Dental Rider

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					                                         Dental Rider
                                   January 1, 2010 – December 31, 2010




                                     High Option Dental Rider
                                                             California




H0543_090713RL05_Dental_Op_Rider
Dear AARP® MedicareComplete® Plan Member:
Thank you for choosing AARP® MedicareComplete®!
This booklet constitutes an explanation of the Optional Supplemental AARP® MedicareComplete® from
SecureHorizons Rider benefits which are a part of the Evidence of Coverage to which it is attached. It is subject to
all the terms and provisions of the Evidence of Coverage, except as stated below. In consideration of any additional
premium, we will provide the coverage described.
This document supplements the AARP® MedicareComplete® 2010 Evidence of Coverage which provides you with
the information you need to understand your AARP® MedicareComplete® benefits. It should be read completely
and carefully. For general information, please call the Customer Service number listed on the back of your AARP®
MedicareComplete® Plan identification card.
Please look through your materials and familiarize yourself with your additional benefits and equally important, be
sure to take full advantage of the services offered by your plan. You should have this rider along with your Evidence
of Coverage materials where you can find them easily, in case you have questions about your coverage in the
future.
We are committed to ensuring that you get the most out of your AARP® MedicareComplete® Plan and we look
forward to continuing to serve you as a valued member of the AARP® MedicareComplete® Plan. If you have any
questions about your plan, please call Customer Service. They will be happy to help you. The number is listed on
the back of this booklet. Please also visit us online at www.AARPMedicareComplete.com.
Table of Contents
SECTION 1: Introducing the High Option Dental Rider .....................................................................................1
Enrolling in the Optional Supplemental Dental Rider ..............................................................................................1
When Your Optional Supplemental Dental Rider Begins ..........................................................................................1
Disenrolling From the Optional Supplemental Dental Rider.....................................................................................1
When We End Your Optional Supplemental Dental Rider.........................................................................................1
Refund of Premium ...............................................................................................................................................2
SECTION 2: High Optional Dental Rider Benefits .............................................................................................2
How to Choose an Assigned Contracting Dentist ...................................................................................................2
Making an Appointment ........................................................................................................................................2
Receiving Services ................................................................................................................................................3
Continuity of Care .................................................................................................................................................3
Referral to a Specialist ..........................................................................................................................................3
Emergency Care....................................................................................................................................................3
Procedures and Discount Fees ..............................................................................................................................4
SECTION 3: Organization Determination, Appeal and Grievance Procedures ................................................4
General Information on the Medicare Appeal Process ...........................................................................................4
SECTION 4: Limitations and Exclusions .............................................................................................................5
Limitations of Dental Benefits................................................................................................................................5
Exclusion of Dental Benefits ..................................................................................................................................9
SECTION 5: 2010 Schedule of Dental Rider Discount Fees .......................................................................... 12
SECTION 6: Dental Terms .................................................................................................................................. 26
SECTION 1: Introducing the High Option Dental Rider
Our plan offers some extra benefits that are not covered by Original Medicare and not included in your benefits
package as a plan member. These extra benefits are called “Optional Supplemental Benefits.” If you want these
optional supplemental benefits, you must sign up for them. The optional supplemental benefits included in this
section are subject to the same appeals process as any other benefits.
We realize that flexibility in selecting certain supplemental health care benefits is important to our members. That
is why we developed the High Optional Dental Rider benefit package, an Optional Supplemental Dental Plan. The
High Optional Dental Rider provides you with optional supplemental benefits, in addition to your basic benefits, for
a monthly plan premium of $24. These optional supplemental benefits include: diagnostic and preventive services,
including basic and major dental services.
If you have additional questions about the High Optional Dental Rider, please call the Customer Service number on
the back of this booklet.

Enrolling in the Optional Supplemental Dental Rider
There are two ways to enroll in an Optional Supplemental Dental Rider: (1) Call Customer Service at
1-800-950-9355 (for the hearing impaired, 711), 8 a.m. to 8 p.m, local time, 7 days a week, or (2) Completing
an Optional Supplemental Plan Application available through Customer Service. You may enroll in an Optional
Supplemental Dental Rider any time throughout the year.
Please note that you cannot be enrolled in an Optional Supplemental Dental Rider and the Optional Supplemental
Deluxe Rider at the same time during the calendar year.

When Your Optional Supplemental Dental Rider Begins
In general, completed requests to elect an Optional Supplemental Dental Rider received by the last day of the
month will be effective the first day of the following month. For example, if we receive your completed Optional
Plan Application or you call Customer Service by December 31, your Optional Supplemental Dental Rider benefits
will begin on January 1.

Disenrolling From the Optional Supplemental Dental Rider
If you wish to disenroll from an Optional Supplemental Dental Rider, you may either send us an Optional Plan
Application, a letter or a fax requesting disenrollment from your Optional Supplemental Dental Rider or call
Customer Service. To obtain an Optional Plan Application, please call Customer Service.
Optional Supplemental Dental Rider disenrollment requests received by the last day of the month will be effective
the first day of the following month. Members will be responsible for their Optional Supplemental Dental Rider
premium payment if the disenrollment request is received after the last day of the month. Disenrollment from an
Optional Supplemental Dental Rider will not result in disenrollment from your AARP® MedicareComplete® Plan.

When We End Your Optional Supplemental Dental Rider
Your enrollment in the Optional Supplemental Dental Rider may be terminated if you fail to pay required Monthly
Plan Premiums. Non-payment of plan premiums for an Optional Supplemental Rider will not result in disenrollment
from your health plan, only the loss of the Optional Supplemental Rider and your return to the basic benefit plan.
We may terminate your AARP® MedicareComplete® Membership for additional reasons. Please see your AARP®
MedicareComplete® Evidence of Coverage.
If you cease to be a Member of AARP® MedicareComplete,® your Dental Rider will terminate the same effective
date as your disenrollment from AARP® MedicareComplete.®

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Refund of Premium
Members enrolled in an Optional Supplemental Dental Rider have a monthly plan premium and are entitled to a
refund for any overpayments of plan premiums made during the course of the year or at the time of disenrollment.
Overpayments of plan premiums will be refunded upon request or disenrollment. We will refund any overpayments
within thirty (30) business days of notification. We may apply your overpayment of Optional Supplemental Dental
Rider premiums to your monthly health plan premiums, if any.
If your membership terminates due to death, it is the Member’s family’s responsibility to notify us. We will not
retroactively reimburse Monthly Dental Premiums for a period longer than 3 months because the deceased
Member’s family has not notified us of the Member’s death.

SECTION 2: High Optional Dental Rider Benefits
When you elect the High Option Dental Rider, you will enjoy enhanced dental care coverage and reduce your out-
of-pocket expenses for Covered Dental Services for a Monthly Dental Plan Premium of $24.
  •	You are required to pay the $5 office visit fee for up to four office visits per year. You pay $0 for additional
    office visits per year. This fee is due in addition to any other Discount Fees specified for procedures or services
    rendered.
  •	$0 copayment for each oral examination.
  •	$5 copayment for each routine cleaning once every 6 months.
  •	$0 copayment X-rays prescribed by your Assigned Contracting Dentist.
  •	You are covered for Specialty services up to a Calendar Year Maximum of $1,000.
Unlimited general dentistry for Covered Dental Services at Assigned Contracting Dental Offices is subject to
Limitations and Exclusions of the Dental Rider. Increased discounts on numerous services are available including
Specialty care. Specialty referrals are required if the services of a Specialist are needed for a Covered Dental
Service on the High Option Dental Rider.

How to Choose an Assigned Contracting Dentist
You must choose an Assigned Contracting Dental Office from the Dental Directory. If the Dental Office you
selected is not available, or you fail to select an office, we will assign one to you. If you wish to select another
contracting Dental Office, you may contact Customer Service at 1-800-950-9355 (for the hearing impaired,
711), 8 a.m. to 8 p.m. local time, 7 days a week. If we receive your request to transfer to another contracting
dental provider by the 15th of the month, your transfer will be effective on the 1st day of the following month. For
example: If your request to transfer is received by June 15th, your transfer will be effective on July 1st.
All treatments started at your Assigned Contracting Dental Office should be completed before requesting a change
to another contracting dental office, to ensure continuity of care, unless a quality of care issue is identified. If you
elect to change contracting dental offices without completing treatment, you may be responsible for the UCR fees
at your new Assigned Contracting Dental Office.
Transfer of records at the Member’s initiation will be subject to a duplication fee of $0.25 per page or $0.50 per
page for records that are copied from microfilm and any additional reasonable clerical costs incurred in making the
records available. Duplication of X-rays will be subject to a fee of $10.00.

Making an Appointment
Once you have an Assigned Contracting Dental Office, you can make an appointment by directly calling that dental
office. If you have any questions regarding office location, office hours, emergency hours, please call your Assigned

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Contracting Dental Office or call Customer Service. For information on other Contracting Dental Providers in your
area, please contact Customer Service at 1-800-950-9355 (for the hearing impaired at 711), 8 a.m. to 8 p.m. local
time, 7 days a week or visit our Web site at www.AARPMedicareComplete.com.

Receiving Services
Covered Dental Services must be obtained through your Assigned Contracting Dental Office, except for those
dental services defined as Emergency Care in this Dental Benefits booklet. The fees for any dental procedures
not provided by your Assigned Contracting Dental Office, or not provided as an Emergency Care or an Out-of-
Area Service, may be the responsibility of the Member at the dental provider’s Usual, Customary and Reasonable
(UCR) charges.
If dental Specialty care is required and the procedure is covered, you will be referred by your Assigned Contracting
Dental Office to a contracting dentist who is a Specialist.
If your Assigned Contracting Dental Office is unable to perform under the terms of its contract, has breached the
contract or has been canceled by us, we will notify you of your new Assigned Contracting Dental Office 30 days in
advance of termination.

Continuity of Care
If, upon your Effective Date, you are under treatment for an Acute Condition through a non-contracting dental
provider, we will honor your claims. If you are a Member who is undergoing treatment for either an Acute Condition
or a Serious Chronic Condition, you may call Customer Service for directions on continuing your care.

Referral to a Specialist
As a Member of the High Option Dental Rider, Specialty Referral Dental Benefits are part of your Covered Dental
Services. Specialty Referral Dental Benefits include the provision of Covered Dental Services by contracting
Endodontists, Periodontists, Pedodontists and Oral Surgeons. As a Member of the High Option Dental Rider,
which has a Specialty Referral Dental Benefit, your Assigned Contracting Dental Office will assess your need for a
Referral to a dental Specialist.
Note: As a Member of the High Option Dental Rider, you have a Calendar Year Maximum of $1,000 for Specialty
Referral benefits. Any Specialty fees over and above the Calendar Year Maximum are not covered. With the
exception of Pedodontic services, when Specialty services are provided, the Member’s responsibility is limited
to applicable Discount Fee, and any fees in excess of the Calendar Year Maximum. Prior to meeting the Calendar
Year Maximum, our financial responsibility for Specialty services is limited to the difference between the applicable
Discount Fee and the Specialist’s contracted fee.

Emergency Care
Your Assigned Contracting Dental Office will be available for Emergency Care 24 hours a day, 7 days a week. If you
need Emergency Care, you must contact your Assigned Contracting Dental Office. If you are unable to reach your
Assigned Contracting Dental Office or you are Out-of-Area, you may receive care by any licensed dentist. We will
reimburse you for the covered Emergency Care only, up to $50 per occurrence. Send us the itemized bill, marked
“PAID” (proof of payment/credit), along with a brief explanation of why Emergency Care was necessary, within 60
days to the address below. We will provide reimbursement within 30 days of receipt. You do not have to submit
a claim form. You must use the emergency dentist only for relief of pain, or to immediately diagnose and treat a
condition that a reasonable person under the circumstance believes that if not given immediate attention may lead
to disability, dysfunction, or death. We will cover Out-of-Area follow-up care by a non-contracting dental provider as
long as the care continues to meet the definition of Emergency Care.



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All reimbursement requests should be mailed to:
P.O. Box 25187
Mailstop: CA 152-0293
Santa Ana, CA 92799

Procedures and Discount Fees
We will provide you with Dental Benefits only for the Covered Dental Services listed in the Schedule of Dental
Discount Fees. It is your responsibility to understand your dental coverage and use your Dental Benefits
appropriately. Covered Dental Services are a Dental Benefit only when diagnosed as needed by your Assigned
Contracting Dental Office.
Many dental services require a payment called a Discount Fee. This amount is listed next to each procedure on
the Schedule of Discount Fees. Other procedures do not require a Discount Fee. These are listed as $0.00 or No
Charge. Procedures not listed are not covered on the plan. Contracting dentists will ask all Members to sign an
informed consent document detailing the risks, Dental Benefits and alternatives to all recommended treatments.
The Member may choose the least expensive clinically acceptable procedure prescribed by the dentist. In the
performance of recommended dental treatments, outcomes can not always be accurately predicted. Sometimes,
during a specific procedure, an immediate change in treatment may be required. In these instances, the
contracting dentist must make a judgment with regard to continuing care that is in the Member’s best interest.
Following the procedure, it is the obligation of the contracting dentist to explain in detail why these changes in
treatment were required and to explain the differences in costs to the Member, if any.

SECTION 3: Organization Determination, Appeal and Grievance
Procedures
The Appeals and Grievance provisions described below are in addition to the Organization Determination, Appeal
and Grievance Procedures of your AARP® MedicareComplete® Evidence of Coverage.

General Information on the Medicare Appeal Process
As an AARP® MedicareComplete® Plan Member, you have the right to appeal any organization determination about
our payment for, or failure to arrange or continue to arrange for, what you believe is Covered Services (including
Optional Supplemental Benefits) under your Medicare Advantage Plan.
Use the Appeal procedure when you want a reconsideration of a decision (organization determination) that was
made regarding a service or the amount of payment we paid for a service.
Use the Grievance procedure for any complaints or other disputes that are not denied claims or denied services
subject to organization determination as explained above. If you have a question about which complaint process to
use, please call Customer Service.
1. You may notify us of your concern or submit a complaint to us either by telephone or in writing. Please call
   AARP® MedicareComplete® Customer Service at 1-800-950-9355 (for the hearing impaired 711), 8 a.m. to
   8 p.m. local time, 7 days a week. You may write a letter to the Appeals Department at:
   Appeals and Grievance Department
   P.O. Box 6106
   Mailstop: CY124-0157
   Cypress, CA 90630
   If you have any questions about the status of your complaint, you may contact Customer Service at any time.



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2. An Appeals Coordinator will conduct an investigation of your complaint. The Appeals Coordinator may request
   and review any relevant dental records from the dental office as appropriate.
3. If a quality of care issue is identified, the Appeals Coordinator and the Quality of Care Department will take
   appropriate action or recommend a review by the network administrator. A written response will be sent to
   you within thirty (30) days informing you that the matter will be investigated, but the details of the investigation
   cannot be given due to peer review protection.

SECTION 4: Limitations and Exclusions

Limitations of Dental Benefits
All dental procedures and services are limited as specifically described below:
1. Non-Covered Benefits
   Assigned Contracting Dentists and contracting dental Specialists may offer Members Covered Dental Services
   that are not included on the list of Dental Benefits, and for which there is no alternative listed Covered Dental
   Services. In such cases, the Assigned Contracting Dentist may offer the service for the dentist’s UCR. For
   example, if an Assigned Contracting Dentist offers and the Member consents to cosmetic tooth bleaching,
   there is no alternative Covered Dental Service and the dentist may charge UCR.
2. Laboratory Upgrades
   A. Upgrades to a Covered Procedure:
      Fees for upgrades such as precious or semiprecious metal alloys, upgraded denture teeth, permanent
      denture soft acrylic bases, and denture characterization or “personalization” will be limited to the
      additional laboratory fee charged to the contracting dentist by the dental laboratory for the upgrade. For
      example, the Assigned Contracting Dentist offers, and the Member accepts, the alternative of a precious
      metal (gold) crown instead of a base metal crown. The contracting dentist may charge no more than the
      listed Discount Fee for the base metal crown, plus the actual fee charged by the dental laboratory for the
      use of the precious metal.
   B. Treatment Plan decision making when two or more treatment alternatives are Covered Dental Services:
      When several Covered Dental Services are treatment alternatives for needed care, all treatment
      alternatives are considered Covered Dental Services. The determination of which Covered Dental Service
      best meets the Member’s needs is the decision or judgment of the treating contracting dentist in concert
      with the Member. In this instance, either chosen Covered Dental Service would be available to the Member
      at the listed Discount Fee for the chosen Covered Dental Services. An example is the decision with regard
      to the replacement of bilateral missing teeth. In this scenario, either the removable partial denture or the
      fixed bridges would be considered a Covered Dental Service. The choice would be made by the Assigned
      Contracting Dentist and the Member considering professionally recognized standards of care, clinical
      condition of each restoration, technical difficulty of both restorative alternatives and any other factors that
      may be present with regard to the Member’s specific dental condition.
3. Restorations, “Fillings” and Crowns
   A. Amalgam, resin-based composite, and/or tooth-colored filling material restorations for treatment
      of decay or broken teeth are covered under your Dental Rider. If a tooth can be restored with such
      materials, any cast restoration (crown) is considered Not a Covered Benefit. If such a procedure is
      performed, the Member must pay the contracting dentist’s UCR fee.
   B. Restorations using resin-based composite or tooth-colored filling material are covered on all teeth with
      the exception of the primary posterior (molar and bicuspid) teeth.



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   C. Porcelain, porcelain fused to metal (PFM), and cast metal crowns are not a Covered Dental Service for
      children under 16 years of age. The Covered Dental Service in such cases is a prefabricated stainless
      steel or resin crown. If a porcelain, PFM or cast metal crown is performed, the parent or guardian must
      pay the contracting dentist’s UCR fee.
   D. If a porcelain, PFM or cast metal crown is less than five years old, even if unserviceable, its replacement
      is not a Covered Dental Service.
4. Fixed Bridges
   A. Both a new bridge and a new partial denture are Not Covered Benefits in the same arch. In such cases
      the Covered Dental Service is for a partial denture that would replace all missing teeth in the arch or
      multiple bridges.
   B. Fixed bridges are not a Dental Benefit for Members under 16 years of age. In such a case, the Dental
      Benefit is for a removable denture, or space maintainer. If the bridge is performed, the Member or
      guardian must pay the contracting dentist’s UCR fee.
   C. If an unserviceable existing bridge is less than five years old; its replacement is Not a Covered Benefit.
5. Office Visit Benefit
   A. The Discount Fee specified in this schedule for office visits is limited to four per year. This fee(s) is due in
       addition to any other Discount Fee(s) specified for procedures or services rendered. Office visits beyond
       four per year are provided at no charge.
   B. The Discount Fee specified in this schedule for oral examinations is limited to four per year, per Member.
      Oral examinations beyond four per year are provided at no charge. This fee(s) is due in addition to any
      other Discount Fee(s) specified for procedures or services rendered.
   C. The office visit fee for fillings is due only once per quadrant, even if fillings are done on separate visits.
   D. The office visit fee for root canals and crowns is due only once per procedure, regardless of the number
      of visits necessary to complete that procedure. For multiple procedures, the office visit fee is due once
      for each procedure.
   E. Covered general dental services are unlimited when prescribed and performed by the Assigned
       Contracting Dental Office, subject to the Limitations and Exclusions of your Dental Rider. A Member may
       be referred to a dental Specialist for procedures that are beyond the scope of the general dentist. The
       services of a Specialist are limited to a $1,000 Calendar Year Maximum for the High Option Dental Rider
       Charges for a Specialist’s Covered Dental Services in excess of the $1,000 Calendar Year Maximum are
       the responsibility of the Member.
6. Workers’ Compensation
   Should any benefit or service be rendered as a result of a Workers’ Compensation Injury Claim, the Member
   shall assign his/her right to reimbursement from other sources to us or the contracting dental provider who
   rendered the services. Any reimbursement in excess of the reasonable value of the services performed shall be
   refunded by us or the contracting dental provider who rendered the service(s).
7. Prophylaxis (Cleaning)
   Routine cleaning of teeth, including polishing and required supragingival (above the gum) and coronal scaling,
   is an allowable once every six months preventive Covered Dental Service per the Member’s Dental Benefit
   booklet when diagnosed as needed by the Assigned Contracting Dental Office.
8. Full Mouth Radiographs (X-rays)
   X-rays are limited to once in a two-year period. Bitewing X-rays are limited to no more than one series of four in
   any six-month period.



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9. Fluoride Treatments
   Treatments are limited to only once per Calendar Year.
10. Periodontal Scaling and Root Planing
    Both procedures are Covered Dental Services only when the need can be demonstrated radio graphically and/
    or by pocket charting. Only two quadrants are allowable at an appointment with a maximum of four quadrants
    per Calendar Year.
11. Periodontal Maintenance Procedures
    (ADA procedure #4910) are Dental Benefits following active therapy once every six months at the Assigned
    Contracting Dental Office.
12. Prosthetics
    A. Removable Prosthetics
       1. Temporary or Transitional Dentures are not a Covered Benefit.
       2. Partial and Full Dentures
         a. When permanent teeth are missing, a fixed bridge and/or a tooth supported partial denture is a Dental
            Benefit. The Dental Benefit is dependent upon:
            •	The Exclusions and Limitations, and
            •	The specific treatment recommendations of your Assigned Contracting Dental Office in concert
              with the Member, subject to clinical appropriateness, and the best alternatives available to meet the
              Member’s dental needs and to restore function.
         b. Laboratory Upgrades include, but are not limited to:
            •	Precious metal for removable appliance framework or a metal base for a full denture
            •	“Personalization” and characterization
            •	Special denture teeth
       3. Specialized services and laboratory upgrades for dentures, or charges for specialized techniques
          involving precision attachments or stress-breakers are Not Covered Benefits. Denture(s)
          “personalization,” characterization or special teeth are laboratory upgrades, which are limited to the
          amount actually charged by the dental laboratory for the upgrade.

   B. Fixed Prosthetics:
      To replace missing natural teeth, a fixed bridge is covered unless:
      1. The clinical condition of the teeth that would support the bridge is unfavorable.
       2. There are inadequate teeth available to support the bridge.
       3. The same dental arch has a serviceable existing partial denture to which additional denture teeth may
          be added to replace the missing natural teeth.
       4. A Member under 16 years of age loses a permanent tooth, in which case, an interim anterior stayplate
          would be the Covered Dental Service to replace the missing tooth.
       5. The new bridge would replace an existing bridge that is either less than 5 years old or still serviceable.




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       6. The bridge would be supported in whole or in part by dental implants or acid-etched resin bridge
          retainers (a “Maryland” bridge).
       7. A bridge would be used only to realign malaligned teeth.
       8. It is a long spanning bridge (anything beyond 4 abutments and/or pontics).
       9. The bridge would have an abutment (support) only on one side.

   C. Single Crowns:
      Single crowns are a Covered Dental Service when there is not enough retentive quality left in a tooth to
      hold a filling or if the tooth requires cuspal protection to avoid an unacceptable risk of tooth fracture. The
      use of precious or semi-precious metals in crowns is considered a laboratory upgrade, which the Assigned
      Contracting Dentist may offer the Member for a fee not to exceed the amount charged to the dentist by the
      dental laboratory for the use of these upgraded metal alloys. The Assigned Contracting Dentist may not,
      however, charge any additional laboratory fee in excess of the listed Discount Fee if a base metal alloy is
      used in a crown.
      1. Replacement of a crown is a Covered Dental Service as long as the existing restoration is at least 5
         years old, unserviceable and cannot be made serviceable, as determined by the Assigned Contracting
         Dentist.
       2. For crowns and fixed bridges, the maximum Dental Benefit within a twelve-month period is any
          combination of seven crowns or pontics (artificial teeth that are part of a fixed bridge). If more than
          seven crowns and/or pontics are done for a Member within a twelve-month period, the Assigned
          Contracting Dentist’s fee for any additional crowns within that period would not be limited to the listed
          Discount Fee, but instead can reflect the contracting dentist’s UCR.
13. Denture Repairs and Relines
    A. The addition of new denture teeth for existing full or partial dentures is covered if a natural tooth or a
       denture tooth is lost.
   B. Replacement of an existing full or partial denture is a Dental Benefit only if the existing denture is at least
      5 years old, has been determined unserviceable and cannot be made serviceable by the contracting
      dentist.
   C. If an existing permanent denture needs to be repaired and/or relined to be made serviceable, and then
      repairs and/or relines are also a Dental Benefit. Denture relines are limited to twice per year from the
      date of delivery. The addition of denture teeth, repairs and relines of secondary (“back-up,” “spare” or
      “temporary”) dentures are Not Covered Benefits.
    D. Adjustments for new dentures are included in the Discount Fee for the denture for six months following
        delivery, if the adjustments are made by the same contracting dentist who originally made the denture.
        For existing dentures or new dentures after the initial six months, the Member is responsible for the
        listed Discount Fee for a denture adjustment. Adjustments of secondary (“back-up” or “spare”) dentures
        are Not a Covered Benefit.
14. Occlusal Adjustment – Complete (D9952)
    Reshaping of the biting surfaces of the teeth to create harmonious contact and relationships between teeth in
    the upper and lower jaw. The correction of occlusion on natural teeth or existing restorations is Not a Covered
    Benefit. However, adjustment of the bite on a new restoration, crown, bridge and denture will be provided at no
    additional charge, if performed by the Assigned Contracting Dentist who provided the service.




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15. Dowel Posts and Pins
    Dowel posts are a Dental Benefit for teeth that have had root canal therapy and lack sufficient structure
    to otherwise support and provide adequate retention of a restoration. Pins are a separate Dental Benefit if
    deemed by the Assigned Contracting Dentist necessary to provide adequate retention of a restoration.
16. Restorations and Dental Prosthetics
    Restorations and/or fixed or removable prosthetics needed solely to increase vertical dimension or restore the
    Occlusal plane are Not Covered Benefits.
17. Specialty Referral
    As a Member of the High Option Dental Rider, our liability is per Calendar Year, above the Member’s Discount
    Fee for such Specialty treatment. Any fees in excess of the Discount Fee and our liability are the responsibility
    of the Member. The Member’s Specialty Calendar Year Maximum is $1,000.
   The High Option Dental Rider Benefit for Covered Dental Services of a Specialist is limited to:
   •	Member who’s Dental Rider includes Specialty Referral benefits.
   •	Covered Dental Services performed by an Oral Surgeon, Endodontist, Periodontist and Pedodontist, which
     are beyond the scope of practice of your Assigned Contracting Dentist.

Exclusion of Dental Benefits
The following dental procedures and services are excluded Dental Benefits and Not Covered Benefits [under the
Optional Dental Rider] [and the High Option Dental Rider] as specifically described below:
1. Referral to a Specialist, if you are a Member of the Optional Dental Rider.
2. Dental services provided by a Prosthodontist.
3. Cosmetic dental care.
4. General anesthesia (intravenous sedation), relative analgesia (N2O2) and the services of an anesthesiologist or
   nurse anesthesiologist.
5. The provision of dental services in hospitals, extended care facilities or Members’ homes.
6. Treatment of fractured bones and dislocated joints.
7. Replacement of lost or stolen dentures is not covered. Crowns or bridgework lost due to negligence are not
   covered, unless the crown or bridge became dislodged because of recurrent dental caries, tooth fracture,
   substandard tooth preparation or poor margins (as previously determined in an examination by the Assigned
   Contracting Dentist or based upon a review of a pre-existing radiograph).
8. Replacement of lost, stolen or broken orthodontic appliances.
9. Services which are provided to the Member by a state government or agency or are provided without cost to
   the Member by a municipality, county or other subdivision.
10. Dental expense incurred in connection with any dental procedure started after termination of eligibility for
    benefits.
11. Work-in-progress such as the completion of dental services started before the Member’s Effective Date with
    AARP® MedicareComplete, or started by a non-contracting dentist without our prior approval. Note: This
                                ®
    Exclusion does not apply to a current Member who has a temporary placed, a tooth opened and medicated
    as a palliative service while Out-of-Area or when the Assigned Contracting Dentist is unavailable to render
    Palliative Care.


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12. The treatment of congenital and/or developmental malformations, which includes the treatment of congenitally
    missing and extra, supernumerary teeth and related pathology.
13. The treatment of non-dentigerous cysts, benign and malignant tumors, neoplasms and dysplasias.
14. Dental ridge augmentation, vestibuloplasties and the excision of benign hyperplastic tissue.
15. Drugs prescribed by a dentist or drugs used for dental treatment, except in accordance with Medicare
    guidelines.
16. Any dental procedure unable to be performed in the Assigned Contracting Dental Office because of the
    Member’s general health and physical limitations.
17. Oral surgery and procedures performed to facilitate or allow orthodontic treatment, which include, but are not
    limited to: orthodontic extraction, serial extraction, orthognathic surgery, transeptal fiberotomy, gingivectomy
    and surgery to uncover impacted teeth.
18. Services rendered by a dental office other than Member’s Assigned Contracting Dental Office, unless
    previously authorized by us in writing. An exception is made for Emergency Care.
19. The placement, maintenance and removal of implants. Crowns and fixed prosthesis supported by implants.
20. Restorations of natural teeth other than those needed for replacement of unserviceable existing restorations
    or to replace tooth structure lost due to fracture, endodontic access preparations or dental caries. Treatment
    includes, but is not limited to:
   •	Replacing or stabilizing tooth structure loss by attrition, abrasion or erosion
   •	Periodontal splinting/grafting
   •	The replacement of otherwise serviceable amalgam restorations, with new reiterations of a different material
     solely to eliminate the presence of amalgam
21. Restorations and dental prosthetics that are done solely to alter the vertical dimension of occlusion, alter the
    plane of occlusion, modify a parafunctional habit, and/or treat temporomandibular joint dysfunction and/or
    myofascial pain syndrome. If performed, the Member must pay UCR. These services include, but are not limited
    to:
   •	Realignment of teeth
   •	Gnathologic recording
   •	Occlusal Adjustment – Complete (D9952)
   •	Occlusal splints and night guards
   •	Overlays, implant supported partial dentures and over dentures
   •	The replacement of otherwise serviceable existing restorations and dental prosthetics
   •	Precision attachments and stress-breakers
22. Dental services which we determine not to be medically necessary or consistent with good professional
    practice.
23. The provision of dental services which would not be consistent with the Member’s dental needs and/or
    generally accepted professional standards of dental therapeutics for that Member.




                                                          10
24. The premature extraction of asymptomatic or non-pathologic impacted teeth at an early stage of tooth
    development, which, if allowed to further develop and erupt, would reduce the likelihood of needing a more
    invasive surgery and/or experiencing postoperative complications.
25. Adjunctive dental services that are performed only to allow or facilitate the performance of another non-
    covered dental service.
26. Medical services for treatment of fractures, dislocations, tumors, non-dentigerous cysts, and neoplasms,
    and other medically necessary surgeries of the jaws or related joints. Requests for such services should be
    submitted to the Member’s full service medical Health Plan.
27. Liability insurance cases: Dental care which is covered under automobile, medical, no-fault or similar type
    insurance.




                                                         11
SECTION 5: 2010 Schedule of Dental Rider Discount Fees
NTCV = Not a benefit – patient pays full UCR fee

ADA                     SERVICE DESCRIPTION                                                          HIGH
CODE CDT09                                                                                           OPTION
                        Office Visit (see limitation at end of document)                             $5
                        Broken Appointment Fee                                                       $0
                        Initial charting with pocket depth summary                                   $10
                        Annual Maximum on Specialty Referrals                                        $1,000
 DIAGNOSTIC
D0120                   Periodic Oral Evaluation                                                     $0
D0140                   Limited Oral Evaluation – problem focused                                    $0
D0145                   Oral Evaluation for a patient under three years of age and counseling with   $0
                        primary caregiver
D0150                   Comprehensive Oral Evaluation – new or established patient                   $0
D0160                   Detailed and extensive oral evaluation – problem focused, by report          $0
D0170                   Re-evaluation – limited, problem focused                                     $0
D0180                   Comprehensive periodontal evaluation – new or established patient            $0
 RADIOGRAPHS
                         PERIAPICAL & BITEWING X-RAYS NOT TO EXCEED COMPLETE SERIES FEE
D0210                   Intraoral – complete series (including bitewings; every two years)           $0
D0220                   Intraoral – periapical – first film                                          $0
D0230                   Intraoral – periapical – each additional film                                $0
D0240                   Intraoral – occlusal film                                                    $0
D0250                   Extraoral – first film                                                       NTCV
D0260                   Extraoral – each additional film                                             NTCV
D0270                   Bitewings – single film                                                      $0
D0272                   Bitewings – two films                                                        $0
D0273                   Bitewings – three films                                                      $0
D0274                   Bitewings – four films                                                       $0
D0277                   Vertical bitewings – 7 to 8 films                                            NTCV
D0290                   Posterior – anterior or lateral skull and facial bone survey film            NTCV
D0310                   Sialography                                                                  NTCV
D0320                   Temporomandibular joint arthrogram, including injection                      NTCV
D0321                   Other temporomandibular joint films, by report                               NTCV
D0322                   Tomographic survey                                                           NTCV
D0330                   Panoramic film                                                               $0


                                                           12
ADA                    SERVICE DESCRIPTION                                                           HIGH
CODE CDT09                                                                                           OPTION
D0340                  Cephalometric film                                                            NTCV
D0350                  Oral/facial photographic images                                               NTCV
D0415                  Collection of microorganisms for culture and sensitivity                      NTCV
D0416                  Viral Culture                                                                 NTCV
D0417                  Collection and preparation of saliva sample for laboratory and diagnostic     NTCV
                       testing
D0418                  Analysis of saliva sample                                                     NTCV
D0421                  Genetic test for susceptibility to oral caries                                NTCV
D0425                  Caries susceptibility tests                                                   NTCV
D0460                  Pulp vitality tests                                                           $0
D0470                  Diagnostic casts                                                              NTCV
D0472 - D0502          ORAL PATHOLOGY LABORATORY                                                     NTCV
D0501                  Histopathologic examinations                                                  NTCV
PREVENTIVE
D1110                  Prophylaxis – adult (once every six months)                                   $5
D1120                  Prophylaxis – child (once every six months)                                   $5
D1201                  Topical application of fluoride (including prophylaxis) – child (under age 18) $10
D1203                  Topical application of fluoride – child (under age 18)                        $10
D1204                  Topical application of fluoride – adult                                       $10
D1205                  Topical application of fluoride (including prophylaxis) – adult               $10
D1206                  Topical fluoride varnish; therapeutic application for moderate to high caries NTCV
                       risk patients
D1310                  Nutritional counseling for the control of dental disease                      NTCV
D1320                  Tobacco counseling for the control and prevention of oral disease             NTCV
D1330                  Oral hygiene instruction                                                      $0
D1351                  Sealant – per tooth (under age 18 only)                                       NTCV
D1510                  Space maintainer – fixed – unilateral                                         NTCV
D1515                  Space maintainer – fixed – bilateral                                          NTCV
D1520                  Space maintainer – removable – unilateral                                     NTCV
D1525                  Space maintainer – removable – bilateral                                      NTCV
D1550                  Recementation of space maintainer                                             NTCV
D1555                  Removal of space maintainer                                                   NTCV
RESTORATIVE
* The member is responsible for the additional cost of the precious metal, not to exceed the actual amount billed
  by the lab.



                                                        13
ADA                     SERVICE DESCRIPTION                                                            HIGH
CODE CDT09                                                                                             OPTION
If alloy restorations are not provided or offered in the dental practice, payment for posterior composites are to be
based on the amalgam copayment.
D2140                   Amalgam – one surface, primary or permanent                                    $20
D2150                   Amalgam – two surfaces, primary or permanent                                   $35
D2160                   Amalgam – three surfaces, primary or permanent                                 $45
D2161                   Amalgam – four or more surfaces, primary or permanent                          $60
D2330                   Resin-based composite – one surface, anterior                                  $30
D2331                   Resin-based composite – two surfaces, anterior                                 $45
D2332                   Resin-based composite – three surfaces, anterior                               $50
D2335                   Resin-based composite – four or more surfaces or involving incisal angle       $65
                        (anterior)
D2390                   Resin-based composite crown, anterior                                          NTCV
D2391                   Resin-based composite – one surface, posterior                                 $70
D2392                   Resin-based composite – two surfaces, posterior                                $85
D2393                   Resin-based composite – three surfaces, posterior                              $105
D2394                   Resin-based composite – four or more surfaces, posterior                       $115
D2410                   Gold foil – one surface                                                        NTCV
D2420                   Gold foil – two surfaces                                                       NTCV
D2430                   Gold foil – three surfaces                                                     NTCV
D2510                   Inlay – metallic – one surface*                                                $200*
D2520                   Inlay – metallic – two surfaces*                                               $200*
D2530                   Inlay – metallic – three or more surfaces*                                     $200*
D2542                   Onlay – metallic – two surfaces*                                               $200*
D2543                   Onlay – metallic – three surfaces*                                             $200*
D2544                   Onlay – metallic – four or more surfaces*                                      $200*
D2610                   Inlay – porcelain/ceramic – one surface                                        NTCV
D2620                   Inlay – porcelain/ceramic – two surfaces                                       NTCV
D2630                   Inlay – porcelain/ceramic – three or more surfaces                             NTCV
D2642                   Onlay – porcelain/ceramic – two surfaces                                       NTCV
D2643                   Onlay – porcelain/ceramic – three surfaces                                     NTCV
D2644                   Onlay – porcelain/ceramic – four or more surfaces                              NTCV
D2650                   Inlay – resin-based composite – one surface (laboratory processed)             NTCV
D2651                   Inlay – resin-based composite – two surfaces (laboratory processed)            NTCV
D2652                   Inlay – resin-based composite – three or more surfaces (laboratory             NTCV
                        processed)
D2662                   Onlay – resin-based composite – two surfaces                                   NTCV

                                                          14
ADA          SERVICE DESCRIPTION                                                   HIGH
CODE CDT09                                                                         OPTION
D2663        Onlay – resin-based composite – three surfaces                        NTCV
D2664        Onlay – resin-based composite – four or more surfaces                 NTCV
D2710        Crown – resin-based composite (indirect)                              $125
D2712        Crown – 3/4 resin-based composite (indirect)                          $125
D2720        Crown – resin with high noble metal*                                  $290*
D2721        Crown – resin with predominantly base metal                           $290*
D2722        Crown – resin with noble metal*                                       $290*
D2740        Crown – porcelain/ceramic substrate (not for molars)                  $250
D2750        Crown – porcelain fused to high noble metal *                         $275*
D2751        Crown – porcelain fused to predominantly base metal                   $275*
02752        Crown – porcelain fused to noble metal*                               $275*
D2780        Crown – 3/4 cast high noble metal*                                    $250*
D2781        Crown – 3/4 cast predominantly base metal                             $250*
D2782        Crown – 3/4 cast noble metal*                                         $250*
D2783        Crown – 3/4 porcelain/ceramic                                         $200
D2790        Crown – full cast high noble metal*                                   $275*
D2791        Crown – full cast predominantly base metal                            $275*
D2792        Crown – full cast noble metal*                                        $275
D2794        Crown – titanium*                                                     $275*
D2799        Provisional crown                                                     NTCV
D2910        Recement inlay, onlay or partial coverage restoration                 $15
D2915        Recement cast or prefabricated post and core                          $15
D2920        Recement crown                                                        $15
D2930        Prefabricated stainless steel crown – primary tooth                   NTCV
D2931        Prefabricated stainless steel crown – permanent tooth                 $40
D2932        Prefabricated resin crown                                             $40
D2933        Prefabricated stainless steel crown with resin window                 NTCV
D2934        Prefabricated esthetic coated stainless steel crown – primary teeth   NTCV
D2940        Sedative filling                                                      $18
D2950        Core buildup, including any pins                                      $65
D2951        Pin retention – per tooth, in addition to restoration                 $10
D2952        Cast post and core in addition to crown* (indirectly fabricated)      $85*
D2953        Each additional indirectly fabricated post – same tooth*              $65*
D2954        Prefabricated post and core in addition to crown                      $65
D2955        Post removal (not in conjunction with endodontic therapy)             NTCV


                                              15
ADA           SERVICE DESCRIPTION                                                                HIGH
CODE CDT09                                                                                       OPTION
D2957         Each additional prefabricated post – same tooth                                    $55
D2960         Labial veneer (resin laminate) – chairside                                         NTCV
D2961         Labial veneer (resin laminate) – laboratory                                        NTCV
D2962         Labial veneer (porcelain laminate) – laboratory                                    NTCV
D2970         Temporary crown (fractured tooth)                                                  $20
D2971         Additional procedures to construct new crown under existing partial                $100
              denture framework
D2975         Coping                                                                             $50
D2980         Crown repair, by report                                                            NTCV
ENDODONTICS
                                INCLUDES ALL INTRA-OPERATIVE X-RAYS
D3110         Pulp cap – direct (excluding final restoration)                                    $12
D3120         Pulp cap – indirect (excluding final restoration)                                  $18
D3220         Therapeutic pulpotomy (excluding final restoration)                                $20
D3221         Pulpal debridement, primary and permanent teeth                                    NTCV
D3222         Partial pulpotomy for apexogenesis – permanent tooth with incomplete root NTCV
              development
D3230         Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final     NTCV
              restoration)
D3240         Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final    NTCV
              restoration)
D3310         Endodontic therapy, anterior tooth (excluding final restoration)                   $165
D3320         Endodontic therapy, bicuspid tooth (excluding final restoration)                   $225
D3330         Endodontic therapy, molar tooth (excluding final restoration)                      $350
D3331         Treatment of root canal obstruction; non-surgical access                           NTCV
D3332         Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $150
D3333         Internal root repair of perforation defects                                        NTCV
D3346         Retreatment of previous root canal therapy – anterior                              $245
D3347         Retreatment of previous root canal therapy – bicuspid                              $280
D3348         Retreatment of previous root canal therapy – molar                                 $400
D3351         Apexification/recalcification – initial visit (apical closure/calcific repair of   NTCV
              perforations, root resorption, etc.
D3352         Apexification/recalcification – interim medication replacement (apical             NTCV
              closure/cancific repair of perforations, root resorption, etc.)
D3353         Apexification/recalcification – final visit (includes completed root canal,        NTCV
              therapy-apical closure/calcific repair of perforations, root resorption, etc.)
D3410         Apicoectomy/periradicular surgery – anterior                                       $200

                                                16
ADA            SERVICE DESCRIPTION                                                          HIGH
CODE CDT09                                                                                  OPTION
D3421          Apicoectomy/periradicular surgery – bicuspid (first root)                    $200
D3425          Apicoectomy/periradicular surgery – molar (first root)                       $200
D3426          Apicoectomy/periradicular surgery (each additional root)                     $80
D3430          Retrograde filling – per root (included in allowance for apicoectomy)        $80
D3450          Root amputation – per root                                                   NTCV
D3460          Endodontic endosseous implant                                                NTCV
D3470          Intentional replantation (including necessary splinting)                     NTCV
D3910          Surgical procedure for isolation of tooth with rubber dam                    NTCV
D3920          Hemisection (including any root removal), not including root canal therapy   NTCV
D3950          Canal preparation and fitting of performed dowel or post, should not be      $0
               reported in conjunction with 02952 or 02954 by the same practitioner
PERIODONTICS
                 SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE SERVICES)
D4210          Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded     $180
               teeth spaces per quadrant
D4211          Gingivectomy or gingivoplasty – one to three contiguous teeth or bounded     $45
               teeth spaces per quadrant
D4230          Anatomical crown exposure – four or more contiguous teeth per quadrant       NTCV
D4231          Anatomical crown exposure – four or more contiguous teeth per quadrant       NTCV
D4240          Gingival flap procedure, including root planing – four or more contiguous    $175
               teeth or bounded teeth spaces per quadrant
D4241          Gingival flap procedure, including root planing – one to three contiguous    $85
               teeth or bounded teeth spaces per quadrant
D4245          Apically positioned flap                                                     NTCV
D4249          Clinical crown lengthening – hard tissue                                     NTCV
D4260          Osseous surgery (including flap entry and closure)- four or more             $500
               contiguous teeth or bounded teeth spaces per quadrant
D4261          Osseous surgery (including flap entry and closure)- one to three contiguous $250
               teeth or bounded teeth spaces per quadrant
D4263          Bone replacement graft – first site in quadrant                              NTCV
D4264          Bone replacement graft – each additional site in quadrant                    NTCV
D4265          Biological materials to aid in soft and osseous tissue regeneration          NTCV
D4266          Guided tissue regeneration – resorbable barrier, per site, per tooth         NTCV
D4267          Guided tissue regeneration – nonresorbable barrier, per site, per tooth      NTCV
               (includes membrane removal)
D4268          Surgical revision procedure, per tooth                                       NTCV
D4270          Pedicle soft tissue graft procedure                                          NTCV


                                               17
ADA                     SERVICE DESCRIPTION                                                            HIGH
CODE CDT09                                                                                             OPTION
D4271                   Free soft tissue graft procedure (including donor site surgery)                NTCV
D4273                   Subepithelial connective tissue graft procedure, per tooth                     NTCV
D4274                   Distal or proximal wedge procedure (when not performed in conjunction          NTCV
                        with surgical procedures in the same anatomical area)
D4275                   Soft tissue allograft                                                          NTCV
D4276                   Combined connective tissue and double pedical graft, per tooth                 NTCV
D4320                   Provisional splinting – intracoronal                                           NTCV
D4321                   Provisional splinting – extracoronal                                           NTCV
D4341                   Periodontal scaling and root planing – four or more teeth per quadrant         $40
D4342                   Periodontal scaling and root planing – one to three teeth per quadrant         $20
D4355                   Full mouth debridement to enable comprehensive periodontal evaluation          $40
                        and diagnosis
D4381                   Localized delivery of antimicrobial agents via a controlled release vehicle    NTCV
                        into diseased crevicular tissue, per tooth, by report
D4910                   Periodontal maintenance procedures (following active therapy; once every       $40
                        six months)
D4920                   Unscheduled dressing change (by someone other than treating dentist)           NTCV
PROSTHODONTICS, REMOVABLE
Includes post delivery care and adjustments for the first 6 months (at the office delivering the removable
prosthesis)
D5110                   Complete denture – maxillary                                                   $310
D5120                   Complete denture – mandibular                                                  $310
D5130                   Immediate denture – maxillary                                                  $330
D5140                   Immediate denture – mandibular                                                 $330
D5211                   Maxillary partial – resin base (including any conventional clasps, rests and   $150
                        teeth)
D5212                   Mandibular partial – resin base (including any conventional clasps, rests      $150
                        and teeth)
D5213                   Maxillary partial – cast metal base with resin denture bases (including any    $330
                        conventional clasps, rests and teeth)
D5214                   Mandibular partial – cast metal base with resin denture bases (including       $330
                        any conventional clasps, rests and teeth)
D5225                   Maxillary partial denture – flexible base (including any clasps, rests and     $360
                        teeth)
D5226                   Mandibular partial denture – flexible base (including any clasps, rests and    $360
                        teeth)




                                                        18
ADA             SERVICE DESCRIPTION                                                      HIGH
CODE CDT09                                                                               OPTION
D5281           Removable unilateral partial denture – one piece cast metal (including   $275
                clasps and teeth)
D5410           Adjust complete denture – maxillary                                      $20
D5411           Adjust complete denture – mandibular                                     $20
D5421           Adjust partial denture – maxillary                                       $20
D5422           Adjust partial denture – mandibular                                      $20
D5510           Repair broken complete denture base                                      $30
D5520           Replace missing or broken teeth – complete denture (each tooth)          $20
D5610           Repair resin denture or base                                             $45
D5620           Repair cast framework                                                    $35
D5630           Repair or replace broken clasp                                           $40
D5640           Replace broken teeth – per tooth                                         $40
D5650           Add tooth to existing partial denture                                    $40
D5660           Add clasp to existing partial denture                                    $40
D5670           Replace all teeth and acrylic on cast metal framework (maxillary)        $165
D5671           Replace all teeth and acrylic on cast metal framework (mandibular)       $165
D5710           Rebase complete maxillary denture                                        NTCV
D5711           Rebase complete mandibular denture                                       NTCV
D5720           Rebase maxillary partial denture                                         NTCV
D5721           Rebase mandibular partial denture                                        NTCV
D5730           Reline complete maxillary denture (chairside)                            $60
D5731           Reline complete mandibular denture (chairside)                           $60
D5740           Reline maxillary partial denture (chairside)                             $60
D5741           Reline mandibular partial denture (chairside)                            $60
D5750           Reline complete maxillary denture (laboratory)                           $100
D5751           Reline complete mandibular denture (laboratory)                          $100
D5760           Reline maxillary partial denture (laboratory)                            $100
D5761           Reline mandibular partial denture (laboratory)                           $100
D5810           Interim complete denture (maxillary)                                     NTCV
D5811           Interim complete denture (mandibular)                                    NTCV
D5820           Interim partial denture (maxillary)                                      NTCV
D5821           Interim partial denture (mandibular)                                     NTCV
D5850           Tissue conditioning, maxillary                                           $35
D5851           Tissue conditioning, mandibular                                          $35
D5860 – D5899   OTHER REMOVABLE PROSTHETIC SERVICES                                      NTCV


                                                 19
ADA                    SERVICE DESCRIPTION                                                           HIGH
CODE CDT09                                                                                           OPTION
D5900 – D5999          MAXILLOFACIAL PROSTHETICS                                                     NTCV
D6000 – D6199          IMPLANT SERVICES                                                              NTCV
PROSTHODONTICS – FIXED
                              EACH ABUTMENT AND EACH PONTIC CONSTITUTE ONE UNIT
* The member is responsible for the additional cost of the precious metal, not to exceed the actual amount billed
  by the lab.
D6210                  Pontic – cast high noble metal*                                               $275*
D6211                  Pontic – cast predominantly base metal                                        $275
D6212                  Pontic – cast noble metal*                                                    $275*
D6214                  Pontic – titanium*                                                            $275*
D6240                  Pontic – porcelain fused to high noble metal*                                 $275*
D6241                  Pontic – porcelain fused to predominantly base metal                          $275
D6242                  Pontic – porcelain fused to noble metal*                                      $275*
D6245                  Pontic – porcelain/ceramic                                                    $275
D6250                  Pontic – resin with high noble metal*                                         $200*
D6251                  Pontic – resin with predominantly base metal                                  $200
D6252                  Pontic – resin with noble metal*                                              $200*
D6253                  Provisional pontic                                                            NTCV
D6545                  Retainer – cast metal for resin bonded fixed prosthesis                       NTCV
D6548                  Retainer – porcelain/ceramic for resin bonded fixed prosthesis                NTCV
D6600                  Inlay – porcelain/ceramic, two surfaces                                       NTCV
D6601                  Inlay – porcelain/ceramic, three or more surfaces                             NTCV
D6602                  Inlay – cast high noble metal, two surfaces*                                  $200*
D6603                  Inlay – cast high noble metal, three or more surfaces*                        $200*
D6604                  Inlay – cast predominantly base metal, two surfaces                           $200
D6605                  Inlay – cast predominantly base metal, three or more surfaces                 $200
D6606                  Inlay – cast noble metal, two surfaces*                                       $200*
D6607                  Inlay – cast noble metal, three or more surfaces*                             $200*
D6608                  Onlay – porcelain/ceramic, two surfaces                                       NTCV
D6609                  Onlay – porcelain/ceramic, three or more surfaces                             NTCV
D6610                  Onlay – cast high noble metal, two surfaces*                                  NTCV
D6611                  Onlay – cast high noble metal, three or more surfaces*                        NTCV
D6612                  Onlay – cast predominantly base metal, two surfaces                           NTCV
D6613                  Onlay – cast predominantly base metal, three or more surfaces                 NTCV
D6614                  Onlay – cast noble metal, two surfaces*                                       NTCV


                                                       20
ADA            SERVICE DESCRIPTION                                                            HIGH
CODE CDT09                                                                                    OPTION
D6615          Onlay – cast noble metal, three or more surfaces*                              NTCV
D6624          Inlay – titanium*                                                              $200*
D6634          Onlay – titanium*                                                              NTCV
D6720          Crown – resin with high noble metal*                                           $200*
D6721          Crown – resin with predominantly base metal                                    $200
D6722          Crown – resin with noble metal*                                                $200*
D6740          Crown – porcelain/ceramic                                                      $250
D6750          Crown – porcelain fused to high noble metal*                                   $275*
D6751          Crown – porcelain fused to predominantly base metal                            $275
D6752          Crown – porcelain fused to noble metal*                                        $275*
D6780          Crown – 3/4 cast high noble metal*                                             $275*
D6781          Crown – 3/4 cast predominantly base metal                                      $275
D6782          Crown – 3/4 cast noble metal*                                                  $275*
D6783          Crown – 3/4 cast porcelain/ceramic                                             $250
D6790          Crown – full cast high noble metal*                                            $200*
D6791          Crown – full cast predominantly base metal                                     $200
D6792          Crown – full cast noble metal*                                                 $200*
D6793          Provisional retainer crown                                                     NTCV
D6794          Crown-titanium*                                                                $275*
D6920          Connector Bar                                                                  NTCV
D6930          Recement fixed partial denture                                                 $30
D6940          Stress breaker                                                                 NTCV
D6950          Precision attachment                                                           NTCV
D6970          Cast post and core in addition to fixed partial bridge retainer* (indirectly   $85
               fabricated)
D6971          Cast post as part of bridge retainer                                           $90
D6972          Prefabricated post and core in addition to fixed partial bridge retainer       $65
D6973          Core build up for retainer, including any pins                                 $65
D6975          Coping – metal                                                                 NTCV
D6976          Each additional indirectly fabricated post – same tooth                        $65
D6977          Each additional prefabricated post – same tooth                                $55
D6980          Fixed partial denture repair, by report                                        NTCV
ORAL SURGERY
                 INCLUDES LOCAL ANESTHESIA AND ROUTINE POSTOPERATIVE CARE
D7111          Extraction, coronal remnants – deciduous tooth                                 $25


                                                21
ADA             SERVICE DESCRIPTION                                                           HIGH
CODE CDT09                                                                                    OPTION
D7140           Extraction, erupted tooth or exposed root (elevation and/or forceps           $25
                removal)
D7210           Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap $50
                and removal of bone and/or section of tooth
D7220           Removal of impacted tooth – soft tissue                                       $100
D7230           Removal of impacted tooth – partially bony                                    $135
D7240           Removal of impacted tooth – completely bony                                   $170
D7241           Removal of impacted tooth – completely bony, with unusual surgical            NTCV
                complications
D7250           Surgical removal of residual tooth roots (cutting procedure)                  $90
D7260 – D7282   OTHER SURGICAL PROCEDURES                                                     NTCV
D7285           Biopsy of oral tissue – hard (bone, tooth)                                    $100
D7286           Biopsy of oral tissue – soft                                                  $100
D7287           Exfoliative cytological sample collection                                     NTCV
D7290           Surgical repositioning of teeth                                               NTCV
D7291           Transseptal fiberotomy/supra crestal fiberotomy, by report                    NTCV
D7310           Alveoloplasty in conjunction with extractions – four or more teeth or tooth   $100
                spaces, per quadrant
D7311           Alveoloplasty in conjunction with extractions – one to three teeth or tooth   $80
                spaces, per quadrant
D7320           Alveoloplasty not in conjunction with extractions – four or more teeth or     $150
                tooth spaces, per quadrant
D7321           Alveoloplasty not in conjunction with extractions – one to three teeth or     $75
                tooth spaces, per quadrant
D7340           Vestibuloplasty – ridge extension (secondary epithelialization)               NTCV
D7350           Vestibuloplasty – ridge extension (including soft tissue grafts, muscle       NTCV
                attachments, revision of soft tissue attachment, and management of
                hypertrophied and hyperplastic tissue)
D7410           Excision of benign lesion up to 1.25 cm                                       NTCV
D7411           Excision of benign lesion greater than 1.25 cm                                NTCV
D7412           Excision of benign lesion, complicated                                        NTCV
D7413           Excision of malignant lesion up to 1.25 cm                                    NTCV
D7414           Excision of malignant lesion greater than 1.25 cm                             NTCV
D7415           Excision of malignant lesion, complicated                                     NTCV
D7440 – D7465   SURGICAL EXCISION OF INTRA OSSEOUS/SOFT TISSUE LESIONS                        NTCV
D7471           Removal of lateral exostosis (maxilla and mandible)                           $150
D7472           Removal of torus palatinus                                                    $150


                                                  22
ADA                     SERVICE DESCRIPTION                                                           HIGH
CODE CDT09                                                                                            OPTION
D7473                   Removal of torus madibularis                                                  $150
D7485                   Surgical reduction of osseous tuberosity                                      $150
D7490                   Radical resection of maxilla or mandible                                      NTCV
D7510                   Incision and drainage of abscess – intraoral soft tissue                      $35
D7511                   Incision and drainage of abscess – intraoral soft tissue – complicated        $50
                        (includes drainage of multiple fascial spaces)
D7520                   Incision and drainage of abscess – extraoral soft tissue                      $50
D7521                   Incision and drainage of abscess – extraoral soft tissue – complicated        $60
                        (includes drainage of multiple fascial spaces)
D7530                   Removal of foreign body, skin, or subcutaneous alveolar tissue                NTCV
D7540                   Removal of reaction producing foreign bodies, musculoskeletal system          NTCV
D7550                   Partial ostectomy/sequestrectomy for removal of non-vital bone                NTCV
D7560                   Maxillary sinusotomy for removal of tooth fragment or foreign body            NTCV
D7610 – D7680           TREATMENT OF FRACTURE-SIMPLE                                                  NTCV
D7710 – D7780           TREATMENT OF FRACTURES-COMPOUND                                               NTCV
D7810 – D7899           REDUCTION OF DISLOCATION AND MANAGEMENT OF TMJ                                NTCV
                        DYSFUNCTIONS
D7910 – D7999           OTHER REPAIR PROCEDURES                                                       NTCV
ORTHODONTICS
D8110 - D8999           ORTHODONTIC TREATMENT                                                         NTCV
ADJUNCTIVE GENERAL SERVICES
Charges for general anesthesia, nitrous oxide and IV sedation are the responsibility of the patient
D9110                   Palliative (emergency) treatment of dental pain – minor procedures            $0
D9120                   Fixed partial denture sectioning                                              NTCV
D9210                   Local anesthesia not in conjunction with operative or surgical procedures     NTCV
D9211                   Regional block anesthesia                                                     NTCV
D9212                   Trigeminal division block anesthesia                                          NTCV
D9215                   Local anesthesia                                                              $0
D9220                   Deep sedation general anesthesia – first 30 minutes                           NTCV
D9221                   Deep sedation general anesthesia – each additional 15 minutes                 NTCV
D9230                   Analgesia, anxiolysis, inhalation of nitrous oxide                            NTCV
D9241                   Intervaneous conscious sedation/analgesia – first 30 minutes                  NTCV
D9242                   Intravaneous conscious sedation/analgesia – each additional 15 minutes        NTCV
D9248                   Non-intravenous conscious sedation                                            NTCV
D9310                   Consultation (diagnostic service provided by dentist or physician other than $50
                        practitioner providing treatment)


                                                         23
ADA          SERVICE DESCRIPTION                                                          HIGH
CODE CDT09                                                                                OPTION
D9410        House call                                                                   NTCV
D9420        Hospital call                                                                NTCV
D9430        Office visit for observation (during regularly scheduled hours) – no other   $5
             services performed
D9440        Office visit – after regularly scheduled hours                               $30
D9450        Case presentation, detailed and extensive treatment planning                 $30
D9610        Therapeutic parenternal drug, single administration                          NTCV
D9630        Other drugs and/or medicaments, by report                                    NTCV
D9910        Application of desensitizing medicaments                                     NTCV
D9911        Application of desensitizing resin for cervical and/or root surface, per     NTCV
             tooth
D9920        Behavior management, by report                                               NTCV
D9930        Treatment of complication (post-surgical)-unusual circumstances, by report NTCV
D9940        Occlusal guard, by report                                                    NTCV
D9941        Fabrication of athletic mouth guard                                          NTCV
D9942        Repair and/or reline of occlusal guard                                       NTCV
D9950        Occlusion analysis – mounted case                                            NTCV
D9951        Occlusal adjustment – limited                                                $15
D9952        Occlusal adjustment – complete                                               NTCV
D9970        Enamel Microabrasion                                                         NTCV
D9971        Odontoplasty 1 – 2 teeth; includes removal of enamel projections             NTCV
D9972        External bleaching – per arch                                                NTCV
D9973        External bleaching – per tooth                                               NTCV
D9974        Internal bleaching – per tooth                                               NTCV




                                              24
ADA                      SERVICE DESCRIPTION                                                                HIGH
CODE CDT09                                                                                                  OPTION
LIMITATIONS:
1. The copayment specified in this schedule for office visits is limited to 4 per year, per person. Office visits
   beyond 4 per year are at no charge. This copayment is due in addition to any other copayment(s) specified for
   procedures or services rendered.
2. The copayment specified in this schedule for oral examinations is limited to 4 per year, per person. Oral
   exams beyond 4 per year are at no charge. This copayment is due in addition to any other copayment(s)
   specified for procedures or services rendered.
3. For fillings, the office visit copayment is due only once per quadrant, even if fillings are done on separate visits.
4. For root canals and crowns, the office visit copayment is due only once per procedure, regardless of the
   number of visits necessary to complete that procedure. For multiple procedures, the office visit copayment is
   due once for each procedure.
5. Covered general dental services are unlimited when prescribed and performed by the assigned dental office. A
   member may be referred to a dental specialist for procedures that are beyond the scope of the general dentist.
The services of a specialist are limited to a $1,000 annual maximum for the High Option Dental Rider,
and are not a benefit on the Optional Dental Rider.




                                                           25
SECTION 6: Dental Terms
1. Assigned Contracting Dentist or Dental Office – the dentist or dental office, contracting with us, where
   you are assigned to receive Dental Benefits.
2. Claim – written notification of purpose in a form acceptable to us that a Covered Service has been rendered
   or furnished to a Member.
3. The Centers for Medicare & Medicaid Services (CMS) – the federal agency responsible for administering
   Medicare.
4. Covered Dental Service(s) – those Dental Benefits, treatments and services listed in this Dental Benefits
   Booklet and provided by your Assigned Contracting Dental Office.
5. Dental Benefits – the Dental Benefits available to Members under the High Option Dental Rider.
6. Discount Fee – the fee charged by your Contracting Dental Office at the time Covered Dental Services are
   performed in accordance with your Dental Rider.
7. Effective Date – the date your AARP® MedicareComplete® Optional Supplemental Dental Rider begins.
8. Endodontist – a dental Specialist who limits his/her practice to treating disease and injuries of the pulp and
   associated periradicular conditions.
9. Exclusion – any services or items not included under the Dental Rider.
10. General Dentist – a dentist licensed by the State in which he/she practices General Dentistry and who is not
    a Specialist in a particular field of dentistry.
11. Health Plan – the Plan under which a Member receives covered medical services. For Members of the Dental
    High Option Rider, the Health Plan is AARP® MedicareComplete.®
12. Laboratory Cost – if the services of a dental lab are required for any procedure, the Member is responsible
    for the full Laboratory Cost, not to exceed the actual amount billed by the lab.
13. Limitation – any restriction on Dental Benefits (other than an Exclusion) under the Dental Rider.
14. Maximum Allowable Fee Schedule – The fee schedule upon which we base Claim payments to Non-
    Contracted Dentists. The fee schedule may or may not be equal to the Dentist’s Usual, Customary and
    Reasonable fee and varies by geographic region.
15. Monthly Dental Plan Premium – the monthly payment which entitles a Member to receive Covered Dental
    Services. The Monthly Dental Rider Premium may be in addition to a Health Plan Premium.
16. Not Covered Benefit – a non-Covered Dental Service, for which there is no covered service that may serve as
    an acceptable clinical alternative. Because there is no covered allowance, when this type of treatment is done,
    Members can be charged the dentist’s full Usual, Customary and Reasonable (UCR) fee.
17. Optional Supplemental Dental Rider – non-Medicare covered benefits that can be purchased beyond
    the benefits included in AARP® MedicareComplete® which may be elected at a Member’s option. There
    is a Plan Premium associated with Optional Supplemental Dental Rider benefits. Members of AARP®
    MedicareComplete® must voluntarily elect an Optional Supplemental Dental Rider in order to receive dental
    benefits.
18. Oral and Maxillofacial Surgeon – a dental Specialist whose practice is limited to the diagnosis, surgical
    and adjunctive treatment of diseases, injuries, deformities, defects and esthetic aspects of the oral and
    maxillofacial regions.


                                                        26
19. Out-of-Area Coverage – dental coverage while a Member is anywhere outside the Service Area of the Dental
    Rider and also includes coverage for Emergency Care to prevent serious deterioration of a Member’s health
    resulting from an unforeseen illness or injury for which treatment cannot be delayed until the Member returns
    to the Dental Plan’s Service Area.
20. Palliative Care – emergency treatment of dental pain, that relieves pain, but is not curative.
21. Pedodontist – a dental Specialist whose practice is limited to treatment of children from birth through
    adolescence.
22. Periodontist – a dental Specialist whose practice is limited to the treatment of diseases of the supporting and
    surrounding tissues of the teeth.
23. Prophylaxis (Teeth Cleaning) – the routine cleaning of the teeth including polishing and required
    supragingival (above the gum) and coronal scaling.
24. Prosthodontist – a dental Specialist whose practice is limited to the restoration of the natural teeth and/or
    the replacement of missing teeth with artificial substitutes.
25. Service Area – the geographical area in which we offer covered dental services for AARP®
    MedicareComplete® members.
26. Specialty or Specialist – services of a dentist who has been certified as a dental practice Specialist by the
    appropriate board or authority.
27. Usual, Customary and Reasonable (UCR) – the fee dental providers most frequently charge for services
    rendered in a particular geographic area.




                                                         27
Notes:
        Customer Service:
        1-800-950-9355
        8 a.m. – 8 p.m. local time, 7 days a week


        TTY:
        711
        8 a.m. – 8 p.m. local time, 7 days a week


        Visit our Web site at:
        www.AARPMedicareComplete.com




AARP is not an insurer. UnitedHealthcare pays a fee to AARP and its affiliate for use of the AARP trademark
and other services. Amounts paid are used for the general purposes of AARP and its members. The AARP®
MedicareComplete® plans are available to all eligible Medicare beneficiaries, including both members and
non-members of AARP. [AARP and the AARP Logo are trademarks or registered trademarks of AARP. The
SecureHorizons® and MedicareComplete marks are trademarks or registered trademarks of United Healthcare
Alliance, LLC and its affiliates.]
AARP does not make health plan recommendations for individuals. You are strongly encouraged to evaluate your
needs before choosing a health plan.




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