Have a Question?Call us at 800.451.1181

Value. Limited Costs. Fixed Fees.Backed by the security of a name trusted for nearly 80 years, BlueCross Dental plans give you greater control of your dental health with more choices and opportunities to save.

Choose a Primary Care Dentist

Choose a primary care dentist — who will coordinate all of your dental care and arrange for specialty care when needed — from one of the largest regional dental provider networks1. You can easily find a BlueCross Dental Select network dentist using our provider directory. We will contact you after you enroll to select a primary care dentist.

No Annual Maximums, Deductibles, or Waiting Periods2

BlueCross Dental Select makes getting quality care easier on your budget. With fixed copayments including low or no copayments for diagnostic and preventive services3, you have the power to make smart decisions about your care. Refer to the plan document, which lists specific copayments for each covered dental procedure.

Orthodontia Benefits for Adults and Children

Our plans provide orthodontic coverage for adults and children. For children, medically necessary services are covered, and value-added discounts for nonmedically necessary pediatric services are available.

Easy Access on capbluecross.com

• Find a BlueCross Dental Select network provider

• View your benefits, eligibility, and claims

• Print insurance ID cards

• Use tools designed to help you live healthy

See What’s in Store

As a Capital BlueCross customer, you have access to more than dental and vision benefits. Stop by a Capital Blue store to try an exercise class, enjoy a healthy snack, or consult with a fitness trainer or nutritionist.

Visit CapitalBlueStore.com for hours, locations, and class and event schedules.

BlueCross DentalSM Select

1 Dental Select plans require the selection of a primary care dentist (PCD) from the BlueCross Dental Select network. Your PCD provides routine care and arranges or provides most other medically necessary services. Except for emergency services, benefits are covered only when provided or properly referred by the member’s PCD, authorized by Capital BlueCross, or as stated within the dental policy.

2 12-month waiting period is applicable to medically necessary pediatric orthodontic services. Please see policy and coverage schedule for specific benefits, coverages, and limitations.3 Plan documents describe specific benefits, coverages, and limitations.

capbluecross.com | capitalbluestore.com

BCD-38 (10/03/16)

On behalf of Capital BlueCross, Dominion National assists in the administration of the BlueCross Dental benefits. Dominion National is an independent company.

BlueCross Dental Select is issued by Capital Advantage Assurance Company®, a subsidiary of Capital BlueCross. Independent licensees of the BlueCross BlueShield Association, serving 21 counties in central Pennsylvania and the Lehigh Valley. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

C-572 (09/12/16)

Nondiscrimination and Foreign Language Assistance Notice

At Capital BlueCross and our family of companies, our customers and the community we serve are at the heart of everything we do. We know health insurance is complicated, and we’re here to make it simple so you can focus on living healthy.

Capital BlueCross and its family of companies comply with applicable federal civil rights laws and do not discriminate on the

basis of race, color, national origin, age, disability, or sex. Capital BlueCross does not exclude people or treat them

differently because of race, color, national origin, age, disability, or sex.

Capital BlueCross provides free aids and services to people with disabilities to communicate effectively with us, such as:

qualified sign language interpreters or written information in other formats (large print, audio, accessible electronic format,

other formats). Capital BlueCross provides free language service to people whose primary language is not English, such as:

qualified interpreters, and information written in other languages.

If you need these services, contact our Civil Rights Coordinator.

If you believe that Capital BlueCross has failed to provide these services or discriminated in another way on the basis of

race, color, national origin, age disability, or sex, you can file a grievance with our Civil Rights Coordinator at

Capital BlueCross, P.O. Box 779880, Harrisburg, PA 17177-9880, call 800.417.7842 (TTY: 711), fax, 855.990.9001 or

email at CRC@capbluecross.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a

grievance, our Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights

electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or

by mail or phone at:

U.S. Department of Health and Human Services, 200 Independence Avenue, SW., Room 509F, HHH Building,

Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This notice may have important information about your application or coverage through your health plan. Look for key dates in this notice; you may need to take action by certain deadlines to keep your health coverage or help with costs. If you, or someone you’re helping, has questions or needs assistance or information about your health plan or this notice, you have the right to get help in your language at no cost. To talk to an interpreter, call 800.962.2242 (TTY: 711).

Spanish Este aviso puede contener información importante acerca de su solicitud o cobertura a través de su plan de salud. Ponga atención a la fechas importantes en este aviso; es posible que tenga que actuar antes de ciertas fechas límite para mantener su cobertura de salud o con ayuda del costo. Si usted, o alguien a quien usted ayuda, tiene preguntas o necesita asistencia o información acerca de su plan de salud o este aviso, tiene el derecho de obtener ayuda en su idioma sin costo alguno. Para hablar con un intérprete, llame al 800.962.2242 (TTY: 711).

Chinese

本通知可能包含有关您的健康计划申请或涵盖范围的重要信息。请注意本通知中的重要日期；您可能需

要在具体的截止期限前采取行动维护您的健康涵盖范围或缴纳费用。如果您自己或者您提供帮助的某个

人对您的健康计划或本通知有任何疑问或者需要获得帮助或信息，您有权免费获得以您的语言提供的帮助。欲与翻译员通话，请拨打电话 800.962.2242（聋哑人电话 TTY：711)。

Vietnamese

Thông báo này có thể chứa những thông tin quan trọng về đơn xin của quý khách hoặc phạm vi bảo hiểm trong chương

trình bảo hiểm sức khỏe của quý khách hàng. Hãy xem những ngày quan trọng trong thông báo này; quý khách có thể

cần xử lý trước khi đến hạn cuối để duy trì bảo hiểm sức khỏe hoặc để giảm chi phí. Nếu quý khách hàng, hoặc người

nào đó đang trợ giúp cho quý khách hàng, có câu hỏi hay cần trợ giúp hay thông tin về chương trình bảo hiểm sức khỏe

của quý khách, quý khách có quyền yêu cầu được trợ giúp bằng ngôn ngữ của quý khách mà không phát sinh chi phí nào.

Để kết nối với thông dịch viên, hãy gọi 800.962.2242 (TTY: 711).

Russian Данное уведомление может содержать важную информацию по вашей заявке и медицинской страховке. Просмотрите ключевые даты в этом уведомлении – может понадобиться придерживаться некоторых сроков для сохранения медицинской страховки или же внести плату. Если у вас или помогающего вам есть вопросы, а также нужна помощь или информация по медицинской страховке или по данному уведомлению, позвоните на бесплатный телефон. Для соединения с переводчиком, звоните 800.962.2242 (TTY: 711).

Pennsylvanian Dutch Die notice hot vielleicht wichtige information iwwer dei bitt oder coverage darrich dei gesundheitsplans. Guck for die certain days in daere notice; du brauchscht vielleicht ebbes duh bis certain deadlines fa dei gesundheits versicherings bhalde odder fa mit die koschde zu helfe. Wann du, odder ebber ess du am helfe bischt, froge hot odder hilf braucht odder information iwwer dei gesundheits plan odder iwwer die notice, hoscht du die recht fa hilf griege in dei sprooch es nichts koschtet. Fa schwetze mit me dolmetscher, ruf 800.962.2242 (TTY: 711).

Korean 이안내문에는 귀하의 건강보험을 통한 신청 또는 보장에 관한 중요한 정보가 포함될 수 있습니다. 이 안내문의

주요 날짜를 확인해 주십시오! 건강보험을 유지하거나 비용 지원을 위해 특정 마감일까지 관련 조처를 해야 할

수도 있습니다. 귀하 또는 귀하가 부양하는 사람이 귀하의 건강보험이나 이 안내문에 관하여 문의 사항이 있거나

도움말 또는 정보가 필요할 때는, 무료로 귀하의 언어를 통하여 도움을 받을 권리가 있습니다. 통역사에게

문의하려면 800.962.2242 (TTY: 711)으로 전화해 주십시오.

Italian Questo avviso potrebbe avere importanti informazioni circa la vostra applicazioni o copertura attraverso il vostro programma di salute. Cercate les principali date in questo avviso; pottrebe essere necessario applicare missuri ritoccando alcune scadenze per mantenere le vostre programma di salute o per contribuire con i costi. Se voi, o qualcuno voi state aiutando, ha quesiti o necessita di assistenza o informazione circa il vostro programma di salute o questo avviso, voi avvere può le diritto per ottenere aiuto in la vostra lingua gratuitamente. Per parlare con un interprete, chiamate 800.962.2242 (TTY: 711).

Arabic أوحول طلبك حول التغطية منخالل خطتك الصحية. ابحث عن التواريخ الرئيسية في هذا اإلشعار؛ ربما تحتاج إلى اتخاذ إجراء م خالل

هائية للحفاظ على التغطية الصحية الخاصة بك أو المساعدة في سداد التكاليف.بعض المواعيد إذا كنت تحتاج إلى مساعدة، أو كنت تساعد النهذا اإلشعار، فلديك شخًصا أخر، أو كان لديك أسئلة أو بحاجة إلى المساعدة أو بحاجة للحصول على معلومات حول خطتك الصحية أو حول

مساعدة بلغتك األم مجاًنا. للتحدث إلى مترجم فوري، اتصل على الرقم الحق في الحصول على ال هاتف النصي: 800.962.2242 (.711)ال

French Le présent avis peut avoir information importante concernant votre application ou la couverture à travers de votre plan sanitaire. Regarde pour clef dates dans cet avis ; vous pourries devoir prendre des mesures à certaines dates pour maintenir votre plan sanitaire ou de l’aidé à payer les coûts. Si vous, ou quelqu’un vous les aidez avoir des questions ou il a besoin d’aide ou information concernant votre plan sanitaire ou cet avis, vous avez le droit à obtenir de l’aide dans votre langue à titre gratuit. Pour parler à un interprète, appel 800.962.2242 (TTY: 711).

C-572 (09/12/16)

German Diese Mitteilung enthält eventuell wichtige Informationen bezüglich Ihres Antrages auf oder Ihres Schutzes durch Ihre Krankenversicherung. Suchen Sie nach Schlüsseldaten in diesem Dokument. Eventuell müssen Sie innerhalb von gewissen Fristen handeln um Ihren Versicherungsschutz zu behalten oder Hilfe mit Kosten zu erhalten. Fall Sie oder jemand, dem/der Sie helfen, Fragen hat oder Hilfe benötigt bezüglich dieser Mitteilung oder der Krankenversicherung, haben Sie Anspruch auf kostenlose Hilfe in Ihrer Sprache. Um mit einem Dolmetscher zu sprechen, rufen Sie an unter 800.962.2242 (TTY [Schreibtelefon]: 711).

Gujarati

આ નોટિસ માાં તમારી અરજી અથવા તમારી આરોગ્ય યોજના મારફતે કવરેજ વવશે મહત્વની જાણકારી હોઈ શકે છે. આ નોટિસ માાં મહત્વ ની તારીખો જુઓ; તમારા આરોગ્ય કવરેજ ને જાળવવા માિે અથવા ખર્ચ બર્ાવવા માિે અમકુ ર્ોક્કસ મદુતો સધુી તમને પગલાાં લેવા પડી શકે છે. જો તમે, અથવા જેની તમે મદદ કરી રહ્યા છો, તેમણે કોઈ સવાલ હોય અથવા સહાય કે તમારી આરોગ્ય યોજના અથવા આ નોટિસ વવશે માટહતી જોઇએ, તો તમને તમારી ભાષા માાં કોઇ પણ ખર્ચ વગર મદદ મેળવવા નુાં અવધકાર છે. દુભાવષયા સાથે વાત કરવા માિે,

800.962.2242 (TTY : 711) ફોન કરો.

Polish To powiadomienie może zawierać ważne informacje na temat Pana/Pani wniosku lub zakresu ubezpieczenia w posiadanym planie. Zalecamy zapoznać się z kluczowymi terminami w tym powiadomieniu; może istnieć konieczność podjęcia działania przed upłynięciem pewnych terminów, aby utrzymać ubezpieczenie zdrowotne lub uzyskać pomoc w kosztach. Jeżeli Pan/Pani lub ktoś, komu Pan/Pani pomaga, ma pytania bądź potrzebuje pomocy lub informacji w sprawie planu ubezpieczenia zdrowotnego albo tego powiadomienia, przysługuje Panu/Pani prawo do nieodpłatnego uzyskania pomocy w ojczystym języku. Aby porozmawiać z tłumaczem ustnym, prosimy zadzwonić pod numer 800.962.2242 (TTY: 711).

French Creole Avi sila a ka genyen enfòmasyon ki enpòtan konsènan aplikasyon w lan oubyen asirans ou atravè plan lasante w la. Chèche dat enpòtan yo ki nan avi sila a; ou ka gen pou w fè sèten bagay anvan kèk dat limit pou w sa kenbe asirans ou a oubyen pou yo ede w ak kèk depans. Si oumenm, oubyen yon lòt moun w ap ede, genyen kesyon oubyen bezwen èd oswa plis enfòmasyon sou plan lasante w oswa sou avi sila a, ou genyen dwa pou w resevwa asistans nan lang ou pale a san li pa koute w anyen ditou. Pou w pale ak yon entèprèt, rele 800.962.2242 (TTY: 711).

Cambodian–Mon-Khmer ការជូនដំណឹងននេះអាចមានពត៌មានសំខាន់អំពីកម្ម វធីិការធានារ៉ា ប់រងរបស់អនកតាម្រយៈគនរមាងសុខភាពរបស់អនក។កនម្ើលកាលបរនិចេទសំខាន់ៗនៅកន ុងការជូនដំណឹងននេះកអាចនធវ ើចំណាត់ការនោយកាលបរនិចេទជាក់លាក់នដើម្បីរកាការធានារ៉ា ប់រងសុខភាពជួយជាមួ្យនឹងការចំណាយ។សិនជាអនកនរណាមាន ក់ដដលអនកកំពុងជួយនសំណួររតវូការជំនួយពត៌មានអំពីគនរមាងសុខភាពរបស់អនកការជូនដំណឹងននេះកមានសិទធិនដើម្បីទទួលជំនួយជាភាសារបស់អនកនោយម្ិនគិតថ្លៃ។ នដើម្បីនយិាយាយនៅកាន់អនកបកដរបផ្ទា ល់មាត់ សូម្នៅនៅកាន់នលខ 800.962.2242 (TTY: 711)។

Portuguese Este aviso pode ter informações importantes sobre a sua aplicação ou cobertura de plano de saúde. Olhe para as datas importantes neste aviso; pode ser necessário tomar medidas em determinados prazos para manter a sua cobertura de saúde ou ajudar com os custos. Se você, ou alguém que você está ajudando, tem dúvidas ou precisa de assistência ou informação sobre seu plano de saúde ou este aviso, você tem o direito de obter ajuda na sua língua sem nenhum custo. Para falar com um intérprete, ligue para 800.962.2242 (TTY: 711).

C-572 (09/12/16)

BlueCross DentalSM Dental Select* Basic - Adult Services (age 19 and over)* This plan requires the selection of a primary care dentist (PCD) from the Plan’s dental HMO/Select network. The member’s PCD provides routine care and arranges or provides most other medically necessary services. Except for emergency services, benefits are covered only when provided or properly referred by the member’s PCD, preauthorized by Capital or as stated within the dental policy.

D2750/51/52 Crown - porcelain fused metal ............................................. 523D2780/81/82 Crown - 3/4 cast with metal ................................................. 478D2783 Crown - 3/4 porcelain/ceramic ..............................................511D2790/91/92 Crown - full cast metal ......................................................... 495D2910/20 Recement inlay, onlay/crown or partial coverage rest. .......... 43D2931 Prefab. stainless steel crown - perm. tooth .......................... 121D2932 Prefabricated resin crown .................................................... 140D2950 Core buildup, including any pins .......................................... 125D2952 Cast post and core in addition to crown ............................... 186D2954 Prefab. post and core in addition to crown .......................... 154D2955 Post removal (not in conj. with endo. therapy) ..................... 105D2970 Temporary crown (fractured tooth) ........................................... 0D2980 Crown repair, by report ........................................................ 102 PROSTHETICS (DENTURES)D5110/20 Complete denture - maxillary/mandibular ............................ 697D5130/40 Immediate denture - maxillary/mandibular ........................... 722D5211/12 Maxillary/mandibular partial denture - resin base ................ 649D5213/14 Maxillary/mandibular partial denture - cast metal ................ 750D5225/26 Maxillary/mandibular partial denture - flexible base ............. 750D5281 Rem. unilateral partial denture - one piece cast metal ............. 419D5410/11 Adjust complete denture - maxillary/mandibular .................... 38D5421/22 Adjust partial denture - maxillary/mandibular ......................... 38D5510/5610 Repair broken denture base (complete/resin) ....................... 87D5520 Replace missing or broken teeth - complete denture ............ 87D5620 Repair cast framework ........................................................... 87D5630/60 Clasp repaired, replaced or added .......................................115D5640 Replace broken teeth - per tooth ........................................... 87D5650 Add tooth to existing partial denture ...................................... 87D5670/71 Replace all teeth and acrylic on cast metal framework ........ 287D5710/11 Rebase complete maxillary/mandibular denture .................. 260D5720/21 Rebase maxillary/mandibular partial denture ...................... 260D5730/31 Reline complete maxillary/mandibular denture (chairside) ..........159D5740/41 Reline maxillary/mandibular partial denture (chairside) ............ 155D5750/51 Reline complete maxillary/mandibular denture (lab) ............ 224D5760/61 Reline maxillary/mandibular partial denture (lab) ................ 224D5810/11 Interim complete denture - maxillary/mandibular ................. 362D5820/21 Interim partial denture - maxillary/mandibular ...................... 362D5850/51 Tissue conditioning - maxillary/mandibular ............................ 79 BRIDGE & PONTICS♦

D6000-D6199 ALL IMPLANT SERVICES - 15% DISCOUNT* (incl. D0360-D0363 cone beam imaging w/ implants)D6210/11/12 Pontic - metal ....................................................................... 495D6240/41/42 Pontic - porcelain fused metal ............................................. 523D6245 Pontic - porcelain/ceramic ................................................... 560D6250/51/52 Pontic - resin with metal ....................................................... 495D6545 Retainer - cast metal for resin bonded fixed prosthesis ........... 251D6548 Ret. - porc./ceramic for resin bonded fixed prosthesis ........ 393D6600 Inlay - porc./ceramic, two surfaces ...................................... 427D6601 Inlay - porc./ceramic, >=3 surfaces ...................................... 445D6602 Inlay - cast high noble metal, two surfaces .......................... 407D6603 Inlay - cast high noble metal, >=3 surfaces ......................... 425D6604 Inlay - cast predominantly base metal, two surfaces ........... 407D6605 Inlay - cast predominantly base metal, >=3 surfaces .......... 425D6606 Inlay - cast noble metal, two surfaces .................................. 407D6607 Inlay - cast noble metal, >=3 surfaces ................................. 425D6608 Onlay -porc./ceramic, two surfaces ..................................... 479D6609 Onlay - porc./ceramic, three or more surfaces .................... 499D6610 Onlay - cast high noble metal, two surfaces ........................ 458D6611 Onlay - cast high noble metal, >=3 surfaces ....................... 524D6612 Onlay - cast predominantly base metal, two surfaces ......... 458D6613 Onlay - cast predominantly base metal, >=3 surfaces ......... 524D6614 Onlay - cast noble metal, two surfaces ................................ 458D6615 Onlay - cast noble metal, >=3 surfaces ............................... 524D6720/21/22 Crown - resin with metal ...................................................... 495D6740 Crown - porcelain/ceramic ................................................... 560D6750/51/52 Crown - porcelain fused metal ............................................. 523D6780 Crown - 3/4 cast high noble metal ....................................... 470D6781 Crown - 3/4 cast predominantly base metal ........................ 470D6782 Crown - 3/4 cast noble metal ............................................... 470

DIAGNOSTIC/PREVENTIVED9439 Office visit .............................................................................. 10D0120 Periodic oral eval - established patient .................................... 0D0140 Limited oral eval - problem focused ......................................... 0D0150 Comprehensive oral eval - new or established patient ............ 0D0160 Detailed and extensive oral eval - problem focused ................ 0D0170 Re-evaluation - limited, problem focused ................................ 0D0210 Intraoral - complete series (including bitewings) .................... 26D0220 Intraoral - periapical first film .................................................... 0D0230 Intraoral - periapical each add. film .......................................... 0D0240 Intraoral - occlusal film ............................................................. 0D0250/60 Extraoral - first film and each add. film .................................... 0D0270-74 Bitewing x-rays - 1 to 4 films .................................................... 0D0277 Vertical bitewings - 7 to 8 films ................................................ 0D0330 Panoramic film ....................................................................... 30D0340 Cephalometric Film .................................................................. 0D0350 Oral/facial photographic images .............................................. 0D0460 Pulp vitality tests ...................................................................... 0D0470 Diagnostic casts ....................................................................... 0D1110 Prophylaxis (cleaning) - adult ................................................ 13D1110* Additional cleaning (expecting mothers or Diabetics) ............ 40D1204 Topical application of fluoride - adult ........................................ 0D1206 Topical fluoride varnish for mod/high risk caries patients ........ 0D1310 Nutritional counseling for control of dental disease ................. 0D1320/30 Oral hygiene instructions ......................................................... 0 RESTORATIVE DENTISTRY (FILLINGS) AMALGAM RESTORATIONS (SILVER)D2140 Amalgam - one surface, prim. or perm. ................................. 41D2150 Amalgam - two surfaces, prim. or perm. ................................ 51D2160 Amalgam - three surfaces, prim. or perm. ............................. 64D2161 Amalgam - >=4 surfaces, prim. or perm. ............................... 78 RESIN/COMPOSITE RESTORATIONS (TOOTH COLORED)D2330 Resin-based composite - one surface, anterior ..................... 69D2331 Resin-based composite - two surfaces, anterior .................... 83D2332 Resin-based composite - three surfaces, anterior ................. 99D2335 Resin-based composite - >=4 surfaces, anterior ..................119D2390 Resin-based composite crown, anterior .............................. 192D2391 Resin-based composite - one surface, posterior ................... 73D2392 Resin-based composite - two surfaces, posterior .................. 87D2393 Resin-based composite - three surfaces, posterior ............. 102D2394 Resin-based composite - >=4 surfaces, posterior ............... 123 D2940 Sedative filling ........................................................................ 39D2951 Pin retention - per tooth, in addition to restoration ................. 22D3110/20 Pulp cap - direct/indirect (excl. final restoration) .................... 32 CROWN & BRIDGE♦

D2510 Inlay - metallic - one surface ................................................ 407D2520 Inlay - metallic - two surfaces .............................................. 407D2530 Inlay - metallic - three or more surfaces .............................. 425D2542 Onlay - metallic-two surfaces ............................................... 458D2543 Onlay - metallic-three surfaces ............................................ 524D2544 Onlay - metallic-four or more surfaces ................................. 524D2610 Inlay - porcelain/ceramic - one surface ................................ 427D2620 Inlay - porcelain/ceramic - two surfaces .............................. 427D2630 Inlay - porcelain/ceramic - >=3 surfaces .............................. 445D2642 Onlay - porcelain/ceramic - two surfaces ............................. 479D2643 Onlay - porcelain/ceramic - three surfaces .......................... 499D2644 Onlay - porcelain/ceramic - >=4 surfaces ............................ 499D2650 Inlay - resin-based composite - one surface ........................ 440D2651 Inlay - resin-based composite - two surfaces ...................... 440D2652 Inlay - resin-based composite - >=3 surfaces ...................... 440D2662 Onlay - resin-based composite - two surfaces ..................... 444D2663 Onlay - resin-based composite - three surfaces .................. 444D2664 Onlay - resin-based composite - >=4 surfaces .................... 444D2710 Crown - resin based composite (indirect) ............................ 272D2712 Crown - 3/4 resin-based composite (indirect) ...................... 485D2720/21/22 Crown - resin with metal ...................................................... 495D2740 Crown - porcelain/ceramic substrate ................................... 560

BCDINDCSDHMO (04/2016)

Issued By

CAPITAL ADVANTAGE ASSURANCE COMPANYHarrisburg, PAA Capital BlueCross company. Independent licensees of the BlueCross BlueShield Association.

ADA MEMBERCODE BENEFIT COPAYMENT(S)

ADA MEMBERCODE BENEFIT COPAYMENT(S)

♦All fees exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used.

ORTHODONTICS2

D8660 Pre-orthodontic treatment visit ............................................. 413D8090 Comp. ortho. treatment - adult dentition ............................ 3658D8670 Periodic ortho. treatment visit (as part of contract) ...............118D8680 Orthodontic retention (rem. of appl. and placement of retainer(s)) ................................................................... 413

2 Phase I Treatment (D8010 - D8050) is provided at a 15% reduction* from the orthodontist’s UCR fees. See exclusion #15 for additional coverage exclusions.

D6783 Crown - 3/4 porc./ceramic .....................................................511D6790/91/92 Crown - full cast metal ......................................................... 495D6930 Recement fixed partial denture .............................................. 69D6970 Post and core in addition to fixed part. dent. ret. ................. 185D6972 Prefab post and core in addition to fixed part. dent. ret. .........154D6973 Core build up for retainer, including any pins ....................... 125D6975 Coping - metal ..................................................................... 325D6976 Each add. indirectly fabricated post - same tooth ................ 130D6977 Each add. prefab post - same tooth ....................................... 60D6980 Fixed partial denture repair, by report .................................. 172 ADJUNCTIVE GENERAL SERVICESD9110 Palliative (emergency) treatment of dental pain .................... 43D9210/15 Local anesthesia ...................................................................... 0D9211 Regional block anesthesia ....................................................... 0D9212 Trigeminal division block anesthesia ....................................... 0D9220 Deep sedation/general anesthesia - first 30 min. ................ 205D9221 Deep sedation/general anesthesia - each add. 15 min. ........... 103D9241 Intravenous conscious sedation/analgesia - first 30 min. ..........205D9242 IV conscious sedation/analgesia - each add. 15 min. .......... 103D9230 Analgesia, anxiolysis, inhalation of nitrous oxide ................... 37D9310 Consultation (diagnostic service by nontreating dentist) .............43D9910 Application of desensitizing medicament ............................... 31D9930 Treatment of complications (post-surgical) ............................ 43D9990 Broken office appointment ..................................................... 50 ENDODONTICS1

D3220 Therapeutic pulpotomy (excl. final restor.) ............................. 81D3221 Pulpal debridement, prim. and perm. teeth ............................ 94D3310 Endodontic therapy, anterior tooth ....................................... 341D3320 Endodontic therapy, bicuspid tooth ...................................... 418D3330 Endodontic therapy, molar ................................................... 512D3333 Internal root repair of perforation defects ............................. 105D3346 Retreat of prev. root canal therapy, anterior ......................... 387D3347 Retreat of prev. root canal therapy, bicuspid ........................ 465D3348 Retreat of prev. root canal therapy, molar ............................ 558D3410 Apicoectomy/periradicular surgery, anterior......................... 323D3421 Apicoectomy/periradicular surgery, bicuspid (first root) ....... 364D3425 Apicoectomy/periradicular surgery, molar (first root) ........... 418D3426 Apicoectomy/periradicular surgery (each add. root) ............ 152D3430 Retrograde filling - per root ...................................................119D3450 Root amputation - per root ................................................... 234D3920 Hemisection, not inc. root canal therapy .............................. 234D3950 Canal prep/fitting of preformed dowel or post ...................... 136 PERIODONTICS1

D0180 Comp. periodontal eval - new or established patient ............. 36D4210 Gingivectomy or gingivoplasty - >3 cont. teeth, per quad. ...........279D4211 Gingivectomy or gingivoplasty - <=3 teeth, per quad. ......... 100D4240 Gingival flap proc., inc. root planing - >3 cont. teeth, per quad ..........................................................345D4241 Gingival flap proc, inc. root planing - <=3 cont. teeth, per quad ................................................. 106D4260 Osseous surgery - >3 cont. teeth, per quad ........................ 499D4261 Osseous surgery - <=3 cont. teeth, per quad ...................... 392D4268 Surgical revision proc., per tooth ......................................... 358D4274 Distal or proximal wedge procedure .................................... 308D4341 Perio scaling and root planing - >3 cont teeth, per quad. ..........109D4342 Perio scaling and root planing - <= 3 teeth, per quad ............ 63D4355 Full mouth debridement ......................................................... 89D4381 Localized delivery of chemotherapeutic agents ..................... 98D4910 Periodontal maintenance ....................................................... 74D9940 Occlusal guard, by report ..................................................... 272D9950 Occlusion analysis - mounted case ..................................... 104D9951 Occlusal adjustment - limited ................................................. 66D9952 Occlusal adjustment - complete ........................................... 266 ORAL SURGERY1

D7111 Extraction, coronal remnants - deciduous tooth .................... 56D7140 Extraction, erupted tooth or exposed root .............................. 69D7210 Surgical rem. of erupted tooth req. bone cut ....................... 133D7220 Removal of impacted tooth - soft tissue ............................... 151D7230 Removal of impacted tooth - partially bony .......................... 196D7240 Removal of impacted tooth - completely bony ..................... 241D7241 Removal of imp. tooth - completely bony, with unusual surg. complications ..................................... 217D7250 Surgical removal of residual tooth roots .............................. 141D7270 Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth .............226D7280 Surgical access of an unerupted tooth ................................ 153D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report ...........60D7310/20 Alveoloplasty, per quad ........................................................ 141D7510 Incision and drainage of abscess - intraoral soft tissue ......... 96D7960 Frenulectomy (frenectomy/frenotomy) - separate proc. ....... 263

1As performed by a Participating General Dentist. See Plan Exclusion #13.

Adult Plan Exclusions1. Services which are covered under worker’s compensation, employer’s liability laws or the Pennsylvania Motor Vehicle Financial Responsibility Law.2. Services which are not necessary for the patient’s dental health as determined by the Plan.3. Cosmetic, elective or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth as determined by the Plan.4. Oral surgery requiring the setting of fractures or dislocations.5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where, in the opinion of the Plan, such services should not be performed in a dental office.6. Dispensing of drugs.7. Hospitalization for any dental procedure.8. Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared, or while on active duty as a member of the armed forces of any nation.9. Replacement due to loss or theft of prosthetic appliance.10. Procedures not listed as covered benefits under this Plan.11. Services obtained outside of the dental office in which enrolled and that are not preauthorized by such office or the Plan (with the exception of out-of-area emergency dental services).12. Services related to the treatment of TMD (Temporomandibular Disorder). 13. Services related to procedures that are of such a degree of complexity as to not be normally performed by a Participating General Dentist. Above copayments do not apply when performed by a Participating Specialist (with the exception of orthodontics). Participating Specialists, if available, have entered into an agreement to provide dental services to members at a 25% reduction from their Usual, Customary, and Reasonable (UCR) fees. 14. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth as determined by the Plan.15. The Invisalign system and similar appliances are not a covered benefit. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient’s responsibility.

Adult Plan Limitations1. Two (2) evaluations are covered per calendar year per patient including a maximum of one (1) comprehensive evaluation per 36 months.2. One (1) problem focused exam is covered per calendar year per patient.3. Two (2) teeth cleanings (prophylaxis) are covered per calendar year per patient (one additional cleaning is covered during pregnancy and for diabetic patients).4. One (1) topical fluoride or fluoride varnish is covered per calendar year per patient.5. Two (2) bitewing x-rays are covered per calendar year per patient.6. One (1) set of full mouth x-rays or panoramic film is covered every three (3) years per patient.7. Replacement of a filling is covered if it is more than two (2) years from the date of original placement.8. Replacement of a bridge, crown or denture is covered if it is more than seven (7) years from the date of original placement.9. Crown and bridge fees apply to treatment involving five or fewer units when presented in a single treatment plan. Additional crown or bridge units, beginning with the sixth unit, are available at the provider’s Usual, Customary, and Reasonable (UCR) fee, minus 25%.*10. Relining and rebasing of dentures is covered once every 24 months per patient.11. Retreatment of root canal is covered if it is more than two (2) years from the original treatment.12. Root planing or scaling is covered once every 24 months per quadrant per patient.13. Full mouth debridement is covered once per lifetime per patient.14. Procedure Code D4381 is limited to one (1) benefit per tooth for three teeth per quadrant or a total of 12 teeth for all four quadrants per twelve (12) months per patient. Must have pocket depths of five (5) millimeters or greater.15. Periodontal surgery of any type, including any associated material, is covered once every 36 months per quadrant or surgical site per patient.16. Periodontal maintenance after active therapy is covered twice per calendar year, within 24 months after definitive periodontal therapy, per patient.

* A discount for these services may be available to members through the Plan’s, or it designee’s, agreements with certain of its participating providers.

Only current ADA CDT codes are considered valid by the Plan.Current Dental Terminology © American Dental Association.

ADA MEMBERCODE BENEFIT COPAYMENT(S)

ADA MEMBERCODE BENEFIT COPAYMENT(S)

D9439 Office visit ..................................................................... 10 DIAGNOSTIC/PREVENTIVED0120 Periodic oral eval - established patient ........................... 0D0140 Limited oral eval - problem focused ................................ 0D0145 Oral eval for a patient under 3 years of age .................... 0D0150 Comprehensive oral eval - new or established patient ... 0D0160 Detailed and extensive oral eval - problem focused ....... 0D0170 Re-evaluation - limited, problem focused ........................ 0D0210 Intraoral - complete series (including bitewings) ........... 26D0220/30 Intraoral - periapical first film and each additional ........... 0D0240 Intraoral - occlusal film .................................................... 0D0250/60 Extraoral - first film and each additional .......................... 0D0270-74 Bitewing x-rays - 1-4 films ............................................... 0D0277 Vertical bitewings - 7 to 8 films ........................................ 0D0330 Panoramic film .............................................................. 30D0340 Cephalometric film .......................................................... 0D0350 Oral/facial photographic images ..................................... 0D0391 Interpretation of diagnostic image only ........................... 0D0460 Pulp vitality tests ............................................................. 0D0470 Diagnostic casts .............................................................. 0D1110 Prophylaxis (cleaning) - adult .......................................... 0D1120 Prophylaxis (cleaning) - child .......................................... 0D1206 Topical fluoride varnish for mod/high risk caries patients .... 0D1208 Topical application of fluoride .......................................... 0D1310 Nutritional counseling for control of dental disease ........ 0D1320/30 Oral hygiene instructions ................................................ 0D1351 Sealant - per tooth ........................................................ 21D1352 Prev resin rest. mod/high caries risk – perm. tooth ....... 21 SPACE MAINTAINERSD1510/20 Space maintainer - fixed/removable - unilateral .......... 143D1515/25 Space maintainer - fixed/removable - bilateral ............ 198D1550 Re-cementation of space maintainer ............................ 34 RESTORATIVE DENTISTRY (FILLINGS) AMALGAM RESTORATIONS (SILVER)D2140 Amalgam - one surface, prim. or perm. ........................ 41D2150 Amalgam - two surfaces, prim. or perm. ....................... 51D2160 Amalgam - three surfaces, prim. or perm. .................... 64D2161 Amalgam - >=4 surfaces, prim. or perm. ...................... 78 RESIN/COMPOSITE RESTORATIONS (TOOTH COLORED)D2330 Resin-based composite - one surface, anterior ............ 69D2331 Resin-based composite - two surfaces, anterior ........... 83D2332 Resin-based composite - three surfaces, anterior ........ 99D2335 Resin-based composite - >=4 surfaces, anterior ........ 119D2390 Resin-based composite crown, anterior ...................... 192D2391 Resin-based composite - one surface, posterior .......... 73D2392 Resin-based composite - two surfaces, posterior ......... 87D2393 Resin-based composite - three surfaces, posterior .... 102D2394 Resin-based composite - >=4 surfaces, posterior ...... 123 D2940 Sedative filling ............................................................... 39D2941 Interim therapeutic restoration, primary dentition .......... 31D2950 Core buildup, including any pins ................................. 125D2951 Pin retention - per tooth, in addition to restoration ........ 22D3110/20 Pulp cap - direct/indirect (excl. final restoration) ........... 32 CROWNS & BRIDGES♦

D2510 Inlay- metallic - one surface ........................................ 407D2520 Inlay- metallic - two surfaces ....................................... 407D2530 Inlay - metallic - three or more surfaces ...................... 425D2542 Onlay - metallic-two surfaces ...................................... 458D2543 Onlay - metallic - three surfaces ................................. 524D2544 Onlay - metallic - four or more surfaces ...................... 524D2610 Inlay - porcelain/ceramic - one surface ....................... 427D2620 Inlay - porcelain/ceramic - two surfaces ...................... 427D2630 Inlay - porcelain/ceramic - >=3 surfaces ..................... 445D2642 Onlay - porcelain/ceramic - two surfaces .................... 479D2643/44 Onlay - porcelain/ceramic - >=3 surfaces ................... 499D2650/51/52 Inlay - resin-based composite - >=1 surface(s) ........... 440D2662/63/64 Onlay - resin-based composite - >=2 surfaces ........... 444D2710 Crown - resin based composite (indirect) ................... 272

All fees exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used.

Annual Out-of-Pocket Maximum: $350 per child per calendar year for medically necessary treatment (maximum of $700 for policy covering two or more children)

BlueCross DentalSM Dental Select* Basic - Pediatric Services (under age 19)* This plan requires the selection of a primary care dentist (PCD) from the Plan’s dental HMO/Select network. The member’s PCD provides routine care and arranges or provides most other medically necessary services. Except for emergency services, benefits are covered only when provided or properly referred by the member’s PCD, preauthorized by Capital or as stated within the dental policy.

D2712 Crown - 3/4 resin-based composite (indirect) ............. 485D2720/21/22 Crown - resin with metal ............................................. 495D2740 Crown - porcelain/ceramic substrate .......................... 560D2750/51/52 Crown - porcelain fused metal .................................... 523D2780/81/82 Crown - 3/4 cast with metal ......................................... 478D2783 Crown - 3/4 porcelain/ceramic .................................... 511D2790-94 Crown - full cast metal ................................................ 495D2910/20 Recement inlay, onlay/crown or partial coverage rest. ..... 43D2929 Procelain/cermaic crown - prim. tooth ......................... 560D2930 Prefab. stainless steel crown - prim. tooth .................. 110D2931 Prefab. stainless steel crown - perm. tooth ................. 121D2932 Prefabricated resin crown ........................................... 140D2952 Cast post and core in addition to crown ...................... 186D2954 Prefab. post and core in addition to crown .................. 154D2955 Post removal (not in conj. with endo. therapy) ............ 105D2970 Temporary crown (fractured tooth) .................................. 0D2980 Crown repair, by report ............................................... 102D2981 Inlay repair .................................................................. 102D2982 Onlay repair ................................................................ 102D2983 Veneer repair .............................................................. 102D2990 Resin infitration lesion ................................................... 41 PROSTHETICS (DENTURES)D5110/20 Complete denture - maxillary/mandibular ................... 697D5130/40 Immediate denture - maxillary/mandibular .................. 722D5211/12 Maxillary/mandibular partial denture - resin base ....... 649D5213/14 Maxillary/mandibular partial denture - cast metal ....... 750D5225/26 Maxillary/mandibular partial denture - flexible base .... 750D5281 Rem. unilateral partial denture - one piece cast metal.... 419D5410/11 Adjust complete denture - maxillary/mandibular ........... 38D5421/22 Adjust partial denture - maxillary/mandibular ................ 38D5510/5610 Repair broken complete denture base (complete/resin) ...87D5520 Replace missing or broken teeth - complete denture ... 87D5620 Repair cast framework .................................................. 87D5630/60 Clasp repaired, replaced or added .............................. 115D5640 Replace broken teeth - per tooth .................................. 87D5650 Add tooth to existing partial denture ............................. 87D5670/71 Replace all teeth and acrylic on cast metal framework (maxillary/mandibular) ........................................... 287D5710/11 Rebase complete maxillary/mandibular denture ......... 260D5720/21 Rebase maxillary/mandibular partial denture .............. 260D5730/31 Reline complete maxillary/mandibular denture (chairside) ..159D5740/41 Reline maxillary/mandibular partial denture (chairside) .. 155D5750/51 Reline complete maxillary/mandibular denture (lab) ... 224D5760/61 Reline maxillary/mandibular partial denture (lab) ........ 224D5810/11 Interim complete denture - maxillary/mandibular ........ 362D5820/21 Interim partial denture - maxillary/mandibular ............. 362D5850/51 Tissue conditioning - maxillary/mandibular ................... 79 BRIDGES & PONTICS♦

D6010 Surgical placement of implant body, endosteal ......... 1716D6011 Second stage implant surgery .................................... 200D6012 Surgical placement of interim implant body .............. 1782D6013 Surgical placement of mini implant ............................. 572D6040 Surgical placement, eposteal implant ....................... 3564D6050 Surgical placement, transosteal implant ................... 4455D6053 Implant/abutment supported rem. denture (comp. edentulous arch) ..................................... 1667D6054 Implant/abutment supported rem. denture (part. edentulous arch) ......................................... 176D6055 Dental implant supported connecting bar ................. 1611D6056 Prefabricated abutment ............................................... 456D6058 Abutment supported porcelain/ceramic crown ............ 560D6059/60/61 Abutment supported porcelain fused to metal crown - metal .. 523D6062/63/64 Abutment supported cast metal crown - metal ............ 495D6065 Implant supported porcelain/ceramic crown ............... 560D6066 Implant supported porcelain fused to metal crown - titanium, titanium allow, high noble metal ............. 523D6067 Implant supported metal crown - titanium, titanium alloy, high noble metal .............. 523D6068 Abutment supported retainer for porc/ceramic ............ 788D6069 Abutment supp. retainer for porc/high noble ............... 843D6070 Abutment supp. retainer for porc/pred. base .............. 695D6071 Abutment supp. retainer for porc/noble ....................... 704

ADA MEMBERCODE BENEFIT COPAYMENT(S)

ADA MEMBERCODE BENEFIT COPAYMENT(S)

ADA MEMBERCODE BENEFIT COPAYMENT(S)

ADA MEMBERCODE BENEFIT COPAYMENT(S)

1 See exclusion #15 and limitation #24 for additional coverage information. Only current ADA CDT codes are considered valid by Plan.

Current Dental Terminology © American Dental Association.Specialty care is provided at the listed copayment whether performed by a Participating General Dentist or a Participating Specialist. Referrals to a specialist must be made by a Member’s Primary Care Dentist. See Plan Exclusion #13.

D6072 Abutment supp retainer for cast high noble ................ 788D6073 Abutment supp. retainer for cast high noble ............... 749 D6074 Abutment supp. retainer for cast noble metal ............. 758D6075 Implant supported retainer for ceramic FPD ............... 874D6076 Implant supported retainer for porc/metal FPD ........... 823D6077 Implant supported retainer for cast metal FPD ........... 872D6078 Imp/abut supp fixed dent for compl edent arch ......... 2216D6079 Imp/abut supp fixed dent for part. edent arch ........... 1803D6080 Implant maintenance procedures .................................. 61D6090 Repair implant supported prosthesis .......................... 362D6091 Replacement of precision attachment ........................... 34D6095 Repair implant abutment, by report ............................. 391D6100 Implant removal, by report .......................................... 241D6101 Debribement periimplant defect .................................... 90D6102 Deridement and osseous contouring periimplant defect... 180D6103 Bone graft repair perrimplant defect ........................... 600D6104 Bone graft at time of implant placement ..................... 600D6190 Radiographic surgical implant index, by report ............... 0D6210-14 Pontic - metal .............................................................. 495D6240/41/42 Pontic - porcelain fused to metal ................................. 523D6245 Pontic - porcelain/ceramic ........................................... 560D6250/51/52 Pontic - resin with metal .............................................. 495D6545 Ret. - cast metal for resin bonded fixed prosthesis ..... 251D6548 Ret. - porc./ceramic for resin bonded fixed prosthesis .. 393D6600 Inlay - porc./ceramic, two surfaces ............................. 427D6601 Inlay - porc./ceramic, >=3 surfaces ............................. 445D6602 Inlay - cast high noble metal, two surfaces ................. 407D6603 Inlay - cast high noble metal, >=3 surfaces ................ 425D6604 Inlay - cast predominantly base metal, two surfaces .... 407D6605 Inlay - cast predominantly base metal, >=3 surfaces ... 425D6606 Inlay - cast noble metal, two surfaces ......................... 407D6607 Inlay - cast noble metal, >=3 surfaces ........................ 425D6608 Onlay -porc./ceramic, two surfaces ............................. 479D6609 Onlay - porc./ceramic, three or more surfaces ............ 499D6610 Onlay - cast high noble metal, two surfaces ............... 458D6611 Onlay - cast high noble metal, >=3 surfaces ............... 524D6612 Onlay - cast predominantly base metal, two surfaces .... 458D6613 Onlay - cast predominantly base metal, >=3 surfaces... 524D6614 Onlay - cast noble metal, two surfaces ....................... 458D6615 Onlay - cast noble metal, >=3 surfaces ...................... 524D6720/21/22 Crown - resin with metal ............................................. 495D6740 Crown - porcelain/ceramic .......................................... 560D6750/51/52 Crown - porcelain fused metal .................................... 523D6780/81/82 Crown - 3/4 cast metal ................................................ 470D6783 Crown - 3/4 porc./ceramic ........................................... 511D6790/91/92 Crown - full cast metal ................................................ 495D6930 Recement fixed partial denture ..................................... 69D6975 Coping - metal ............................................................. 325D6980 Fixed partial denture repair, by report ......................... 172 ADJUNCTIVE GENERAL SERVICESD9110 Palliative (emergency) treatment of dental pain ............ 43D9210/15 Local anesthesia ............................................................. 0D9211/12 Regional block anesthesia .............................................. 0D9220 Deep sedation/general anesthesia - first 30 min. ........ 205D9221 Deep sedation/general anesthesia - each add. 15 min. ..103D9230 Analgesia, anxiolysis, inhalation of nitrous oxide .......... 37D9241 Intravenous conscious sedation/analgesia - first 30 min. .. 205D9242 IV conscious sedation/analgesia - each add. 15 min. ... 103D9310 Consultation (diagnostic service by nontreating dentist) ... 43D9910 Application of desensitizing medicament ...................... 31D9930 Treatment of complications (post-surgical) ................... 43D9940 Occlusal guard, by report ............................................ 272D9950 Occlusion analysis - mounted case ............................ 104D9951 Occlusal adjustment - limited ........................................ 66D9952 Occlusal adjustment - complete .................................. 266D9990 Broken office appointment ............................................ 50 ENDODONTICS D3220 Therapeutic pulpotomy (excl. final restor.) .................... 81D3221 Pulpal debridement, prim. and perm. teeth ................... 94D3222 Partial pulpotomy for apexogenesis ............................ 160D3230 Pulpal therapy - resorbable filling, anterior ................. 160D3240 Pulpal therapy - resorbable filling, posterior ................ 164D3310 Endodontic therapy, anterior tooth .............................. 341D3320 Endodontic therapy, bicuspid tooth ............................. 418D3330 Endodontic therapy, molar .......................................... 512D3333 Internal root repair of perforation defects .................... 105D3346 Retreat of prev. root canal therapy, anterior ................ 387D3347 Retreat of prev. root canal therapy, bicuspid ............... 465D3348 Retreat of prev. root canal therapy, molar ................... 558D3351 Apexification/recalcification - initial visit ...................... 202

D3352 Apexification/recalcification - interim med. repl. .......... 589D3353 Apexification/recalcification - final visit ........................ 449D3355 Pulpal regeneration - initial visit .................................. 202D3356 Pulpal regeneration - interim medication replacement ....589D3357 Pulpal regeneration - completion of treatment ............ 449D3410 Apicoectomy/periradicular surgery, anterior ................ 323D3421 Apicoectomy/periradicular surgery, bicuspid (first root) ...364D3425 Apicoectomy/periradicular surgery, molar (first root) .. 418D3426 Apicoectomy/periradicular surgery (each add. root) ... 152D3427 Periradicular surgery w/o apicoectomy ....................... 266D3430 Retrograde filling - per root ......................................... 119D3450 Root amputation - per root .......................................... 234D3920 Hemisection, not inc. root canal therapy ..................... 234D3950 Canal prep/fitting of preformed dowel or post ............. 136 PERIODONTICS D0180 Comp. periodontal eval - new or established patient ...... 0D4210 Gingivectomy or gingivoplasty - >3 cont. teeth, per quad. .. 279D4211 Gingivectomy or gingivoplasty - <=3 teeth, per quad. .. 100D4212 Gingivectomy or gingivoplasty, rest., per tooth ............. 40D4240 Gingival flap proc., inc. root planing - >3 cont. teeth, per quad........................................ 345D4241 Gingival flap proc, inc. root planing - <=3 cont. teeth, per quad ..................................... 106D4249 Clinical crown lengthening - hard tissue ..................... 576D4260 Osseous surgery - >3 cont. teeth, per quad ............... 499D4261 Osseous surgery - <=3 cont. teeth, per quad ............. 392D4268 Surgical revision proc., per tooth ................................ 358D4270 Pedicle soft tissue graft procedure .............................. 643D4273 Subepithelial connective tissue graft proc. .................. 800D4274 Distal or proximal wedge procedure ........................... 308D4277 Free soft tissue graft, per tooth ................................... 654D4278 Free soft tissue graft, each add. tooth ........................ 100D4341 Perio scaling and root planing - >3 cont teeth, per quad. . 109D4342 Perio scaling and root planing - <= 3 teeth, per quad ... 63D4355 Full mouth debridement ................................................ 89D4381 Localized delivery of chemotherapeutic agents ............ 98D4910 Periodontal maintenance .............................................. 74 ORAL SURGERY D7111 Extraction, coronal remnants - deciduous tooth ............ 56D7140 Extraction, erupted tooth or exposed root ..................... 69D7210 Surgical rem. of erupted tooth req. bone cut ............... 133D7220 Removal of impacted tooth - soft tissue ...................... 151D7230 Removal of impacted tooth - partially bony ................. 196D7240 Removal of impacted tooth - completely bony ............ 241D7241 Removal of imp. tooth - completely bony, with unusual surg. complications .......................... 217D7250 Surgical removal of residual tooth roots ...................... 141D7251 Coronectomy-intentional partial tooth removal ........... 141D7270 Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth.... 226D7280 Surgical access of an unerupted tooth ........................ 153D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report ... 60D7310/20 Alveoloplasty, per quad ............................................... 141D7321 Alveoloplasty not in conj. w/ extractions ..................... 141D7471 Removal of lateral exostosis ....................................... 351D7510 Incision and drainage of abscess - intraoral soft tissue .... 96D7910 Suture of recent small wounds up to 5 cm .................... 59D7921 Collection application of blood concentrate .................. 40D7960 Frenulectomy (frenectomy/frenotomy) - separate proc... 263D7971 Excision of pericoronal gingiva ................................... 131 ORTHODONTICS1

- Pre-authorization required for Medically Necessary OrthodontiaD8010 Limited ortho. treatment of the primary dentition ...... 3304D8020 Limited ortho. treatment of the transitional dentition ... 3304D8030 Limited ortho treatment - adolescent dentition .......... 3422D8050 Interceptive ortho. treatment of the primary dentition .. 3304D8060 Interceptive ortho. treatment - transitional dentition .. 3304D8070 Comp. ortho. treatment - transitional dentition .......... 3304D8080 Comp. ortho. treatment - adolescent dentition .......... 3422D8090 Comp. ortho. treatment - adult dentition ................... 3658D8210 Removable appliance therapy .................................... 770D8220 Fixed appliance therapy .............................................. 783D8660 Pre-orthodontic treatment visit .................................... 413D8670 Periodic ortho. treatment visit (as part of contract) ..... 118D8680 Orthodontic ret. (rem. of appl./placement of retainer(s)) ... 413

Pediatric Plan Exclusions1. Services which are covered under worker’s compensation, employer’s liability laws or the Pennsylvania Motor Vehicle Financial Responsibility Law.2. Services which are not necessary for the patient’s dental health as determined by the Plan.3. Cosmetic, elective or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth as determined by the Plan.4. Oral surgery requiring the setting of fractures or dislocations.5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where, in the opinion of the Plan, such services should not be performed in a dental office.6. Dispensing of drugs.7. Hospitalization for any dental procedure.8. Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared, or while on active duty as a member of the armed forces of any nation.9. Replacement due to loss or theft of prosthetic appliance.10. Procedures not listed as covered benefits under this Plan.11. Services obtained outside of the dental office in which enrolled and that are not preauthorized by such office or the Plan (with the exception of out-of-area emergency dental services).12. Services related to the treatment of TMD (Temporomandibular Disorder) except if TMD is caused by severe, dysfunctional, handicapping malocclusion that requires medically necessary orthodontia services.13. Services performed by a Participating Specialist without a referral from a Participating General Dentist (with the exception of Orthodontics). Participating dentists should refer to Specialty Care Referral Guidelines.14. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth as determined by the Plan. The prophylactic removal of these teeth for medically necessary orthodontia services may be covered subject to review.15. Non-medically necessary orthodontia is not a covered benefit under this policy. However, a discount for non-medically necessary orthodontia may be available to members through the Plan’s, or its designee’s, agreements with certain of its participating orthodontists. The provider agreements create no liability for payment by the Plan, and payments by the member for these services do not contribute to the Out-of-Pocket Maximum. The Invisalign system and similar specialized braces are not a covered benefit. See limitation #24 concerning medically necessary orthodontia.

BlueCross DentalSM Dental Select Basic Exclusions

Pediatric Plan Limitations1. One evaluation (D0120, D0140, D0145, D0150,D0160, D0180) is covered once per six months, per patient. D0150 limited to once in 12 months).2. One (1) teeth cleaning (D1110 or D1120) per 6 months, per patient.3. One (1) fluoride application every 6 months, per patient. 4. One (1) set of bitewing x-rays are covered per six (6) months, per patient starting at age two.5. One (1) set of full mouth x-rays or panoramic film is covered every five (5) years. Panoramic x-rays are limited to ages 6-18. No more than one set of x-rays are covered per visit. 6. One (1) sealant per tooth is covered per 36 months, per patient up to age 18 (limited to occlusal surfaces of posterior permanent teeth without restorations or decay). 7. One (1) space maintainer (D1510, D1520, D1515 or D1525) is covered per 24 months per patient, per arch.8. Replacement of a filling is covered if it is more than three (3) years from the date of original placement.9. Replacement of a primary stainless steel crown (under age 15), crown, denture, or other prosthodontic appliance is covered if it is more than five (5) years from the date of original placement.10. Crown and bridge fees apply to treatment involving five or fewer units when presented in a single treatment plan. Additional crown or bridge units, beginning with the sixth unit, may be available to members through the Plan’s, or it designee’s, agreements with certain of its participating providers at the provider’s Usual, Customary, and Reasonable (UCR) fee, minus 25%.11. Relining and rebasing of dentures is covered once per 24 months, per patient.12. Root canal treatment is covered once per lifetime.13. Periodontal scaling and root planing (D4341 or D4342), limited to one (1) per 24 months, per patient, per quadrant.14. Osseous surgery (D4260 or D4261), gingival flap procedure (D4240), and gingivectomy or gingivoplasy (D4210 - D4212) are limited to one (1) per 36 months.15. Full mouth debridement is covered once per lifetime, per patient.16. Procedure Code D4381 is limited to one (1) benefit per tooth for three teeth per quadrant; or a total of 12 teeth for all four quadrants per twelve (12) months. Must have pocket depths of five (5) millimeters or greater.17. Periodontal surgery of any type, including any associated material, is covered once every 24 months, per quadrant or surgical site.18. Periodontal maintenance is covered twice per calendar year in addition to adult prophylaxis, within 24 months after definitive periodontal therapy.19. Denture rebase and denture reline is limited to 1 in a 36 month period 6 months after initial placement.20. General anesthesia and analgesic (only when provided in connection with a covered procedure(s) when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifiable medical or dental conditions), including intravenous and nonintravenous sedation with a maximum of 60 minutes of services (general anesthesia is not covered with procedure codes D9230, D9241 or D9242; intravenous conscious sedation is not covered with procedure codes D9220 or D9221; non-intravenous conscious sedation is not covered with procedure codes D9220 or D9221; requires a narrative of medical necessity be maintained in patient records.21. Occlusal guards are covered by report for patients 13 years of age or older when the purpose of the occlusal guard is for the treatment of bruxism or diagnoses other than temporomandibular dysfunction (TMD). Occlusal guards are limited to one per 12 consecutive month period. 22. Fixed partial dentures, buildups, and posts and cores for members under 16 years of age are only covered if deemed necessary by the Participating Dentist.23. Onlays, crowns, and posts and cores for members 12 years of age or younger are only covered if deemed necessary by the Participating Dentist. Cast posts and cores (D2952) are processed as an alternate benefit of a prefabricated post and core. Posts are eligible only when provided as part of a crown buildup or implant and are considered integral to the buildup or implant. 24. Medically necessary orthodontia, as determined by the Plan, has a 12 month waiting period. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient’s responsibility.

BlueCross DentalSM Dental Select Basic Limitations