including but not limited to any hospital or outpatient care facility cost associated with any dental service).

  2. Any dental service initiated (a) before the effective date of the Member’s enrollment or (b) after the Member’s enrollment ends.

  3. Services provided by Non-Plan Providers unless (a) for services of Non-Plan Specialists as specifically provided in the SPECIALIST SERVICES section of the Copayment Schedule or (b) for Emergency Services as specifically provided in the EMERGENCY PROCEDURES Article of the Evidence of Coverage.

  4. Replacement of bridgework, dentures or other fixed or removable appliances unless (a) at least five years have elapsed since such appliance was provided as a Plan Benefit, or (b) during that five-year period, appliance becomes unusable and cannot be made usable due to the Member’s illness or an accident involving damage to the appliance while it is in use.

  5. Replacement of dentures or other removable appliances due to (a) damage while not in use or (b) loss or theft.

  6. Oral reconstruction using fixed bridgework or other fixed appliances if the overall treatment plan to achieve complete oral reconstruction involves the replacement of six or more teeth (whether those teeth are missing before treatment begins or are extracted as part of the overall treatment plan).

  7. Implants or any related implant appliances, or surgery for the insertion of implants or any related implant appliances, whether fixed or removable.

  8. Surgical removal of implants or implant appliances, or any surgical or non-surgical services to adjust, repair, replace, or treat any problem related to an existing implant or implant appliance, whether fixed or removable.

  9. Restorations or splints used to increase vertical dimension, restore occlusion, or replace or stabilize tooth structure lost by attrition.

  10. Orthodontic treatment involving therapy for myofunctional problems, TMJ (temporomandibular joint) dysfunctions, micrognathia, macroglossia, cleft palate or other growth and developmental abnormalities.

  11. Orthodontic treatment associated with orthognathic surgery, whether the treatment precedes or follows the surgery.

  12. Extractions of third molars (wisdom teeth) that are not symptomatic, whether or not the extractions follow the completion of orthodontic treatment. Examples of symptomatic conditions include decay, odontogenic cysts, chronic pericoronitis and infection.

  13. Treatment of malignancies, neoplasms or cysts, including but not limited to biopsies.




Orthodontic Extractions

Extractions by a Plan Provider for solely orthodontic purposes are not subject to the fixed Copayments shown for extractions in the Copayment Schedule. Instead, such extractions are subject to charges reflecting a 25% reduction from that Plan Provider's normal retail charges for such extractions.



Termination

The Member’s enrollment may be terminated as stated in the TERMINATION article of the Evidence of Coverage.









GDSA Form No. BDC-GDSA-AZ

BDC-A-ENCVR-AZ




01/19/2007 16:01:07 1260683/1




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