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Routine Dental vs. Platinum Dental RiderAdditional coverage that may make you smileAs a UnitedHealthcare member, you may have routine dental included in the plan you select. Youalso have the option to get dental coverage through the Platinum Dental Rider for an additionalmonthly fee. You can purchase the rider anytime during the year. Simply call the number on the backof your member ID card to tell us you’d like to enroll in the Platinum Dental Rider. You may start usingthe benefit on the first day of the month after the rider is purchased.With Routine Dental, you get: Nodeductible 0 copay for covered fillings and preventive and diagnostic servicessuch as oral exams, X-rays, routinecleanings, and fluoride p to 3 cleanings per plan year to helpUmanage gum disease Freedomto see any dentist you choose1For 36 a month (in addition to any premium you pay for your Medicare Advantage planand your Medicare Part B coverage), you’ll get: 0 copay for fillings and for preventive anddiagnostic services such as oral exams,X-rays and routine cleanings No deductible 1,000 yearly maximum (the total amountthe plan will pay for covered services inthe calendar year, this includes preventive,diagnostic, basic and major services) Freedom to see any dentist you choose1With the Platinum Dental Rider, you’ll enjoy 100% coverage for preventive care and fillings with 50%coverage for additional procedures in-network. Out-of-network coverage is available. Please see theback of this page for coverage details and benefit guidelines.To find a network dentist in your area, go to www.UHCMedicareDentistSearch.comselect the National Medicare Advantage Network.For more information on the Platinum Dental Rider, to find a network dentist or toenroll, call the number on the back of your member ID card.You can see any dentist. However, you’ll get greater savings from a network dentist. When yousee an out-of-network dentist, the plan pays according to a maximum allowable fee schedule; youpay the rest. For your convenience, you can change dentists as long as you complete any dentalservice currently in progress.1

Covered Dental ServicesDescription ofDental Copay orCoinsurance 0* 0* 0* 0* 0* 0*n/a 0*Covers intraoral complete seriesof radiographs. Does not cover 0*CTs, cephalograms, or MRIs. 0*Criteria and ExclusionsExamsRoutine periodicexam completedduring check-upLimited exam toevaluate a problemComprehensiveexam (for a newpatient, or anestablished patientafter 3 or moreyears of inactivityfrom dentaltreatment)Detailed andextensive problemfocused examTwo proceduresper plan yearOne procedureper plan yearOne procedureevery three planyearsOne procedureper plan yearCovers periodic, limited,comprehensive, and detailed/extensive oral exams. Doesnot cover periodontal examsseparate from periodic, limited,or comprehensive exams. Onlyone exam code covered perappointment.X-raysFull-mouth/Complete X-rayset for evaluationof the teeth andmouthOne procedureevery three planyearsX-rays for closerevaluation aroundthe roots of teethUnlimited perplan yearBitewing X-rays forevaluation of theteeth and boneOne procedureper plan yearPanoramic X-ray for One procedureevaluation of theevery three planteeth and mouthyearsCovers periapical X-rays. Doesnot cover CTs, cephalograms,or MRIs. Not covered onthe same day as full-mouth/ 0*complete X-ray set forevaluation of the teeth andmouth.Not covered in the same year asa full-mouth/complete X-ray set 0*for evaluation of the teeth andmouth.Covers panoramic radiographs.Does not cover CTs, 0*cephalograms, or MRIs. 0* 0* 0*

PlatinumDentalCopay orCoinsuranceFrequencyCriteria and ExclusionsRoutineDentalCopayStandard adultdental cleaningTwo proceduresper plan yearCovers adult prophylaxis. Notcovered on the same day asRoutine dental cleaning for anadult who has documentedhistory of gum disease orcleaning buildup off the teeth toallow for proper visibility of theteeth for examination. 0* 0*Routine dentalcleaning for anadult who hasdocumentedhistory of gumdiseaseCovers periodontalmaintenance. Only coveredThree procedureswith history of scaling andper plan yearroot planing (deep cleaning) orperiodontal surgery. 0* 0* 0* 0* 0* 0*Description ofDental ProcedureCleaningsOther Preventive ServicesCovers topical applicationof fluoride (either varnish orexcluding varnish).Covers counseling on dietaryhabits as a part of treatmentand control of gum diseaseand/or cavities.FluorideTwo proceduresper plan yearNutritionalCounselingOne procedureper plan yearApplication ofmedication toa tooth to stopor inhibit cavityformationUnlimited perplan yearCovers application of interimcaries arresting medicamentper tooth to a non-symptomaticcarious tooth. 0* 0*Metal or toothcolored fillingsplaced directly into Unlimited perthe mouth on front, plan yearmiddle or backteeth.Covers amalgam and resinbased composite fillings. Doesnot cover gold foil fillings,sealants, or preventive resinrestorations. 0* 0*Medicine placedunder fillings topromote pulphealingCovers pulp capping for anexposed or nearly exposedpulp. Does not cover bases andliners when all caries has beenremoved. 0* 0*FillingsUnlimited perplan year

Description ofDental ProcedureFrequencyCriteria and ExclusionsRoutineDentalCopayPlatinumDentalCopay orCoinsuranceCrowns, Inlays, and OnlaysCap (crown) orpartial crown calledan inlay or onlay— made of metal,porcelain/ceramic, One procedureporcelain fused to per tooth everymetal, or titanium. five plan yearsMade outside themouth and thenplaced into themouth.Covered when there is extensivedecay or destruction of thetooth where the tooth cannotbe fixed with only a filling. Doesnot cover crowns for cosmeticn/areasons or for closing gaps.Veneers are not covered.Implant crowns are not covered.Does not cover "3/4" crowns.50%*Only covered for a tooth with anexisting crown. Not covered forn/acementing a new crown the dayof delivery.50%*n/a50%*n/a50%*n/a50%*This is a root canal performedfor the first time on tooth. Doesnot include root canal treatmentfor a tooth that has already hadn/aa root canal (retreatment), orroot canals performed from theroot tip by access through thegums.50%*Other Restorative ServicesRecementing acrown that hasfallen offSmall filling neededprior to fitting atooth with a crownFilling or pinsplaced whenpreparing a toothfor a crownBuildup of fillingaround a post toprepare the toothfor a crownUnlimited perplan yearOne procedureper tooth everyfive plan yearsOne procedureper tooth everyfive plan yearsOne procedureper tooth everyfive plan yearsHas to be performed togetherwith a crown.Has to be performed togetherwith a crown. Tooth also has tohave had root canal treatment.Root Canals (Endodontic Services)Root canaltreatment for afront, middle,or back tooth(excluding filling orcrown needed afterthe root canal)One procedureper tooth perlifetime of themember

Description ofDental ProcedureFrequencyCriteria and ExclusionsRoutineDentalCopayPlatinumDentalCopay orCoinsurancen/a50%*Scaling and Root PlaningOne procedureper quadrantevery two planDeep cleaning foryears, not to4 or more teeth in aexceed fourmouth quadrantunique quadrantsevery two planyearsOne procedureper quadrantevery two planDeep cleaningyears, not tofor 1-3 teeth in aexceed fourmouth quadrantunique quadrantsevery two planyearsCovered when bone loss isshown on the X-rays in additionto recorded tartar buildup andpocketing of the gums sufficientto warrant deep cleaning.n/a50%*Cleaning buildupoff the teeth toOne procedureallow for properevery three planvisibility of the teeth yearsfor examinationUsed when there is extensivebuildup that needs to beremoved in order to performan exam. Cannot be performedsame day as a Standard adultn/adental cleaning or Routinedental cleaning for an adult whohas documented history of gumdisease.50%*Medicine appliedto gum spacearound a tooth(per tooth) formanagement ofgum diseaseCannot be used same day asdeep cleaning for 4 or moreteeth in a mouth quadrant ordeep cleaning for 1-3 teeth in amouth quadrant.50%*Unlimited perplan yearn/a

Description ofDental ProcedureRoutineDentalCopayPlatinumDentalCopay orCoinsurancen/a50%*n/a50%*One procedureper lifetime ofmemberDenture covered when there areno erupted teeth remaining inn/athe mouth.50%*One procedureper lifetime ofmembern/a50%*FrequencyCriteria and ExclusionsComplete DenturesComplete upperdentureComplete lowerdentureCompleteupper denturedelivered at thetime of extractingremaining upperteethComplete lowerdenture deliveredat the time ofextraction ofremaining lowerteethOne procedureevery five planyearsOne procedureevery five planyears

Description ofDental ProcedureFrequencyCriteria and ExclusionsRoutineDentalCopayPlatinumDentalCopay a50%*n/a50%*n/a50%*Partials (Removable Partial Dentures)Upper partialdenture — resinbaseLower partialdenture — resinbaseUpper partialdentures — castmetal frameworkwith resin denturebasesLower partialdenture — castmetal frameworkwith resin denturebaseUpper partialdenture deliveredat the time ofextractions — resinbaseLower partialdenture deliveredat the time ofextractions — resinbaseUpper partialdenture — flexiblebaseLower partialdenture — flexiblebaseOne procedureevery five planyearsOne procedureevery five planyearsOne procedureevery five planyearsOne procedureevery five planyearsOne procedureevery five planyearsOne procedureevery five planyearsOne procedureevery five planyearsOne procedureevery five planyearsPartial denture covered whenremaining/supporting teeth arefree of cavities and have goodbone to support the partialdenture. Includes retentive/clasping materials, rests andteeth.

Description ofDental ProcedureFrequencyCriteria and ExclusionsRoutineDentalCopayPlatinumDentalCopay orCoinsurancen/a50%*n/a50%*Adjustments and Repairs for Complete DenturesDentureadjustments ortissue conditioningfor complete upperand/or lowerdentureRepairs andrelines for brokencomplete upperand/or lowerdenturesTwo of each typeof procedure per Covers adjustments, relines,denture per plan repairs, tissue conditioning,yearand replacing of missing orbroken teeth for completedentures. Cannot be billedOne of each type within 6 months of delivery ofof procedure per the new denture.denture per planyearAdjustments and Repairs for Partial DenturesAdjustment ofTwo proceduresupper and/or lower per denture perpartial dentureplan yearCovers partial dentureadjustments and relines.n/aCovers repairs to frameworkof the partial denture, repairor replacement of missing orOne procedure of broken partial denture teeth,Repair or reline for each procedure and addition of clasps orupper and/or lower type per partialn/adenture teeth to an existingpartial denturedenture per plan partial denture. Cannot be billedyearwithin 6 months of delivery ofthe new partial denture.50%*50%*BridgesPart of the bridgethat is the faketooth replacing themissing tooth (thepontic)One procedureper tooth everyfive plan yearsCan only be used to replace amissing tooth. Covers bridgesmade of porcelain/ceramic;porcelain fused to high noble,predominately base, or noblemetal; full cast high noble,predominately base, or noblemetal; and titanium. Does notcover any part of an implantsupported bridge.Crowns that areplaced on teethsupporting thebridge (retainercrowns)One procedureper tooth everyfive plan yearsOnly covers crowns that arepart of a bridge. Does notsupport any part of an implantsupported bridge.n/a50%*n/a50%*