WIXLIB

D6612D6613D6614D6615D6624D6634Add tooth to existing partial dentureAdd clasp to existing partial dentureReplace all teeth and acrylic on cast metal framework (maxillary)Replace all teeth and acrylic on cast metal framework (mandibular)Rebase complete maxillary dentureRebase complete mandibular dentureRebase maxillary partial dentureRebase mandibular partial dentureReline complete maxillary denture (chairside)Reline complete mandibular denture (chairside)Reline maxillary partial denture (chairside)Reline mandibular partial denture (chairside)Reline complete maxillary denture (laboratory)Reline complete mandibular denture (laboratory)Reline maxillary partial denture (laboratory)Reline mandibular partial denture (laboratory)Interim partial denture (maxillary)Interim partial denture (mandibular)Tissue conditioning, maxillaryTissue conditioning, mandibularVII. MAXILLOFACIAL PROSTHETICSObturator prosthesis, surgical ####Obturator prosthesis, definitive ####Obturator prosthesis, modification ####Obturator prosthesis, interim ####VIII. IMPLANT SERVICES - Not CoveredIX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unitof fixed partial denture [bridge]) ###Pontic - cast high noble metal** Pontic - cast predominately base metal Pontic - cast noble metal Pontic - titanium Pontic - porcelain fused to high noble metal** Pontic - porcelain fused to predominately base metal Pontic - porcelain fused to noble metal Pontic - porcelain/ceramic Inlay - porcelain/ceramic, two surfacesInlay - porcelain/ceramic, three or more surfacesInlay - cast high noble metal, two surfaces**Inlay - cast high noble metal, three or more surfaces**Inlay - cast predominantly base metal, two surfacesInlay - cast predominantly base metal, three or more surfacesInlay - cast noble metal, two surfacesInlay - cast noble metal, three or more surfacesOnlay - porcelain/ceramic, two surfacesOnlay - porcelain/ceramic,three or more surfacesOnlay - cast high noble metal, two surfaces**Onlay - cast high noble metal, three or more surfaces**Onlay - cast predominantly base metal, two surfacesOnlay - cast predominantly base metal, three or more surfacesOnlay - cast noble metal, two surfacesInlay - cast noble metal, three or more surfacesInlay - titaniumOnlay - titaniumIP-MDG-DHMO-SCH-U10FLI04-FL-17 81 102 223 223 230 230 230 230 130 130 125 125 186 186 186 186 190 190 60 60 2,415 1,687 245 4,023 400 400 400 400 400 400 400 410 368 383 368 383 368 383 368 383 383 400 383 400 383 400 383 400 368 383

D7451D7471D7472D7473D7510D7511D7610D7620D7630Crown - porcelain/ceramic Crown - porcelain fused to high noble metal** Crown - porcelain fused to predominately base metal Crown - porcelain fused to noble metal Crown - 3/4 cast high noble metal** Crown - 3/4 cast predominately base metal Crown - 3/4 cast noble metal Crown - 3/4 porcelain/ceramic Crown - full cast high noble metal** Crown - full cast predominately base metal Crown - full cast noble metal Crown - titaniumRecement fixed partial denturePost and core in addition to fixed partial denture retainer, indirectly fabricatedPrefabricated post and core in addition to fixed partial denture retainerCore build up for retainer, including any pinsEach additional cast post - same toothEach additional prefabricated post - same toothMultiple crown and bridge unit treatment plan - per unit, six or more units pertreatment plan ###X. ORAL AND MAXILLOFACIAL SURGERYExtraction, coronal remnants - deciduous toothExtraction, erupted tooth or exposed root (elevation and/or forceps removal)Surgical removal of erupted tooth requiring removal of bone and/or sectioning oftooth, and including elevation of mucoperiosteal flap if indicatedRemoval of impacted tooth - soft tissueRemoval of impacted tooth - partially bonyRemoval of impacted tooth - completely bonyRemoval of impacted tooth - completely bony with unusual surgical complicationsSurgical removal of residual tooth roots (cutting procedure)Primary closure of a sinus perforationSurgical access of an unerupted toothPlacement of device to facilitate eruption of impacted toothBiopsy of oral tissue - hard (bone, tooth)Biopsy of oral tissue - softBrush biopsy - transepithelial sample collectionAlveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, perquadrantAlveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, perquadrantAlveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces,per quadrantAlveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces,per quadrantRemoval of benign odontogenic cyst or tumor - lesion diameter up to 1.25cmRemoval of benign odontogenic cyst or tumor - lesion diameter greater than 1.25cmRemoval of lateral exostosis (maxilla or mandible)Removal of torus palatinusRemoval of torus mandibularisIncision and drainage of abscess - intraoral soft tissueIncision and drainage of abscess - intraoral soft tissue - complicated (includesdrainage of multiple fascial spaces)Maxilla - open reduction (teeth immobilized, if present) ####Maxilla - closed reduction (teeth immobilized, if present) ####Mandible - open reduction (teeth immobilized, if present) ####IP-MDG-DHMO-SCH-U10FLI04-FL-17 450 430 430 430 430 430 430 430 430 430 430 430 26 160 130 113 50 29 125 20 35 110 145 180 215 240 110 250 250 35 125 85 65 53 26 92 65 200 260 215 215 215 44 48 1,500 1,100 5,000

D9951D9971D9972D9975 Mandible - closed reduction (teeth immobilized, if present) ####Repair of maxillofacial soft and/or hard tissue defect ####Frenulectomy – also known as frenectomy or frenotomy - separate procedure notincidental to another procedureFrenuloplastyXII. ADJUNCTIVE GENERAL SERVICESPalliative (emergency) treatment of dental pain - minor procedureFixed partial denture sectioningLocal anesthesia in conjunction with operative or surgical proceduresDeep sedation/general anesthesia - first 30 minutes Deep sedation/general anesthesia - each additional 15 minutes Inhalation of nitrous oxide/analgesia, anxiolysis ####Intravenous conscious sedation/analgesia - first 30 minutes Intravenous conscious sedation/analgesia - each additional 15 minutes Non-intravenous conscious sedation ####Consultation - diagnostic service provided by dentist or physician other thanrequesting dentist or physicianHospital or ambulatory surgical center call ####Office visit for observation (during regularly scheduled hours) - no other servicesperformedOffice visit - after regularly scheduled hoursCase presentation, detailed and extensive treatment planningOcclusal adjustment - limitedOdontoplasty – 1 – 2 teeth; includes removal of enamel projectionsExternal bleaching - per arch – performed in officeExternal bleaching for home application, per arch; includes material and fabricationof custom traysBroken appointmentCurrent Dental Terminology (CDT) @ American Dental Association (ADA)The Patient Charges for codes D1110, D1120, D1203, D1204, D1206, D1208, andD4910 are limited to the first two services in any 12-month period. For eachadditional service in the same 12-month period, see codes D1999, D2999, andD4999 for the applicable Patient Charge. Covered Services are subject to exclusions, limitations and Plan provisions asdescribed in Member's Plan booklet and the Manual (including the QualityManagement retrospective review). Other codes may be used to describe CoveredServices.#Routine prophylaxis or periodontal maintenance procedure - a total of four servicesin any 12-month period. One of the covered periodontal maintenance proceduresmay be performed by a participating periodontal Specialist if done within three to sixmonths following completion of approved, active periodontal therapy (periodontalscaling and root planing or periodontal osseous surgery) by a participatingperiodontal Specialist. Active periodontal therapy includes periodontal scaling androot planing or periodontal osseous surgery. Fluoride Treatment - a total of four services in any 12-month period.##Sealants are limited to permanent teeth up to the 16th birthday.**If high noble metal is used, there will be an additional Patient Charge for the actualcost of the high noble metal.IP-MDG-DHMO-SCH-U10FLI04-FL-17 2,200 1,500 100 168 25 30 0 195 75 28 195 75 125 34 250 10 50 0 23 23 165 99 25

####### CDTCode D8000D8999The Patient Charge for these services is per unit.Procedure code is classified as a Pediatric Essential Benefit and applies to Membersunder age 19 and the Patient Charge will not exceed the Maximum Out Of Pocket of 350.Procedure code is classified as a Pediatric Essential Benefit and the Patient Chargefor Members under age 19 will not exceed the Maximum Out Of Pocket of 350.There is no Maximum Out Of Pocket for Members age 19 and over and the Memberis responsible for the Patient Charge listed.Procedure codes D9220, D9221, D9241, D9242 and D9248 are limited to aparticipating oral surgery Specialist. Additionally, these services are only covered inconjunction with other surgical services.Plan Schedule U10FLI04 is valid for Covered Services rendered by ParticipatingDentists in the State of Florida.XI. ORTHODONTICSD8070Comprehensive orthodontic treatment of the transitional dentition** D8080Comprehensive orthodontic treatment of the adolescent dentition** D8090Comprehensive orthodontic treatment of the adult dentition** Pre-orthodontic treatment visit (includes treatment plan, records, evaluation andconsultation)D8660D8670D8680Periodic orthodontic treatment visitOrthodontic retention (removal of appliances, construction and placement ofremovable retainers Broken appointment Child orthodontics applies to Members under age 19; adult orthodontics applies toMembers age 19 and above. A Member’s age is determined on the date ofbanding.Covered Services are subject to exclusions, limitations and Plan provisions asdescribed in Member’s Plan Booklet and the Manual. The Copayment limit per Member under age 19 is 350 per calendar year whenservices are medically necessary as defined by your state’s benchmark.Members age 19 and over are subject to the Copayment shown.**The Plan Covers:Orthodontic services as listed under Covered Dental Services and PatientCharges, limited to one (1) course of treatment per Member. We mustpreauthorize treatment, and it must be performed by a Participating OrthodonticSpecialist Dentist.Up to twenty-four (24) months of comprehensive rgeChild: 2,500Child: 2,500Adult: 2,800 250 0 400 25

Treatment plan and records, including initial records and any interim and finalrecords.Comprehensive orthodontic treatment, including the fixed banding appliances andrelated visits only.Retention services following a course of comprehensive orthodontic treatmentthat was covered under this Plan.Orthodontic retention, including any and all necessary fixed and removableappliances and related visits.If a Member has orthodontic treatment associated with orthognathic surgery (anon-covered procedure involving the surgical moving of teeth), the Plan providesthe standard orthodontic benefit. The Member will be responsible for additionalcharges related to the orthognathic surgery and the complexity of the orthodontictreatment. The additional charge will be based on the Participating OrthodonticSpecialist Dentist's usual fee.This Plan Does Not Cover:Any Procedure listed as an exclusion, in excess of Plan limitations, or as notcovered under MDG.Orthodontic treatment performed by any dentist other than a ParticipatingOrthodontic Specialist Dentist.Limited orthodontic treatment and Interceptive (Phase 1) treatment.Treatment beyond twenty-four (24) months. (The Member will be responsible foran additional charge for each additional month of treatment, based upon theparticipating Orthodontic Specialist Dentist’s contracted fee.Except as described under treatment in progress - orthodontic treatment,orthodontic services are not covered if comprehensive treatment begins beforethe Member is eligible for benefits under the Plan. If a Member's coverageterminates after the fixed banding appliances are inserted, the ParticipatingOrthodontist Specialty Care Dentist may prorate his or her usual fee over theremaining months of treatment.Orthodontic services after a Member’s coverage terminates.Any incremental charges for non-standard orthodontic appliances or those madewith clear, ceramic, white or other optional material or lingual brackets.Procedures, appliances or devices to (a) guide minor tooth movement or (b) tocorrect or control harmful habits.Re-treatment of orthodontic cases, or changes in orthodontic treatmentnecessitated by any kind of accident.Replacement or repair of orthodontic appliances damaged due to the neglect ofthe Member.Extractions performed solely to facilitate orthodontic treatment.Orthognathic surgery (moving of teeth by surgical means) and associatedincremental charges.If a Member transfers to another Participating Orthodontic Specialty Care Dentistafter authorized comprehensive orthodontic treatment has started under this Plan,the Member will be responsible for any additional costs associated with thechange in Orthodontic Specialty Care Dentist and subsequent treatment.IP-MDG-DHMO-SCH-U10FLI04-FL-17

Notice Informing Individuals about Nondiscrimination and Accessibility RequirementsDiscrimination is Against the LawGuardian and its subsidiaries comply with applicable Federal civil rights laws and does not discriminateon the basis of race, color, national origin, age, disability, or sex. Guardian and its subsidiaries does notexclude people or treat them differently because of race, color, national origin, age, disability, or sex.Guardian and its subsidiaries provide free aids and services to people with disabilities to communicateeffectively with us, such as: qualified sign language interpreters; written information in other formats(large print, audio, accessible electronic formats); and provides free language services to people whoseprimary language is not English, such as: qualified interpreters and Information written in otherlanguages.If you need these services, call 1-844-561-5600.If you believe that Guardian or its subsidiaries has failed to provide these services or discriminated inanother way on the basis of race, color, national origin, age, disability, or sex, you can file a grievancewith:Guardian Civil Rights CoordinatorATTN: Manager Compliance Metrics, Corporate ComplianceGuardian Life Insurance Company of America7 Hanover Square - 23FNew York, New York 10004212-919-3162You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Guardian’sCivil Rights Coordinator is available to help you.You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Officefor Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available r by mail or phone at:U.S. Department of Health and Human Services200 Independence AvenueSW Room 509F, HHH BuildingWashington, D.C. 202011-800–368–10191-800-537-7697 (TDD)Complaint forms are available 017584GLIC 9.19.2016

IMPORTANT NOTICE REGARDING LANGUAGE ASSISTANCE & DISCRIMINATIONAVISO IMPORTANTE SOBRE LA ASISTENCIA DE IDIOMA Y DISCRIMINACIÓNEnglishIf you or the person you are helping has questions about your insurance benefits, claims, or coverage, you have the right to get help andinformation in your language at no cost. To talk to an interpreter: if you have insurance from your employer, call the telephone number onyour identification card; for all other members, please call 844-561-5600.The Guardian and its subsidiaries* comply with applicable Federal civil rights laws and does not discriminate on the basis of race, color,national origin, age, disability, or sex.SpanishEspañolSi usted o la persona que está ayudando tiene preguntas acerca de su seguro, las reclamaciones o cobertura, usted tiene derecho a obtenerayuda e información en su idioma sin costo alguno. Para hablar con un intérprete: si tiene seguro de su empleador, llame al número deteléfono que aparece en su tarjeta de identificación; para todos los demás miembros, por favor llame al 844-561-5600.The Guardian y sus subsidiarias * cumplir con las leyes federales aplicables de derechos civiles y no discrimina por motivos de raza, color,origen nacional, edad, discapacidad, o �，请致电 ameseTiếng ViệtNếu bạn hoặc người bạn đang giúp đỡ có câu hỏi về quyền lợi bảo hiểm, yêu cầu của bạn, hoặc bảo hiểm, bạn có quyền được trợ giúp vàthông tin trong ngôn ngữ của bạn miễn phí. Để nói chuyện với một thông dịch viên: nếu bạn có bảo hiểm từ công ty của bạn, hãy gọi số điệnthoại trên thẻ nhận dạng của bạn; cho tất cả các thành viên khác, xin vui lòng gọi 844-561-5600.The Guardian và các công ty con của nó * tuân thủ pháp luật quyền dân sự liên bang áp dụng và không phân biệt đối xử trên cơ sở chủngtộc, màu da, nguồn gốc quốc gia, tuổi tác, khuyết tật, hoặc quan hệ tình dục.Korean한국어당신이나 당신이 도움이되고 사람이 당신의 보험 혜택, 청구, 또는 범위에 대한 질문이있는 경우, 당신은 무료로 귀하의 언어로도움과 정보를 얻을 수있는 권리가 있습니다. 통역 얘기하려면, 당신은 당신의 고용주로부터 보험이있는 경우, 귀하의 ID 카드에전화 번호로 전화;

IP-MDG-DHMO-SCH-U10FLI04-FL-17 Covered Dental Services And Patient Charges - Florida individual schedule - U10FLI04. The services covered by this are named in this list. If a procedure is not on this list, it is not Plan covered. All services must be provided by the assigned PCD. The member must pay the listed patient charge.