dental coverage - benefit design group benefit descriptions... · 2013-05-20 · dental insurance...

l Dental

Dental Coverage

PLAN HIGHLIGHTS:

The Arc Montgomery County

Here is your new coverage. Make sure you are aware of the deadline date for your coverage elections.

If you miss the deadline, the coverage may be delayed or you may not be eligible for enrollment this year.

Questions? Concerns?

Helpline (888) 600-1600Call weekdays, 7:00AM to 8:30PM, EST. And refer to

your plan number: 00488327

Learn more about Guardian atwww.guardianlife.com.

We’re ready to get working for youIf you’re like most employees, finding enough time in the day to accomplish your lengthy

to-do list can often be no easy task.

As your Guardian coverage begins, we want you to know that we’re here for you every step

of the way and are committed to providing you with the resources to obtain fast, accurate

answers to your benefits-related questions.

One way in which we do this is through our online member resource, Guardian Anytimesm,

which allows you to manage your benefits when it works best for you — day or night. Plus,

it offers helpful resources to ensure you get access to the quality care you need.

We encourage you to take a couple minutes to check out and register for Guardian

Anytimesm at www.GuardianAnytime.com. We promise it will be time well spent.

Welcome to Guardian!

Plan Details This bookletexplains your basic planoptions. Your detailedcertificate of coverage will beprovided to you after youenroll.

Call the Helpline Questionsanswered at (888) 600-1600.

Find a networkdentist in minutesUse our ProviderOnline Search atwww.guardianlife.com

Optional pre-treatmentreview If you expect yourtreatment will cost $300 ormore, you can find out howmuch your plan will paybefore treatment starts.

Understand your benefitsPlease find a glossary forinsurance terms included.

UNDERSTAND YOUR COVERAGE:

n Review your benefits

n Complete your enrollment form, if applicable

n Sign and return form to your plan administrator

Dear The Arc Montgomery County Employee,

We�re pleased to tell you that Guardian will be our dentalcoverage provider this year. We have chosen Guardian because ofits competitive rates, excellent service reputation, and reliabledental claims payment.

We have worked hard to negotiate group rates that will beaffordable for all employees. All coverage is paid through payrolldeduction.


Prepared for The Arc Montgomery County Guardian Group Plan Number 00488327

Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com Enrollment Kit 00488327, 0001, EN

Welcome

1

Notes:

2

Why Dental Insurance?

Good oral hygiene is important, not only for looks, but for general health as well. A routine dental examination can detect symptoms of more than125 diseases, including heart disease, diabetes, anemia, stomach ulcers, osteoporosis and kidney disease. Regular check ups and cleanings cansave you the pain and expense of future problems. Dental insurance will keep these visits affordable and is a cost-effective way to minimize healthcare costs for you and your family. The American Dental Hygienists� Association estimates that for every $1 spent on prevention or oral health care,as much as $8 to $50 is saved on future emergency and restorative procedures. Using your dental insurance for regular dental check ups canimprove your health by helping you:

1) Prevent Oral Cancer: According to The Oral Cancer Foundation, someone dies from oral cancer every hour of every day in the United Statesalone. When you have your dental cleaning, your dentist is also screening you for oral cancer, which is highly curable if diagnosed early.

2) Prevent Gum Disease: Gum disease is an infection in the gum tissues and bone that keep your teeth in place and is one of the leading causesof adult tooth loss. If diagnosed early, it can be treated and reversed. If treatment is not received, a more serious and advanced stage of gumdisease may follow. Regular dental cleanings and check ups, flossing daily and brushing twice a day are key factors in preventing gum disease.

3) Help Maintain Good Physical Health: Recent studies have linked heart attacks and strokes to gum disease, resulting from poor oral hygiene.A dental cleaning every six months helps to keep your teeth and gums healthy and could possibly reduce your risk of heart disease and strokes,as well as many other serious conditions.

4) Keep Your Teeth: Since gum disease is one of the leading causes of tooth loss in adults, regular dental check ups and cleanings, brushingand flossing are vital to keeping as many teeth as you can. Keeping your teeth means better chewing function and ultimately, better health.

5) Prevent the Need for Advanced Treatment: Your dentist and hygienist will be able to detect any early signs of problems with your teeth orgums that can be easily treatable. If these problems go untreated, root canals, gum surgery and removal of teeth could become the onlytreatment options available.

6) Have a Bright and White Smile: Your dental hygienist can remove most tobacco, coffee and tea stains. During your cleaning, your hygienistwill also polish your teeth to a beautiful shine.

7) Protect your children�s health: Tooth decay is the most common chronic childhood disease, five times more common than asthma and resultsin a loss of 51 million school hours each year. Regular check ups can help prevent tooth decay in your children.

Sources: www.about.com, American Academy of Pediatrics

Prepared for The Arc Montgomery County Guardian Group Plan Number 00488327

Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com Enrollment Kit 00488327, 0001, EN 3

Dental PlansYOUR GUARDIAN

PLAN OFFERS:

No charge for preventive care(subject to plan limits)

Maximum rollover If amember submits at leastone claim and stays underthe claims threshold, a partof the unused maximumwill be rolled over for usein future years.

National PPO network of morethan 87,000 dentists at over200,000 locations nationwide.

Reliable claims payment fourdays on average

Find out if your dentist is inGuardian�s network atwww.guardianlife.com

Let Guardian put its 30-plus yearsof dental benefits experience towork for you and your family.

COMPARE THE PLANS Option 1: Split Value M7 Option 2: Value VZ

Network DentalGuard Preferred DentalGuard Preferred

Your Semi-monthly premium $13.45 $7.93You and 1 dependent (Spouse or Child) $26.23 $16.06

You, spouse and child(ren) $39.30 $22.92

Plan year deductible In-Network Out-Network In-Network Out-Network

Individual $50 $50 $25 $25Family limit 3 per family 3 per familyWaived for Preventive Preventive Preventive Preventive

Charges covered for you (co-insurance) In-Network Out-Network In-Network Out-Network

Preventive Care (e.g. cleanings) 100% 80% 100% 100%

Basic Care (e.g. fillings) 80% 70% 50% 50%

Major Care (e.g. crowns, dentures) 50% 40% 25% 25%

Orthodontia Not Covered Not Covered

Annual Maximum Benefit $1000 $1000 $2000 $2000

Maximum Rollover Yes YesRollover Threshold $500 $800

Rollover Amount $250 $400

Rollover In-network Amount $350 $600

Rollover Account Limit $1000 $1500

Lifetime Orthodontia Maximum Not Applicable Not Applicable

Dependent Age Limits 26 26

Option 1 or 2: With your Split Value M7 or Value VZ plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist.Out-of-network benefits are limited to our PPO fee schedule.

4

CATEGORY PLAN DETAILS Option 1: Split Value M7 Option 2: Value VZPlan pays (on average) Plan pays (on average)

In-network Out-of-network In-network Out-of-network

Preventive Care Cleaning (prophylaxis) 100% 80% 100% 100%

Frequency: 2 in 12 Months 2 in 12 MonthsFluoride Treatments 100% 80% 100% 100%

Limits: Under Age 14 Under Age 14Oral Exams 100% 80% 100% 100%

Periodontal Maintenance 100% 80% 100% 100%

Frequency: Once Every 3 Months Once Every 3 Months(Enhanced) (Enhanced)

Sealants (per tooth) 100% 80% 100% 100%

X-rays 100% 80% 100% 100%

Basic Care Anesthesia* 80% 70% 50% 50%

Fillings� 80% 70% 50% 50%

Simple Extractions 80% 70% 50% 50%

Major Care Bridges and Dentures 50% 40% 25% 25%

Dental Implants 50% 40% 25% 25%

Inlays, Onlays, Veneers** 50% 40% 25% 25%

Perio Surgery 50% 40% 25% 25%

Repair & Maintenance ofCrowns, Bridges & Dentures 50% 40% 25% 25%Root Canal 50% 40% 25% 25%

Scaling & Root Planing (per quadrant) 50% 40% 25% 25%

Single Crowns 50% 40% 25% 25%

Surgical Extractions 50% 40% 25% 25%

This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO and orIndemnity members, Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury or otherpathology when the tooth cannot be restored with amalgam or composite filing material. When Orthodontia coverage is for "Child(ren)"only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-time status is required by your in order toremain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status is maintained. IfOrthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. The total number of cleanings and periodontalmaintenance procedures are combined in a 12 month period. *General Anesthesia - restrictions apply. �For PPO and or Indemnitymembers, Fillings- restrictions may apply to composite fillings.

Please note: The plandetails listed here are someof the most commonservices related to dentalcoverage. The co-insurance percentages forthe PPO plan optionscorrespond to the coveragecategories of Preventive,Basic, Major andOrthodontia listed in thetable above.

Some services may be paidunder a different categorythan listed. The actualco-insurance shownreflects your plan'scoverage.

EXCLUSIONS AND LIMITATIONS

n Important Information about Guardian�s DentalGuard Indemnity and DentalGuard Preferred PPO plans: This policyprovides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose ortreat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: oral hygiene services (exceptas covered under preventive services), orthodontia (unless expressly provided for), cosmetic or experimentaltreatments (unless they are expressly provided for), any treatments to the extent benefits are payable by any otherpayor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillaryto surgical treatment. The plan limits benefits for diagnostic consultations and for preventive, restorative,

endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listed above do notconstitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage.Contract # GP-1-DG2000 et al.

n For PPO and or Indemnity Special Limitation: Teeth lost or missing before a covered person becomes insured by this plan.A covered person may have one or more congenitally missing teeth or have lost one or more teeth before he became insuredby this plan. We won�t pay for a prosthetic device which replaces such teeth unless the device also replaces one or morenatural teeth lost or extracted after the covered person became insured by this plan. R3 � DG2000

5

UNDERSTANDING YOUR BENEFITS�DENTAL

Basic care Moderately complex dental services. Most plans consider fillings and extractions to be basic care.

Co-insurance The portion of the covered charge paid by Guardian.

Claims Payment Basis Value VZ

In-Network: You receive regular contracted savings, and no balance billing.Out-of-Network: Charges will be paid for only up to the maximum fee level established with our contracted network dentists;any amount that is charged over the fee schedule is the responsibility of the patient.

Claims Payment Basis Split Value M7

In-Network: You receive regular contracted savings, paid at a higher co-insurance level; with no balance billing.Out-of-Network: Charges will be paid for only up to the maximum fee level established with our contracted network dentists;any amount that is charged over the fee schedule is the responsibility of the patient.

Deductible The amount of charges you and your family must pay each plan year before the plan pays you any benefits.

Family limit Maximum number of deductibles your family must pay in each plan year before this plan starts paying benefits for all covered familymembers for the rest of the plan year.

In-network charges Charges for services provided by dentists who are a member of your plan's network.

Major care More complex dental services. Most plans consider crowns and dentures to be major care.

Out-of-network charges Charges for services provided by dentists who are not members of your plan's network.

Plan year The 12 month period used to apply this plan's deductible and annual maximum.

PPO (Preferred Provider Organization) Plan that lets you visit any dentist, but usually provides better benefits for the services of PPO network dentists. PPO dentists haveagreed to accept discounted fees as payment in full.

Pre-determination Review Guardian will gladly assist you and your dentist by determining what benefits could be payable for services and procedures over $300.Have your dentist fax your treatment plan to Guardian, note that it is a pre-determination review and we will let your dentist know whatbenefits would be payable. This includes orthodontic treatment if your plan includes it. Pre-determination applies to PPO and Indemnityplans only.

Preventive care Most routine dental services. Most plans consider checkups and cleanings to be preventive care.

6

Introducing your Guardian and Dominion Dual Choice Dental Plan

Through Guardian and Dominion– you can choose the plan that works best for you. Both offer comprehensive coverage to help keep you healthy and save money – all on one bill from Guardian! Choose between:

Guardian’s PPO – access to one of the nation’s largest network • Over 88,0000 in-network dentists nationally – and growing every day

• Dentists offer discounts averaging 30% - helping to save money on important treatments for health

• Strict credentialing process ensures quality care

• Freedom to see any dentist – but can save when visiting a dentist in the network

• Find a dentist online or through your smart phone – www.GuardianAnytime.com

Dominion’s Select/Pre-Paid Plan (same as a DHMO)1 – lower-cost access to dental care • Choice of any participating dentist in one of the area’s largest DHMO-style networks2

• No deductibles, maximum dollar limits, waiting periods, claims forms3 or pre-authorization forms

• Extensive coverage and quality dental care at pre-determined fees

• Orthodontic benefits provided for adults and children

1 Same as a DHMO with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or pre-treatment estimates and no claim forms or proof of loss (except in the case of out-of-area emergencies). 2 Dominion Dental Services, Inc. Competitive Network Survey, 4th Quarter 2012. Participating dentists are subject to change. 3 Out-of-area emergency care reimbursement requires a receipt or other proof of loss.

7

Good News! Your Dental Plan Is Even Better Than You Think

Savings on in-Network providers average 30% of what dentists usually charge!

In-network: You receive regular contracted savings, paid at ahigher co-insurance level; with no balance billing.

Out-of-network: Charges will be paid for only up to themaximum fee level established with our contracted networkdentists; any amount that is charged over the fee schedule isthe responsibility of the patient.

Split Value PlanExample: Network vs. Non-Network Savings*N

Difference in your out-of-pocket expense: $369Benefits for a Root Canal (on a molar)

Network Care Non-Network Care

Typical network dentist fee: $665

Plan Pays: $532**

You Pay: $133

Average non-network dentist fee: $968

Plan Pays: $466**

You Pay: $502

*Savings may be greater or less depending on your dentist’s location** Assumes service is covered at a 70% and an 80% co-insurance level for non-network and network care respectively.

More Reasons to Use Network Care

One of the industry’s largest Preferred Provider networks – highly skilled dental professionals at over 128,000 locations. Network dentists are easy to locate. Simply use the On-Line DentalGuard Provider Directory at www.GuardianLife.com or call the number

on the back of your ID card. If your provider does not participate, Guardian’s convenient dentist referral program can help add them to thenetwork!

No claim forms to complete. Just present your new DentalGuard Preferred Network ID card to the provider.

DentalGuard General Limitations and Exclusions: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductiblesapply. The plan does not pay for: oral hygiene services (except as covered under preventive services), orthodontia (unless expressly provided for), cosmetic or experimental treatments, any treatments to the extent benefits arepayable by any other payor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment, The plan limits benefits for diagnostic consultations and for preventive,restorative, endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter ofcoverage. Contract # GP-1-DG2000 et al. 9

Maximum Rollover®Save Your Dental Annual Maximum Dollars For a Time When You Need Them Most!

With Maximum Rollover, Guardian will roll over a portion of your unused annual maximum into your personal Maximum Rollover Account (MRA). TheMRA can be used in further years, if you reach the plan’s annual maximum.To qualify, you must submit a claim for covered services for which a benefit payment is issued, in excess of any deductible or co-pay, and you must notexceed the paid claims threshold during the benefit year.You and your insured dependents maintain separate MRAs based on your own claim activity. Each MRA may not exceed the MRA limit.You can view your annual MRA statement detailing your account and those of your dependents on www.GuardianAnytime.com.

PLAN ANNUALMAXIMUM ** THRESHOLD MAXIMUM ROLLOVER AMOUNT IN-NETWORK ONLY MAXIMUM

ROLLOVER AMOUNTMAXIMUM ROLLOVER

ACCOUNT LIMIT

$1000 $500 $250 $350 $1000** If a plan has a different annual maximum for PPO benefits vs. non-PPO benefits, ($1500 PPO/$1000 non-PPO for example) the non-PPO maximum determines the Maximum Rollover plan.

NOTES:Cases on either a calendar year or policy year accumulation basis qualify for the Maximum Rollover feature. For calendar year cases with an effectivedate in October, November or December, the Maximum Rollover feature starts as of the first full benefit year. For example, if a plan starts in November of2009, the claim activity in 2010 will be used and applied to MRAs for use in 2011.Under either benefit year set up (calendar year or policy year), Maximum Rollover for new entrants joining with 3 months or less remaining in the benefityear, will not begin until the start of the next full benefit year.Maximum Rollover is deferred for members who have coverage of Major services deferred. For these members, Maximum Rollover starts when coverageof Major services starts, or the start of the next benefit year if 3 months or less remain until the next benefit year.

11

Good News! Your Dental Plan Is Even Better Than You ThinkSavings on in-Network providers average 30% of what dentists usually charge!In-network: You receive regular contracted savings, and nobalance billing.

Out-of-network: Charges will be paid for only up to the maximum fee levelestablished with our contracted network dentists; any amount that is chargedover the fee schedule is the responsibility of the patient.

Value PlanExample: Network vs. Non-Network Savings*N

Difference in your out-of-pocket expense: $369Benefits for a Root Canal (on a molar)

Network Care Non-Network CareTypical network dentist fee: $665Plan Pays: $532**You Pay: $133

Average non-network dentist fee: $968Plan Pays: $532**You Pay: $436

*Savings may be greater or less depending on your dentist’s location**Assumes service is covered at an 80% co-insurance level

More Reasons to Use Network Care• One of the industry’s largest Preferred Provider networks – highly skilled dental professionals at over 128,000 locations.• Network dentists are easy to locate. Simply use the On-Line DentalGuard Provider Directory at www.GuardianLife.com or call the number

on the back of your ID card. If your provider does not participate, Guardian’s convenient dentist referral program can help add them to thenetwork!

• No claim forms to complete. Just present your new DentalGuard Preferred Network ID card to the provider.DentalGuard General Limitations and Exclusions: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductiblesapply. The plan does not pay for: oral hygiene services (except as covered under preventive services), orthodontia (unless expressly provided for), cosmetic or experimental treatments, any treatments to the extent benefits arepayable by any other payor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment, The plan limits benefits for diagnostic consultations and for preventive,restorative, endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter ofcoverage. Contract # GP-1-DG2000 et al.

13


With Maximum Rollover, Guardian will roll over a portion of your unused annual maximum into your personal Maximum Rollover Account (MRA). TheMRA can be used in further years, if you reach the plan’s annual maximum.To qualify, you must submit a claim for covered services for which a benefit payment is issued, in excess of any deductible or co-pay, and you must notexceed the paid claims threshold during the benefit year.You and your insured dependents maintain separate MRAs based on your own claim activity. Each MRA may not exceed the MRA limit.You can view your annual MRA statement detailing your account and those of your dependents on www.GuardianAnytime.com.

PLAN ANNUALMAXIMUM ** THRESHOLD MAXIMUM ROLLOVER AMOUNT IN-NETWORK ONLY MAXIMUM

ROLLOVER AMOUNTMAXIMUM ROLLOVER

ACCOUNT LIMIT

$2000 $800 $400 $600 $1500** If a plan has a different annual maximum for PPO benefits vs. non-PPO benefits, ($1500 PPO/$1000 non-PPO for example) the non-PPO maximum determines the Maximum Rollover plan.

NOTES:Cases on either a calendar year or policy year accumulation basis qualify for the Maximum Rollover feature. For calendar year cases with an effectivedate in October, November or December, the Maximum Rollover feature starts as of the first full benefit year. For example, if a plan starts in November of2009, the claim activity in 2010 will be used and applied to MRAs for use in 2011.Under either benefit year set up (calendar year or policy year), Maximum Rollover for new entrants joining with 3 months or less remaining in the benefityear, will not begin until the start of the next full benefit year.Maximum Rollover is deferred for members who have coverage of Major services deferred. For these members, Maximum Rollover starts when coverageof Major services starts, or the start of the next benefit year if 3 months or less remain until the next benefit year.

15

Dental Care Information Now at Your FingertipsIntroducing new online tools, for Guardian members, to help you take better care of your oral and overallhealth, available at www.GuardianAnytime.com (see the My Benefits tab)

Estimate the cost of your dental care• View estimates for out-of-pocket costs prior to receiving the actual treatment• See the estimated cost savings if you use a Guardian network provider• Access a dental glossary for definitions of key dental terms

Read about tips for a Healthy Smile• Learn more about how to maintain good oral health and its impact on their overall health and well-being• Topics include tips on getting the right care, children’s dental care, prevention and recognizing dental problems

Find a dentist quickly and easily• Create a customized list of providers based on their preferences, or look up a specific provider• Unique features include side-by-side comparisons of provider information, ability to create a short list of “favorite” providers for quick

reference and get maps and directions to an office• Have your results faxed or emailed back to you

17

Guardian’s International Dental Assistance –Access to quality care

when far from home

Guardian is committed to helping you get more value from your dental plan. We are pleased that your Guardian dental planoffers access to International Assist.* You’ll have access to dental care if needed while traveling outside of the United States.

International Assist is available as a resource if you or your family members need emergency dental assistance while abroad:

Simply call collect to a special telephone number, available at any time – 24 hours a day, 7 days a week

You will be provided with referrals to dentists and facilities providing emergency dental care

Details provided include specialty, experience and English-language proficiency

Dentists have gone through strict credentialing, including local accreditation, experience working with foreign patients andpatient care environment

Reimbursement for services through an International Assist dentist will be as an out-of-network service. Simply save receiptsand submit a claim.

Available in over 200 countries it just takes a phone call:International: (call collect) 1-630-766-7710From within the US: 888-647-2701

*International referral program provided by AXA Assistance USA, Inc.

The Guardian Life Insurance Company of America, New York, NY 10004

19

Finding a Provider

How to Look Up DentalGuard Preferred Providers Online

Guardian’s innovative web technology lets you look up a provider right from your computer. Our Find a Provider Search function is simple and easy-to-use. Just follow these steps:

Visit Guardian’s web page at www.GuardianAnytime.com:

• Click on “Find A Provider” at the top of the page

• Click on the box that says “Find a Dentist”

On the next web page, follow these easy steps to search:

• Under “Select Your Dental Plan” Choose PPO

• Under “Search by” select “Search by Location”, “Location & Dentist’s Name”, or “Location & Office Practice Name”.

• Under “Your Location”, enter Zip Code or Street Address information

• Under “Distance” select your mile radius, then “Select your Dental Network” Choose – DentalGuard Preferred Note: You also have the option to include type of Dentist, foreign language spoken, and office status in your search.

• Click “Continue” to view the list of network providers

You can also find a dentist on the go from your smart phone – simply download our app at www.GuardianAnytime.com/mobile.

21

Find a Provider

How to Look Up Dominion Plan Providers Online





On the next web page, follow the easy steps to search:

• Under “Select Your Dental Plan” Choose DHMO/Pre-Paid



• Under “Distance” select you mile radius, then “Select your Dental Network” Choose– Dominion Note: You also have the option to include foreign language spoken and office status in your search.


23

It’s easy to use your dental benefits. You don’t even need an ID card!

Your Guardian dental benefits are designed to save you money on important treatments to keep you healthy, by making it easy for you to find a network dentist in your area. The best way to save money is to see a dentist in your network.

It’s easy to find a Guardian network dentist:

• Visit www.GuardianAnytime.com and click on Find a Provider.

• Under Dental Plan, choose PPO. Your PPO type is DentalGuard Preferred.

• Follow the easy steps to search.

• You can also find a dentist on the go from your smart phone – simply download our app at www.GuardianAnytime.com/mobile.

You’ll need your Group ID number for your first visit with the dentist. The Group ID number is included in your enrollment material and available from your employer.* Once your plan is activated, you can also view and print an image of your ID card from www.GuardianAnytime.com or through our smart phone app. Use your Group ID number to register.

*Your Group ID Number is located on the front of your enrollment materials and on the top right corner of the enrollment form.

2012-8231

25

Guardian AnytimeSM Mobile

Guardian’s network in the palm of your hand.

The best way to save money through your dental and vision benefits is to see a provider in your network. Guardian makes it easy to find a dentist orvision provider near you, online or on the go! Plus, you can access your member ID card to present at your visit.Choose between:

Search on the go!

It’s fast and easy to find a provider from your smart phone through our Guardian Anytime mobile app.It’s easy to download and use! Simply search by location or name.

Visit www.GuardianAnytime.com/mobile.

View/Print your Member ID Card

You no longer need to show your dental or vision provider a paper ID card. Simply access an image ofyour card through Guardian Anytime Mobile and show them at your visit!

You can also Find a Provider at our website www.GuardianAnytime.com. Customize your search, getside-by-side comparisons, or create a quick list of “favorite” providers and more!

27

ADDITIONAL MATERIALS

28

It’s quick and easy to view and print your Guardian ID card!

Simply register for www.GuardianAnytime.com and follow these instructions!

Step 1: Log-in and click on the ID card link on your Home page, or choose “Forms and Materials.”

Step 2: Select View/Print next to the card you want to access Step 3: Choose Open and you can then save or print your ID card

29

Thank You

q Check the coverage you want

q Include your social security number

(and those of your dependents, if applicable)

q Include dates of birth

q Indicate the best way to reach you

q Include your name on each page of the form

q Sign and date form

If applicable, return your completed form to your plan

administrator.

Please remember to:

Date form submitted:

© 2005 The Guardian Life Insurance Company of America,

7 Hanover Square, New York 10004

Make the most of your Guardian benefits at

www.GuardianAnytime.com

Enrolled members and their dependents can access helpful,secure information about their Guardian benefit(s) instantly atwww.GuardianAnytime.com

� Review your benefits� Look up amounts and services covered in your plan� Check the status of a claim� Receive e-mail alerts when a response to your

dental* claim is available online� View and print dental or vision ID cards� Print forms and plan materials...and much more

To register, go to www.GuardianAnytime.com

*Not available to members with Guardian pre-paid Dental/DHMO plans (including FirstCommonwealthand Managed DentalGuard plans).

The Arc MontgomeryCounty Dental BenefitsPlan

0001

Group Number: 00488327

About Your Benefits:

Good oral hygiene is important, not only for looks, but for general health as well. A routine dental examination can detect many

diseases including heart disease, diabetes, anemia, stomach ulcers, osteoporosis and kidney disease. Regular check ups and cleanings

can save you the pain and expense of future problems. Using your dental insurance for regular dental checkups can improve your

health. Your dental insurance can also help save you money if more serious dental treatments are needed.

Option 1 or 2:With your Split Value M7 or Value VZ plan, you can visit any dentist; but you pay less out-of-pocket when youchoose a PPO dentist. Out-of-network benefits are limited to our PPO fee schedule.

The Arc Montgomery County Benefit Summary

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

Dental Benefit Summary


Option 1: Split Value M7 Option 2: Value VZ

Network DentalGuard Preferred DentalGuard Preferred

Your Semi-monthly premium $13.45 $7.93

You and 1 dependent (Spouse or Child) $26.23 $16.06

You, spouse and child(ren) $39.30 $22.92

Plan year deductible In-Network Out-of-Network In-Network Out-of-Network

Individual $50 $50 $25 $25

Family limit 3 per family 3 per family

Waived for Preventive Preventive Preventive Preventive

Charges covered for you (co-insurance) In-Network Out-of-Network In-Network Out-of-Network

Preventive Care (e.g. cleanings) 100% 80% 100% 100%

Basic Care (e.g. fillings) 80% 70% 50% 50%

Major Care (e.g. crowns, dentures) 50% 40% 25% 25%

Orthodontia Not Covered Not Covered

Annual Maximum Benefit $1000 $1000 $2000 $2000

Maximum Rollover Yes Yes

Rollover Threshold $500 $800

Rollover Amount $250 $400

Rollover In-network Amount $350 $600

Rollover Account Limit $1000 $1500

Lifetime Orthodontia Maximum Not Applicable Not Applicable

Dependent Age Limits 26 26

1

A Sample of Services Covered by Your Plan:

The Arc Montgomery County Benefit Summary

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

Option 1: Split Value M7 Option 2: Value VZ

Plan pays (on average) Plan pays (on average)

In-network Out-of-network In-network Out-of-network

Preventive Care Cleaning (prophylaxis) 100% 80% 100% 100%

Frequency: 2 in 12 Months 2 in 12 Months

Fluoride Treatments 100% 80% 100% 100%

Limits: Under Age 14 Under Age 14

Oral Exams 100% 80% 100% 100%

Periodontal Maintenance 100% 80% 100% 100%

Frequency: Once Every 3 Months Once Every 3 Months

(Enhanced) (Enhanced)

Sealants (per tooth) 100% 80% 100% 100%

X-rays 100% 80% 100% 100%

Basic Care Anesthesia* 80% 70% 50% 50%

Fillings‡ 80% 70% 50% 50%

Simple Extractions 80% 70% 50% 50%

Major Care Bridges and Dentures 50% 40% 25% 25%

Dental Implants 50% 40% 25% 25%

Inlays, Onlays, Veneers** 50% 40% 25% 25%

Perio Surgery 50% 40% 25% 25%

Repair & Maintenance ofCrowns, Bridges & Dentures 50% 40% 25% 25%

Root Canal 50% 40% 25% 25%

Scaling & Root Planing (per quadrant) 50% 40% 25% 25%

Single Crowns 50% 40% 25% 25%

Surgical Extractions 50% 40% 25% 25%

This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO and or Indemnitymembers, Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury or other pathology when the toothcannot be restored with amalgam or composite filing material. When Orthodontia coverage is for "Child(ren)" only, the orthodontic appliance mustbe placed prior to the age limit set by your plan; If full-time status is required by your plan in order to remain insured after a certain age; thenorthodontic maintenance may continue as long as full-time student status is maintained. If Orthodontia coverage is for "Adults and Child(ren)" thislimitation does not apply. The total number of cleanings and periodontal maintenance procedures are combined in a 12 month period. *GeneralAnesthesia – restrictions apply. ‡For PPO and or Indemnity members, Fillings – restrictions may apply to composite fillings.

Manage Your Benefits:

Enrolled members and their dependents can accesshelpful, secure information about their Guardian benefits atwww.guardiananytime.com

Find A Dentist:

Visit www.GuardianLife.comUnder “Contact Us”, Click on “Find A Provider”

Questions?

Call the Guardian Helpline (888) 600-1600Call weekdays, 7:00 AM to 8:30 PM, EST. And referto your plan number: 00488327

EXCLUSIONS AND LIMITATIONS

n Important Information about Guardian’s DentalGuard Indemnity andDentalGuard Preferred PPO plans: This policy provides dental insurance only.Coverage is limited to those charges that are necessary to prevent, diagnose ortreat dental disease, defect, or injury. Deductibles apply. The plan does not payfor: oral hygiene services (except as covered under preventive services),orthodontia (unless expressly provided for), cosmetic or experimentaltreatments (unless they are expressly provided for), any treatments to theextent benefits are payable by any other payor or for which no charge is made,prosthetic devices unless certain conditions are met, and services ancillary tosurgical treatment. The plan limits benefits for diagnostic consultations and for

preventive, restorative, endodontic, periodontic, and prosthodontic services.The services, exclusions and limitations listed above do not constitute acontract and are a summary only. The Guardian plan documents are the finalarbiter of coverage. Contract # GP-1-DG2000 et al.

n PPO and or Indemnity Special Limitation: Teeth lost or missing before acovered person becomes insured by this plan. A covered person may have one ormore congenitally missing teeth or have lost one or more teeth before he becameinsured by this plan. We won’t pay for a prosthetic device which replaces such teethunless the device also replaces one or more natural teeth lost or extracted after thecovered person became insured by this plan. R3 – DG2000

2

Introducing your Guardian and Dominion Dual Choice Dental Plan

Through Guardian and Dominion– you can choose the plan that works best for you. Both offer comprehensive coverage to help keep you healthy and save money – all on one bill from Guardian! Choose between:

Guardian’s PPO – access to one of the nation’s largest network • Over 88,0000 in-network dentists nationally – and growing every day

• Dentists offer discounts averaging 30% - helping to save money on important treatments for health

• Strict credentialing process ensures quality care

• Freedom to see any dentist – but can save when visiting a dentist in the network

• Find a dentist online or through your smart phone – www.GuardianAnytime.com

Dominion’s Select/Pre-Paid Plan (same as a DHMO)1 – lower-cost access to dental care • Choice of any participating dentist in one of the area’s largest DHMO-style networks2

• No deductibles, maximum dollar limits, waiting periods, claims forms3 or pre-authorization forms

• Extensive coverage and quality dental care at pre-determined fees

• Orthodontic benefits provided for adults and children

1 Same as a DHMO with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or pre-treatment estimates and no claim forms or proof of loss (except in the case of out-of-area emergencies). 2 Dominion Dental Services, Inc. Competitive Network Survey, 4th Quarter 2012. Participating dentists are subject to change. 3 Out-of-area emergency care reimbursement requires a receipt or other proof of loss.

3

Good News! Your Dental Plan Is EvenBetter Than You ThinkSavings on in-Network providers average 30% of what dentists usually charge!In-network: You receive regular contracted savings,paid at a higher co-insurance level; with no balancebilling.

Out-of-network: Charges will be paid for only upto the maximum fee level established with ourcontracted network dentists; any amount that ischarged over the fee schedule is theresponsibility of the patient.

Split Value PlanExample:

Network vs. Non-Network Savings*Difference in your out-of-pocket expense: $369

Benefits for a Root Canal (on a molar)Network Care Non-Network Care

Typical network dentist fee: $665Plan Pays: $532**You Pay: $133


*Savings may be greater or less depending on your dentist’s location** Assumes service is covered at a 70% and an 80% co-insurance level for non-network and network care respectively.

More Reasons to Use Network Care• One of the industry’s largest Preferred Provider networks – highly skilled dental professionals at over 128,000

locations.• Network dentists are easy to locate. Simply use the On-Line DentalGuard Provider Directory at

www.GuardianLife.com or call the number on the back of your ID card. If your provider does not participate,Guardian’s convenient dentist referral program can help add them to the network!

• No claim forms to complete. Just present your new DentalGuard Preferred Network ID card to the provider.DentalGuard General Limitations and Exclusions: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnoseor treat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: oral hygiene services (except as covered under preventive services), orthodontia (unlessexpressly provided for), cosmetic or experimental treatments, any treatments to the extent benefits are payable by any other payor or for which no charge is made, prostheticdevices unless certain conditions are met, and services ancillary to surgical treatment, The plan limits benefits for diagnostic consultations and for preventive, restorative,endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardianplan documents are the final arbiter of coverage. Contract # GP-1-DG2000 et al.

5


With Maximum Rollover, Guardian will roll over a portion of your unused annual maximum into your personalMaximum Rollover Account (MRA). The MRA can be used in further years, if you reach the plan’s annualmaximum.To qualify, you must submit a claim for covered services for which a benefit payment is issued, in excess of anydeductible or co-pay, and you must not exceed the paid claims threshold during the benefit year.You and your insured dependents maintain separate MRAs based on your own claim activity. Each MRA may notexceed the MRA limit.You can view your annual MRA statement detailing your account and those of your dependents onwww.GuardianAnytime.com.

PLAN ANNUALMAXIMUM ** THRESHOLD MAXIMUM ROLLOVER

AMOUNTIN-NETWORK ONLY

MAXIMUM ROLLOVERAMOUNT

MAXIMUM ROLLOVERACCOUNT LIMIT

$1000 $500 $250 $350 $1000** If a plan has a different annual maximum for PPO benefits vs. non-PPO benefits, ($1500 PPO/$1000 non-PPO for example) the non-PPO maximum determines theMaximum Rollover plan.

NOTES:Cases on either a calendar year or policy year accumulation basis qualify for the Maximum Rollover feature. Forcalendar year cases with an effective date in October, November or December, the Maximum Rollover featurestarts as of the first full benefit year. For example, if a plan starts in November of 2009, the claim activity in 2010 willbe used and applied to MRAs for use in 2011.Under either benefit year set up (calendar year or policy year), Maximum Rollover for new entrants joining with 3months or less remaining in the benefit year, will not begin until the start of the next full benefit year.Maximum Rollover is deferred for members who have coverage of Major services deferred. For these members,Maximum Rollover starts when coverage of Major services starts, or the start of the next benefit year if 3 months orless remain until the next benefit year.

7

Good News! Your Dental Plan Is EvenBetter Than You ThinkSavings on in-Network providers average 30% of what dentists usually charge!In-network: You receive regular contracted savings, and nobalance billing.

Out-of-network: Charges will be paid for only up to themaximum fee level established with our contracted networkdentists; any amount that is charged over the fee schedule isthe responsibility of the patient.

Value PlanExample:

Network vs. Non-Network Savings*Difference in your out-of-pocket expense: $369

Benefits for a Root Canal (on a molar)Network Care Non-Network Care

Typical network dentist fee: $665Plan Pays: $532**You Pay: $133


*Savings may be greater or less depending on your dentist’s location**Assumes service is covered at an 80% co-insurance level

More Reasons to Use Network Care• One of the industry’s largest Preferred Provider networks – highly skilled dental professionals at over 128,000

locations.• Network dentists are easy to locate. Simply use the On-Line DentalGuard Provider Directory at

www.GuardianLife.com or call the number on the back of your ID card. If your provider does not participate,Guardian’s convenient dentist referral program can help add them to the network!

• No claim forms to complete. Just present your new DentalGuard Preferred Network ID card to the provider.

DentalGuard General Limitations and Exclusions: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treatdental disease, defect, or injury. Deductibles apply. The plan does not pay for: oral hygiene services (except as covered under preventive services), orthodontia (unless expresslyprovided for), cosmetic or experimental treatments, any treatments to the extent benefits are payable by any other payor or for which no charge is made, prosthetic devices unlesscertain conditions are met, and services ancillary to surgical treatment, The plan limits benefits for diagnostic consultations and for preventive, restorative, endodontic, periodontic, andprosthodontic services. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter ofcoverage. Contract # GP-1-DG2000 et al.

9


With Maximum Rollover, Guardian will roll over a portion of your unused annual maximum into your personalMaximum Rollover Account (MRA). The MRA can be used in further years, if you reach the plan’s annualmaximum.To qualify, you must submit a claim for covered services for which a benefit payment is issued, in excess of anydeductible or co-pay, and you must not exceed the paid claims threshold during the benefit year.You and your insured dependents maintain separate MRAs based on your own claim activity. Each MRA may notexceed the MRA limit.You can view your annual MRA statement detailing your account and those of your dependents onwww.GuardianAnytime.com.

PLAN ANNUALMAXIMUM ** THRESHOLD MAXIMUM ROLLOVER

AMOUNTIN-NETWORK ONLY

MAXIMUM ROLLOVERAMOUNT

MAXIMUM ROLLOVERACCOUNT LIMIT

$2000 $800 $400 $600 $1500** If a plan has a different annual maximum for PPO benefits vs. non-PPO benefits, ($1500 PPO/$1000 non-PPO for example) the non-PPO maximum determines theMaximum Rollover plan.

NOTES:Cases on either a calendar year or policy year accumulation basis qualify for the Maximum Rollover feature. Forcalendar year cases with an effective date in October, November or December, the Maximum Rollover featurestarts as of the first full benefit year. For example, if a plan starts in November of 2009, the claim activity in 2010 willbe used and applied to MRAs for use in 2011.Under either benefit year set up (calendar year or policy year), Maximum Rollover for new entrants joining with 3months or less remaining in the benefit year, will not begin until the start of the next full benefit year.Maximum Rollover is deferred for members who have coverage of Major services deferred. For these members,Maximum Rollover starts when coverage of Major services starts, or the start of the next benefit year if 3 months orless remain until the next benefit year.

11

Denta

lCare

Informa

tionNo

watY

ourFin

gertips

Introd

ucing

newon

linetoo

ls,for

Guard

ianme

mbers

,tohel

pyou

takeb

etter

careo

fyour

oralan

dover

allhea

lth,av

ailable

atwww

.Guard

ianAn

ytime.c

om(se

etheM

yBene

fitstab

)

Estim

atethe

costo

fyour

dental

care

•Vie

westim

atesfo

rout-of

-pocke

tcosts

priorto

receiv

ingthe

actual

treatme

nt•

Seeth

eestim

atedc

ostsav

ingsif

youuse

aGuar

diann

etwork

provid

er•

Access

adent

alglos

saryfo

rdefini

tionso

fkeyd

entalt

erms

Read

about

tipsfo

raHe

althyS

mile

•Lea

rnmore

abouth

owtom

aintain

goodo

ralhea

lthand

itsimp

acton

theiro

verall

health

andwe

ll-bein

g•

Topics

includ

etips

onget

tingthe

rightca

re,chi

ldren’s

dental

care,p

revent

ionand

recogn

izingd

entalp

roblem

s

Finda

dentist

quick

lyand

easily

•Cre

ateac

ustom

izedli

stofpr

ovider

sbase

donth

eirpre

ference

s,orlo

okup

aspec

ificpro

vider

•Un

iquefe

atures

includ

eside

-by-sid

ecom

pariso

nsofp

rovide

rinform

ation,a

bilityt

ocrea

teasho

rtlisto

f“favor

ite”pro

viders

forqui

ckrefe

rence

andget

maps

anddire

ctions

toano

ffice

•Ha

veyou

rresul

tsfaxe

dorem

ailedb

acktoy

ou

13

Guardian’sInternationalDentalAssistance–Accesstoqualitycare

whenfarfromhome

Gua

rdia

nis

com

mitt

edto

help

ing

you

get

mor

eva

lue

from

your

dent

alpl

an.

We

are

plea

sed

that

your

Gua

rdia

nde

ntal

plan

offe

rsac

cess

toIn

tern

atio

nalA

ssis

t.*Y

ou’ll

have

acce

ssto

dent

alca

reif

need

edw

hile

trav

elin

gou

tsid

eof

the

Uni

ted

Sta

tes.

Inte

rnat

iona

lAss

isti

sav

aila

ble

asa

reso

urce

ifyo

uor

your

fam

ilym

embe

rsne

edem

erge

ncy

dent

alas

sist

ance

whi

leab

road

:

S

impl

yca

llco

llect

toa

spec

ialt

elep

hone

num

ber,

avai

labl

eat

any

time

–24

hour

sa

day,

7da

ysa

wee

k

Y

ouw

illbe

prov

ided

with

refe

rral

sto

dent

ists

and

faci

litie

spr

ovid

ing

emer

genc

yde

ntal

care

D

etai

lspr

ovid

edin

clud

esp

ecia

lty,e

xper

ienc

ean

dE

nglis

h-la

ngua

gepr

ofic

ienc

y

D

entis

tsha

vego

neth

roug

hst

rict

cred

entia

ling,

incl

udin

glo

cal

accr

edita

tion,

expe

rienc

ew

orki

ngw

ithfo

reig

npa

tient

san

dpa

tient

care

envi

ronm

ent

R

eim

burs

emen

tfor

serv

ices

thro

ugh

anIn

tern

atio

nalA

ssis

tden

tistw

illbe

asan

out-

of-n

etw

ork

serv

ice.

Sim

ply

save

rece

ipts

and

subm

ita

clai

m.

Ava

ilabl

ein

over

200

coun

trie

sit

just

take

sa

phon

eca

ll:In

tern

atio

nal:

(cal

lcol

lect

)1-

630-

766-

7710

Fro

mw

ithin

the

US

:888

-647

-270

1

*Int

erna

tiona

lref

erra

lpro

gram

prov

ided

byA

XA

Ass

ista

nce

US

A,I

nc.

The

Gua

rdia

nLi

feIn

sura

nce

Com

pany

ofA

mer

ica,

New

Yor

k,N

Y10

004

15

Finding a Provider

How to Look Up DentalGuard Preferred Providers Online





On the next web page, follow these easy steps to search:

• Under “Select Your Dental Plan” Choose PPO



• Under “Distance” select your mile radius, then “Select your Dental Network” Choose – DentalGuard Preferred Note: You also have the option to include type of Dentist, foreign language spoken, and office status in your search.


You can also find a dentist on the go from your smart phone – simply download our app at www.GuardianAnytime.com/mobile.

17

Find a Provider

How to Look Up Dominion Plan Providers Online





On the next web page, follow the easy steps to search:

• Under “Select Your Dental Plan” Choose DHMO/Pre-Paid



• Under “Distance” select you mile radius, then “Select your Dental Network” Choose– Dominion Note: You also have the option to include foreign language spoken and office status in your search.


19

It’s easy to use your dental benefits. You don’t even need an ID card!

Your Guardian dental benefits are designed to save you money on important treatments to keep you healthy, by making it easy for you to find a network dentist in your area. The best way to save money is to see a dentist in your network.

It’s easy to find a Guardian network dentist:

• Visit www.GuardianAnytime.com and click on Find a Provider.

• Under Dental Plan, choose PPO. Your PPO type is DentalGuard Preferred.

• Follow the easy steps to search.

• You can also find a dentist on the go from your smart phone – simply download our app at www.GuardianAnytime.com/mobile.

You’ll need your Group ID number for your first visit with the dentist. The Group ID number is included in your enrollment material and available from your employer.* Once your plan is activated, you can also view and print an image of your ID card from www.GuardianAnytime.com or through our smart phone app. Use your Group ID number to register.

*Your Group ID Number is located on the front of your enrollment materials and on the top right corner of the enrollment form.

2012-8231

21

Guardian AnytimeSM Mobile

Guardian’s network in the palm of your hand. The best way to save money through your dental and vision benefits is to see a provider in your network. Guardian makes it easy to find a dentist or vision provider near you, online or on the go! Plus, you can access your member ID card to present at your visit.

Search on the go!

It’s fast and easy to find a provider from your smart phone through our Guardian Anytime mobile app. It’s easy to download and use! Simply search by location or name.

Visit www.GuardianAnytime.com/mobile.

View/Print your Member ID Card You no longer need to show your dental or vision provider a paper ID card. Simply access an image of your card through Guardian Anytime Mobile and show them at your visit! You can also Find a Provider at our website www.GuardianAnytime.com. Customize your search, get side-by-side comparisons, or create a quick list of “favorite” providers and more!

23

ADDITIONAL MATERIALS

24

It’s quick and easy to view and print your Guardian ID card!

Simply register for www.GuardianAnytime.com and follow these instructions! Step 1: Log-in and click on the ID card link on your Home page, or choose “Forms and Materials.”

Step 2: Select View/Print next to the card you want to access

Step 3: Choose Open and you can then save or print your ID card

25

D2710 Crown-resinbasedcomposite(indirect)...................... 375D2712 Crown-3/4resin-basedcomposite(indirect)................ 589D2720/21/22 Crown-resinwithmetal................................................ 619D2740 Crown-porcelain/ceramicsubstrate............................. 714D2750/51/52 Crown-porcelainfusedmetal....................................... 677D2780/81/82 Crown-3/4castwithmetal........................................... 539D2783 Crown-3/4porcelain/ceramic....................................... 614D2790/91/92 Crown-fullcastmetal................................................... 611D2910/20 Recementinlay,onlay/crownorpartialcoveragerest..... 61D2930 Prefab.stainlesssteelcrown-prim.tooth..................... 159D2931 Prefab.stainlesssteelcrown-perm.tooth.................... 168D2932 Prefabricatedresincrown.............................................. 185D2950 Corebuildup,includinganypins.................................... 167D2952 Castpostandcoreinadditiontocrown......................... 233D2954 Prefab.postandcoreinadditiontocrown.................... 183D2955 Postremoval(notinconj.withendo.therapy)............... 149D2970 Temporarycrown(fracturedtooth)..................................... 0D2980 Crownrepair,byreport.................................................. 127 PROSTHETICS (DENTURES)D5110/20 Completedenture-maxillary/mandibular...................... 895D5130/40 Immediatedenture-maxillary/mandibular..................... 963D5211/12 Maxillary/mandibularpartialdenture-resinbase.......... 692D5213/14 Maxillary/mandibularpartialdenture-castmetal.......... 960D5225/25 Maxillary/mandibularpartialdenture-flexiblebase....... 960D5281 Rem.unilateralpartialdenture-onepiececastmetal..........540D5410/11 Adjustcompletedenture-maxillary/mandibular.............. 51D5421/22 Adjustpartialdenture-maxillary/mandibular................... 51D5510/5610 Repairbrokendenturebase(complete/resin)............... 113D5520 Replacemissingorbrokenteeth-completedenture...... 99D5620 Repaircastframework................................................... 164D5630 Repairorreplacebrokenclasp...................................... 149D5640 Replacebrokenteeth-pertooth................................... 101D5650 Addtoothtoexistingpartialdenture.............................. 127D5660 Addclasptoexistingpartialdenture.............................. 158D5670/71 Replaceallteethandacryliconcastmetalframework.. 358D5710/11 Rebasecompletemaxillary/mandibulardenture............ 334D5720/21 Rebasemaxillary/mandibularpartialdenture................ 328D5730/31 Relinecompletemaxillary/mandibulardenture(chairside)...212D5740/41 Relinemaxillary/mandibularpartialdenture(chairside)... 212D5750/51 Relinecompletemaxillary/mandibulardenture(lab)...... 275D5760/61 Relinemaxillary/mandibularpartialdenture(lab).......... 271D5810/11 Interimcompletedenture-maxillary/mandibular........... 449D5820/21 Interimpartialdenture-maxillary/mandibular................ 383D5850/51 Tissueconditioning-maxillary/mandibular.................... 107 BRIDGE/PONTICS

D6000-D6199ALLIMPLANTSERVICES-15%DISCOUNT (incl.D0360-D0363conebeamimagingw/implants)D6210/11/12 Pontic-metal................................................................. 611D6240/41/42 Pontic-porcelainfusedmetal....................................... 677D6245 Pontic-porc./ceramic.................................................... 714D6250/51/52 Pontic-resinwithmetal................................................. 619D6545 Retainer-castmetalforresinbondedfixedprosthesis... 304D6548 Ret.-porc./ceramicforresinbondedfixedprosthesis.. 477D6600 Inlay-porc./ceramic,twosurfaces................................ 522D6601 Inlay-porc./ceramic,>=3surfaces................................ 551D6602 Inlay-casthighnoblemetal,twosurfaces.................... 502D6603 Inlay-casthighnoblemetal,>=3surfaces................... 518D6604 Inlay-castpredominantlybasemetal,twosurfaces..... 502D6605 Inlay-castpredominantlybasemetal,>=3surfaces.... 518D6606 Inlay-castnoblemetal,twosurfaces............................ 502D6607 Inlay-castnoblemetal,>=3surfaces........................... 518D6608 Onlay-porc./ceramic,twosurfaces............................... 565D6609 Onlay-porc./ceramic,threeormoresurfaces.............. 593D6610 Onlay-casthighnoblemetal,twosurfaces.................. 541D6611 Onlay-casthighnoblemetal,>=3surfaces................. 575D6612 Onlay-castpredominantlybasemetal,twosurfaces... 541D6613 Onlay-castpredominantlybasemetal,>=3surfaces... 575D6614 Onlay-castnoblemetal,twosurfaces.......................... 541D6615 Onlay-castnoblemetal,>=3surfaces......................... 575D6720/21/22 Crown-resinwithmetal................................................ 619D6740 Crown-porc./ceramic.................................................... 714D6750/51/52 Crown-porcelainfusedmetal....................................... 677D6780 Crown-3/4casthighnoblemetal................................. 539D6781 Crown-3/4castpredominantlybasemetal.................. 539D6782 Crown-3/4castnoblemetal......................................... 539D6783 Crown-3/4porc./ceramic.............................................. 614D6790/91/92 Crown-fullcastmetal................................................... 611

DIAGNOSTIC/PREVENTIVED9439 Officevisit........................................................................ 15D0120 Periodicoraleval-establishedpatient.............................. 0D0140 Limitedoraleval-problemfocused................................... 0D0145 Oralevalforapatientunder3yearsofage...................... 0D0150 Comprehensiveoraleval-neworestablishedpatient...... 0D0160 Detailedandextensiveoraleval-problemfocused........ 67D0170 Re-evaluation-limited,problemfocused.......................... 0D0210 Intraoral-completeseries(includingbitewings).............. 66D0220 Intraoral-periapicalfirstfilm............................................ 14D0230 Intraoral-periapicaleachadd.film.................................. 12D0240 Intraoral-occlusalfilm....................................................... 0D0250/60 Extraoral-firstfilmandeachadd.Film............................. 0D0270 Bitewing-singlefilm........................................................ 14D0272 Bitewings-twofilms........................................................ 22D0273 Bitewings-threefilms...................................................... 27D0274 Bitewings-fourfilms........................................................ 31D0277 Verticalbitewings-7to8films........................................ 48D0330 Panoramicfilm................................................................. 59D0340 CephalometricFilm............................................................ 0D0350 Oral/facialphotographicimages........................................ 0D0460 Pulpvitalitytests.............................................................. 30D0470 Diagnosticcasts................................................................. 0D1110 Prophylaxis(cleaning)-adult............................................ 0D1110* Additionalcleaning(expectingmothersorDiabetics)...... 40D1120 Prophylaxis(cleaning)-child............................................. 0D1203 Topicalapplicationoffluoride-child.................................. 0D1204 Topicalapplicationoffluoride-adult.................................. 0D1206 Topicalfluoridevarnishformod/highriskcariespatients.. 0D1310 Nutritionalcounselingforcontrolofdentaldisease........... 0D1320/30 Oralhygieneinstructions................................................... 0D1351 Sealant-pertooth........................................................... 28D1352 Prevresinrest.mod/highcariesrisk–perm.tooth......... 28 SPACEMAINTAINERSD1510/20 Spacemaintainer-fixed/removable-unilateral............ 176D1515/25 Spacemaintainer-fixed/removable-bilateral.............. 250D1550 Re-cementationofspacemaintainer............................... 44 RESTORATIVE DENTISTRY (FILLINGS) AMALGAMRESTORATIONS(SILVER)D2140 Amalgam-onesurface,prim.orperm............................ 70D2150 Amalgam-twosurfaces,prim.orperm........................... 90D2160 Amalgam-threesurfaces,prim.orperm...................... 107D2161 Amalgam->=4surfaces,prim.orperm........................ 128 RESIN/COMPOSITERESTORATIONS(TOOTHCOLORED)D2330 Resin-basedcomposite-onesurface,anterior............... 80D2331 Resin-basedcomposite-twosurfaces,anterior............ 101D2332 Resin-basedcomposite-threesurfaces,anterior......... 124D2335 Resin-basedcomposite->=4surfaces,anterior........... 157D2391 Resin-basedcomposite-onesurface,posterior............. 90D2392 Resin-basedcomposite-twosurfaces,posterior.......... 118D2393 Resin-basedcomposite-threesurfaces,posterior....... 149D2394 Resin-basedcomposite->=4surfaces,posterior......... 174 D2940 Sedativefilling.................................................................. 60D2951 Pinretention-pertooth,inadditiontorestoration........... 36D3110/20 Pulpcap-direct/indirect(excl.finalrestoration).............. 47 CROWN & BRIDGE

D2390 Resin-basedcompositecrown,anterior........................ 245D2510 Inlay-metallic-onesurface.......................................... 472D2520 Inlay-metallic-twosurfaces........................................ 502D2530 Inlay-metallic-threeormoresurfaces........................ 518D2542 Onlay-metallic-twosurfaces......................................... 541D2543 Onlay-metallic-threesurfaces...................................... 575D2544 Onlay-metallic-fourormoresurfaces........................... 575D2610 Inlay-porcelain/ceramic-onesurface.......................... 492D2620 Inlay-porcelain/ceramic-twosurfaces........................ 522D2630 Inlay-porcelain/ceramic->=3surfaces........................ 551D2642 Onlay-porcelain/ceramic-twosurfaces....................... 565D2643 Onlay-porcelain/ceramic-threesurfaces.................... 593D2644 Onlay-porcelain/ceramic->=4surfaces...................... 593D2650 Inlay-resin-basedcomposite-onesurface.................. 427D2651 Inlay-resin-basedcomposite-twosurfaces................ 479D2652 Inlay-resin-basedcomposite->=3surfaces................ 528D2662 Onlay-resin-basedcomposite-twosurfaces............... 555D2663 Onlay-resin-basedcomposite-threesurfaces............ 577D2664 Onlay-resin-basedcomposite->=4surfaces.............. 577

Plan 7000xDescription of Benefits & Member Copayments

Allfeesexcludethecostofnobleandpreciousmetals.Anadditionalfeewillbechargedifthesematerialsareused.

ADA MEMBERCODE BENEFIT COPAYMENT(S)


ORTHODONTICS2

D8660 Pre-orthodontictreatmentvisit....................................... 413D8070 Comp.ortho.treatment-transitionaldentition............. 3304D8080 Comp.ortho.treatment-adolescentdentition............. 3422D8090 Comp.ortho.treatment-adultdentition...................... 3658D8670 Periodicortho.treatmentvisit(aspartofcontract)........ 118D8680 Orthodonticretention(rem.ofappl.andplacement ofretainer(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.

D6930 Recementfixedpartialdenture........................................ 86D6970 Postandcoreinadditiontofixedpart.dent.ret............ 238D6972 Prefabpostandcoreinadditiontofixedpart.dent.ret......203D6973 Corebuildupforretainer,includinganypins................. 151D6975 Coping-metal............................................................... 389D6976 Eachadd.indirectlyfabricatedpost-sametooth.......... 155D6977 Eachadd.prefabpost-sametooth................................. 72D6980 Fixedpartialdenturerepair,byreport............................ 206 ADJUNCTIVE GENERAL SERVICESD9110 Palliative(emergency)treatmentofdentalpain.............. 64D9210/15 Localanesthesia................................................................ 0D9211 Regionalblockanesthesia................................................. 0D9212 Trigeminaldivisionblockanesthesia................................. 0D9220 Deepsedation/generalanesthesia-first30min........... 205D9221 Deepsedation/generalanesthesia-eachadd.15min... 103D9241 Intravenousconscioussedation/analgesia-first30min....205D9242 IVconscioussedation/analgesia-eachadd.15min..... 103D9230 Analgesia,anxiolysis,inhalationofnitrousoxide............. 35D9310 Consultation(diagnosticservicebynontreatingdentist)......63D9910 Applicationofdesensitizingmedicament......................... 31D9930 Treatmentofcomplications(post-surgical)...................... 48D9990 Brokenofficeappointment............................................... 50 ENDODONTICS1

D3220 Therapeuticpulpotomy(excl.finalrestor.)..................... 112D3221 Pulpaldebridement,prim.andperm.teeth.................... 112D3310 Endodontictherapy,anteriortooth................................. 413D3320 Endodontictherapy,bicuspidtooth................................ 494D3330 Endodontictherapy,molar............................................. 606D3333 Internalrootrepairofperforationdefects....................... 126D3346 Retreatofprev.rootcanaltherapy,anterior................... 453D3347 Retreatofprev.rootcanaltherapy,bicuspid.................. 538D3348 Retreatofprev.rootcanaltherapy,molar...................... 653D3410 Apicoectomy/periradicularsurgery,anterior................... 377D3421 Apicoectomy/periradicularsurgery,bicuspid(firstroot)... 424D3425 Apicoectomy/periradicularsurgery,molar(firstroot)..... 498D3426 Apicoectomy/periradicularsurgery(eachadd.root)...... 189D3430 Retrogradefilling-perroot............................................ 143D3450 Rootamputation-perroot............................................. 270D3920 Hemisection,notinc.rootcanaltherapy........................ 256D3950 Canalprep/fittingofpreformeddowelorpost................ 143 PERIODONTICS1

D0180 Comp.periodontaleval-neworestablishedpatient....... 36D4210 Gingivectomyorgingivoplasty->3cont.teeth,perquad.....369D4211 Gingivectomyorgingivoplasty-<=3teeth,perquad.... 124D4240 Gingivalflapproc.,inc.rootplaning- >3cont.teeth,perquad............................................. 438D4241 Gingivalflapproc,inc.rootplaning- <=3cont.teeth,perquad........................................... 131D4260 Osseoussurgery->3cont.teeth,perquad.................. 616D4261 Osseoussurgery-<=3cont.teeth,perquad................ 491D4268 Surgicalrevisionproc.,pertooth................................... 448D4274 Distalorproximalwedgeprocedure.............................. 393D4341 Perioscalingandrootplaning->3contteeth,perquad....138D4342 Perioscalingandrootplaning-<=3teeth,perquad...... 78D4355 Fullmouthdebridement................................................. 106D4381 Localizeddeliveryofchemotherapeuticagents............. 123D4910 Periodontalmaintenance................................................. 83D9940 Occlusalguard,byreport............................................... 328D9950 Occlusionanalysis-mountedcase............................... 169D9951 Occlusaladjustment-limited........................................... 86D9952 Occlusaladjustment-complete..................................... 361 ORAL SURGERY1

D7111 Extraction,coronalremnants-deciduoustooth.............. 82D7140 Extraction,eruptedtoothorexposedroot........................ 85D7210 Surgicalrem.oferuptedtoothreq.bonecut................. 167D7220 Removalofimpactedtooth-softtissue......................... 196D7230 Removalofimpactedtooth-partiallybony.................... 255D7240 Removalofimpactedtooth-completelybony............... 311D7241 Removalofimp.tooth-completelybony, withunusualsurg.complications............................... 364D7250 Surgicalremovalofresidualtoothroots........................ 181D7270 Toothreimplant./stabiliz.ofacc.evulsed/displacedtooth...315D7280 Surgicalaccessofanuneruptedtooth.......................... 285D7291 Transseptalfiberotomy/supracrestalfiberotomy,byreport..159D7310 Alveoloplasty,inconj.withext.-4ormoreteeth,perquad..175D7320 Alveoloplastynotinconj.withextractions- 4ormoreteeth,perquad.......................................... 258D7510 Incisionanddrainageofabscess-intraoralsofttissue... 137D7960 Frenulectomy(frenectomyorfrenotomy)-separateproc....2691As performed by a participating General Dentist. See Plan Exclusion # 13.

Plan 7000x

Program Exclusions1. Services which are covered under Medicare, worker’s compensation, employer’s liability laws, or the Pennsylvania Motor Vehicle Financial ResponsibilityLaw(Pennsylvaniapolicyholdersonly).2. Serviceswhich,intheopinionoftheattendingdentist,arenotnecessary forthepatient’sdentalhealth.3. Cosmetic, elective or aesthetic dentistry except as required due to accidentalbodilyinjurytosoundnaturalteeth.4. Oralsurgeryrequiringthesettingoffracturesordislocations.5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, anodontic, mandibular prognathism or development malformations where, in the opinion of the Participating Dentist, suchservicesshouldnotbeperformedinadentaloffice.6. Dispensingofdrugs.7. Hospitalizationforanydentalprocedure.8. Treatmentrequiredforconditionsresultingfrommajordisaster,epidemic, war, acts of war, whether declared or undeclared, or while on active dutyasamemberofthearmedforcesofanynation.9. Replacementduetolossortheftofprostheticappliance.10. ProceduresnotlistedascoveredbenefitsunderthisProgram.11. Services obtained outside of the dental office in which enrolled and thatarenotpreauthorizedbysuchofficeorDominionDentalServicesUSA, Inc.(withtheexceptionofout-of-areaemergencydentalservices).12. ServicesrelatedtothetreatmentofTMD(TemporomandibularDisorder).13. Services related to procedures that are of such a degree of complexity astonotbenormallyperformedbyaParticipatingGeneralDentist.Above copaymentsdonotapplywhenperformedbyaParticipatingSpecialist(with theexceptionoforthodontics).ParticipatingSpecialists, ifavailable,have entered into an agreement with Dominion Dental Services to provide dentalservicestomembersata25%reductionfromtheirUsual,Customary, and Reasonable (UCR) fees. In Delaware, Participating Specialists will provide a reduction from their UCR that will vary between specialists.14. Elective surgery including, but not limited to, extraction of non- pathologic,asymptomaticimpactedteeth.15. The Invisalign system and similar specialized braces are not a covered benefit. Patient copaymentswill apply to the routineorthodontic appliance portionofservicesonly. Additionalcosts incurredwillbecome thepatient’s responsibility.Program Limitations1. Two(2)evaluationsarecoveredpercalendaryearincludingamaximumof one(1)comprehensiveevaluation.2. One(1)problemfocusedexamiscoveredpercalendaryear.3. One(1)teethcleaning(prophylaxis)iscoveredpercalendaryear.4. One(1)topicalfluorideorfluoridevarnishiscoveredpercalendaryear.5. Two(2)bitewingx-raysarecoveredpercalendaryear.6. One (1) set of full mouth x-rays or panoramic film is covered every three(3)years.7. One(1)sealantorpreventativeresinrestorationpertoothiscoveredper lifetime,uptoage16(limitedtopermanent1stand2ndmolars).8. Replacementofafillingiscoveredifitismorethantwo(2)yearsfromthe dateoforiginalplacement.9. Replacement of a bridge, crownor denture is covered if it ismore than seven(7)yearsfromthedateoforiginalplacement.10. Crown and bridge fees apply to treatment involving five or fewer units whenpresentedinasingletreatmentprogram.Additionalcrownorbridge units,beginningwith thesixthunit,areavailableat theprovider’sUsual, Customary,andReasonable(UCR)fee,minus25%.11. Reliningandrebasingofdenturesiscoveredonceevery24months.12. Retreatmentofrootcanal iscoveredif it ismorethantwo(2)yearsfrom theoriginaltreatment.13. Rootplaningorscalingiscoveredonceevery24monthsperquadrant.14. Fullmouthdebridementiscoveredonceperlifetime.15. ProcedureCodeD4381islimitedtoone(1)benefitpertoothforthreeteeth perquadrantora totalof12 teeth forall fourquadrantsper twelve (12) months.Musthavepocketdepthsoffive(5)millimetersorgreater.16. Periodontalsurgeryofanytype,includinganyassociatedmaterial,iscovered onceevery36monthsperquadrantorsurgicalsite.17. Periodontalmaintenanceafteractivetherapyiscoveredtwicepercalendar year,within24monthsafterdefinitiveperiodontaltherapy.OnlycurrentADACDTcodesareconsideredvalidbyDominionDentalServices,Inc.Current Dental Terminology © American Dental Association.



dental coverage - benefit design group benefit descriptions... · 2013-05-20 · dental insurance...

Documents