Q U A L I T YCare For You

Combined Evidence of Coverage and Disclosure Form

Provided by:

CAM57(REV 03/04)

12898 Towne Center DriveCerritos, CA 90703-8579

(800) 422-4234www.deltadentalca.org/pmi

GROUP

PLAN

Dental HMO Program

EVIDENCE OF COVERAGEDISCLOSURE FORM

DeltaCare Dental Health Care Program

This booklet is a Combined Evidence of Coverage and Disclosure Form (“EOC”) foryour DeltaCare Dental Health Care Program (“Program”) provided by Private Medical-Care, Inc. (“PMI”). The Program has been established and is administered in accordancewith the provisions of a Group Dental Service Contract (“Contract”) issued by PMI.

THE EOC CONSTITUTES ONLY A SUMMARY OF THEPROGRAM. AS REQUIRED BY THE CALIFORNIA HEALTH& SAFETY CODE, THIS IS TO ADVISE YOU THAT THECONTRACT MUST BE CONSULTED TO DETERMINE THEEXACT TERMS AND CONDITIONS OF THE COVERAGEPROVIDED UNDER IT.

A COPY OF THE CONTRACT WILL BE FURNISHED UPON REQUEST. ANYDIRECT CONFLICT BETWEEN THE CONTRACT AND THE EOC WILL BERESOLVED ACCORDING TO THE TERMS WHICH ARE MOST FAVORABLE TOYOU. PLEASE READ THIS EOC CAREFULLY AND COMPLETELY. PERSONSWITH SPECIAL HEALTHCARE NEEDS SHOULD READ THE SECTION ENTITLED“SPECIAL NEEDS”.

A STATEMENT DESCRIBING PMI’S POLICIES AND PROCEDURES FORPRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLEAND WILL BE FURNISHED TO YOU UPON REQUEST.

PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROMWHOM OR WHAT GROUP OF PROVIDERS DENTAL CARE MAY BEOBTAINED.

The telephone number at which you may obtain information about benefits is(800) 422-4234.

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(A) Deductibles None(B) Lifetime Maximums None(C) Professional Services An Enrollee may be required to pay a Copayment

amount for each procedure as shown in theDescription of Benefits and Copayments, subject tothe Limitations and Exclusions of Benefits.Copayments range by category of service.Examples are as follows:

Diagnostic Services No Cost - $ 5Preventive Services No Cost - $ 15Restorative Services No Cost - $ 395Endodontic Services No Cost - $ 475Periodontic Services $ 45 - $ 450Prosthodontic Services $ 20 - $ 495Oral and Maxillofacial Surgery $ 35 - $ 200Adjunctive General Services No Cost - $ 50

NOTE: Some services may not be covered. Certainservices may be covered only if provided by specifiedproviders, or may be subject to an additional charge.

Limitations apply to the frequency with which someservices may be obtained. For example: cleaningsare limited to once in each 6 month period;replacement of complete dentures, crowns andbridges is limited to once in any 5 year period.

(D) Outpatient Services Not Covered(E) Hospitalization Services Not Covered(F) Emergency Health The Enrollee may receive a maximum Benefit of up

Coverage to $100 during each 12 months for out-of-areaemergency services.

(G) Ambulance Services Not Covered(H) Prescription Drug

Services Not Covered(I) Durable Medical

Equipment Not Covered(J) Mental Health Services Not Covered(K) Chemical Dependency

Services Not Covered(L) Home Health Services Not Covered(M) Other Not Covered

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARECOVERAGE BENEFITS AND IS A SUMMARY ONLY. THIS COMBINEDEVIDENCE OF COVERAGE AND DISCLOSURE FORM AND THE PLANCONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTIONOF COVERAGE BENEFITS AND LIMITATIONS.

INFORMATION CONCERNING BENEFITS UNDER THE DELTACARE PROGRAM

Each individual procedure within each category listed above, and which is coveredunder the Program has a specific Copayment, which is shown in the Description ofBenefits and Copayments, in the Combined Evidence of Coverage and Disclosure Form.

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Table of Contents

Definitions ............................................................................................................... 1

What is the DeltaCare Dental HMO Program? ............................................. 2

How do I choose my Contract Dentistand who will provide my dental care? .......................................................... 2

Provider Compensation ....................................................................................... 3

Emergency Services/Acute Condition ............................................................... 3

Relationship with non-Contract Dentists ......................................................... 4

Specialist Services .................................................................................................. 4

Special Needs ......................................................................................................... 4

Dental Facility Accessibility ................................................................................. 4

Claims for Reimbursement .................................................................................. 4

Second Opinion ..................................................................................................... 5

Coordination of Benefits ...................................................................................... 5

What if I need to change Contract Dentists? .................................................. 6

Processing Policies ................................................................................................. 6

Who is eligible for coverage? .............................................................................. 6

Other Charges ....................................................................................................... 6

Renewal and Termination of Benefits ................................................................. 7

Cancellation of Enrollment .................................................................................. 7

Enrollee Complaint Procedure ........................................................................... 8

Premiums .............................................................................................................. 10

Standing Committee on Public Policy ............................................................ 10

Governing Law .................................................................................................... 10

Description of Benefits and Copayments ...................................................... 11

Limitations of Benefits ........................................................................................ 19

Exclusions of Benefits ........................................................................................ 22

Accident Injury Benefit ...................................................................................... 24

Contract Dentist List .......................................................................................... 26

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DefinitionsAs used in this Combined Evidence of Coverage and Disclosure Form:

ACUTE CONDITION means a condition requiring Emergency Services while aNew Enrollee is within 35 miles from the facility of the assigned ContractDentist.

BENEFITS means dental services shown in the Description of Benefits andCopayments which are available under this Program and are (a) provided byyour Contract Dentist, or a Contract Specialist, (b) provided for EmergencyServices by a non-Contract Dentist as described under "Emergency Services",or (c) preauthorized by PMI and provided by an out-of-Network Specialist asdescribed under "How do I choose my Dentist and who will provide my dentalcare?"

CLIENT means the employer, union or other organization or group contractingto obtain Benefits.

CONTRACT DENTIST means a Dentist who provides services in generaldentistry and who has contracted with and been properly credentialed byPMI to provide dental services which are Benefits under this Program.

CONTRACT SPECIALIST means a Dentist who provides specialist servicesand who has contracted with and been properly credentialed by PMI toprovide Benefits under this Program.

COPAYMENT means the amount shown in the Description of Benefits andCopayments which an Enrollee pays directly to a Contract Dentist or ContractSpecialist.

DENTIST means a licensed Dentist who is legally entitled to practice dentistryat the time and in the state or jurisdiction in which services are performed.

EMERGENCY SERVICES means dental services immediately required for thealleviation of severe pain, swelling or bleeding, or to avoid placing the patient'shealth in serious jeopardy.

ENROLLEE means the person enrolled to receive Benefits under this Program.

NEW ENROLLEE means an Enrollee who is enrolled less than thirty (30) daysfrom the date he or she is eligible for Benefits.

OPTIONAL means any alternative procedure presented by the Contract Dentistthat satisfies the same dental need as a covered procedure, is chosen by theEnrollee, and is subject to the Limitations and Exclusions of this Contract.

PMI means Private Medical-Care, Inc., a specialized health care service planlicensed by the California Department of Managed Health Care.

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SPECIAL HEALTH CARE NEED means a physical or mental impairment,limitation or condition that substantially interferes with your ability to obtainBenefits. Examples of such a Special Health Care Need are (a) your inabilityto obtain access to the assigned Contract Dentist's facility because of aphysical disability, and (b) your inability to comply with the Contract Dentist'sinstructions during examination or treatment because of physical disability ormental incapacity.

SPECIALIST SERVICES means services performed by a Dentist who specializedin the practice of oral surgery, endodontics or periodontics and which mustbe preauthorized in writing by PMI.

What is the DeltaCare Dental HMO Program ("Program")?The DeltaCare Dental HMO Program, offered by PMI, provides comprehensivedental care through a convenient network of Dentists. These Contract Dentistsare screened to ensure that PMI's standards of quality, access and safety aremaintained. The network of dental facilities is composed of established dentalpractices. When you visit your assigned Contract Dentist, you pay only theapplicable Copayment for covered Benefits (listed in the Description of Benefitsand Copayments). There are no deductibles, lifetime maximums or claim formsunder this Program.

How do I choose my Dentist and who will provide my dentalcare?When you enroll in the Program, you will select a Contract Dentist from theenclosed list. You must indicate the Contract Dentist's name and Contract Dentistfacility ID# on the enrollment form.

You must obtain Benefits from your assigned Contract Dentist. Anydental services performed by a Dentist other than your assignedContract Dentist are not covered Benefits, except for out-of-areaEmergency Services or authorized Specialist Services provided by aContract Specialist. If a Contract Specialist is not available within 35miles of your home address, your assigned Contract Dentist must receiveprior written authorization from PMI to refer you to an out-of-networkSpecialist.

In the event that PMI fails to pay a Contract Dentist, you will not beliable to that Dentist for any sums owed by PMI. In the event that PMIfails to pay a non-Contract Dentist, you may be liable to that Dentistfor the cost of services.

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Contact your assigned Contract Dentist for available appointment times. Yourassigned Contract Dentist also maintains a 24-hour Emergency Services systemseven days a week. If for any reason you cannot reach your assigned ContractDentist, call PMI's Customer Service department at (800) 422-4234, between5 a.m. and 6 p.m., Monday through Friday.

Your assigned Contract Dentist may refer you to a Contract Specialist for a coveredendodontic, oral surgery or periodontic procedure if your assigned ContractDentist cannot perform the procedure.

Provider CompensationA Contract Dentist is compensated by PMI through monthly fees based on thenumber of Enrollees assigned to the Contract Dentist, and by Enrollees throughrequired Copayments for treatment received. A Contract Specialist is compensatedby PMI through an agreed upon fee for each covered procedure, and by Enrolleesthrough applicable Copayments. In no event does PMI pay a ContractDentist or Contract Specialist any incentive as an inducement to deny,reduce, limit or delay any appropriate treatment.

You may obtain further information concerning compensation bycalling PMI at the toll-free telephone number shown on the back coverof this Combined Evidence of Coverage and Disclosure Form.

Emergency Services/Acute ConditionIf you require Emergency Services while more than 35 miles from your assignedContract Dentist's facility, PMI will reimburse you for the cost of covered Benefits, lessany applicable Copayment, up to a maximum reimbursement of $100.00 during any12 month period.

If you have been enrolled less than 30 days, and if you are currently experiencingan Acute Condition, contact PMI's Customer Service department at (800)422-4234 for authorization for treatment of this condition.

If PMI determines that the circumstances of your Acute Condition require that youobtain treatment from a dentist who is not one of PMI's Contract Dentists, you willbe instructed:

• to seek treatment immediately necessary to alleviate severe pain, swellingor bleeding, or immediately necessary to avoid placing your health inserious jeopardy; and

• that treatment for an Acute Condition does not include any services exceptEmergency Services;

• that PMI will reimburse you for the cost of such treatment up to a maximumof $100 during any 12-month period; and

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• that you must submit a claim within 90 days after receiving the treatment;and

• that you must visit your Contract Dentist for further treatment.

Relationship With non-Contract DentistsPMI may require a non-Contract Dentist providing treatment to you of an AcuteCondition to agree in writing to meet the same contractual terms and conditionswhich are imposed upon Dentists who have signed a contract with PMI. PMI isnot liable for actions resulting solely from the negligence, malpractice or othertortious or wrongful acts arising out of the treatment provided by a non-ContractDentist.

Specialist ServicesSpecialist Services must be referred by a Contract Dentist, must be authorized inwriting by PMI, and must be provided by a Contract Specialist if one is available.All preauthorized Specialist Services will be paid by PMI less any applicableCopayments. If you are referred to a dental school clinic for Specialist Services,those services may be provided by a Dentist, a dental student, a clinician or adental instructor.

Special NeedsIf you believe you have a Special Health Care Need, you should contact PMI'sCustomer Service department at (800) 422-4234. PMI will confirm whether sucha Special Health Care Need exists, and what arrangements can be made to assistyou in obtaining such Benefits. PMI shall not be responsible for the failure of anyContract Dentist to comply with any law or regulation concerning structuralfacility requirements that apply to a Dentist treating persons with Special HealthCare Needs.

Dental Facility AccessibilityMany dental facilities provide PMI with information about special features of theiroffices, including accessibility information for patients with mobility impairments.To obtain information regarding dental facility accessibility, contact PMI’s CustomerService department at (800) 422-4234.

Claims for ReimbursementClaims for Emergency Services or Specialist Services which are Benefits must besubmitted to PMI at the address shown on the back cover of this combinedEvidence of Coverage and Disclosure Form within 90 days after the services arecompleted. Failure to submit a claim within 90 days will not invalidate or reducethat claim if (a) it was not reasonably possible to submit the claim within 90 days,and (b) the claim was submitted as soon as reasonably possible. The claim mustbe submitted within one year after completion of treatment.

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Second OpinionYou may request a second opinion if you disagree with or question the diagnosisand/or treatment plan determination made by your Contract Dentist. PMI mayalso request that an Enrollee obtain a second opinion to verify the necessity andappropriateness of dental treatment or the application of benefits.

Second opinions will be rendered in a timely manner, appropriate to the nature ofthe Enrollee’s condition by a licensed Dentist. Requests involving cases of imminentand serious health threat will be expedited (authorization approved or deniedwithin 72 hours of receipt of the request, whenever possible). For assistance oradditional information regarding the procedures and timeframes for second opinionauthorizations, you should contact PMI’s Customer Service department at (800)422-4234 or write to the address on the back of this booklet. Second opinionswill be provided at another Contract Dentist facility, unless otherwise authorizedby PMI’s dental consultant. PMI will pay only for a second opinion which PMI hasapproved or authorized.

Coordination of BenefitsThis Program provides Benefits without regard to coverage by any other groupinsurance policy or any other group health benefits program if the other policyor program covers services or expenses in addition to dental care. Otherwise,Benefits provided under this Program by specialists or out-of-network Dentistsare coordinated with any similar benefits provided by any other group dentalinsurance policy or any group dental benefits program. The determination ofwhich policy or program is primary shall be governed by the rules stated in theContract.

When this plan is secondary, it may reduce its Benefits so that the total Benefitspaid or provided by all plans during a claim determination period are not morethan 100 percent of total Allowable Expenses. “Allowable Expense” is definedas a service or expense, including deductibles and Copayments, that is coveredat least in part by any of the plans covering the person.

An Enrollee must provide to PMI and PMI may release to or obtain from anyinsurance company or other organization, any information about the Enrolleethat is needed to administer coordination of benefits. PMI will, in its sole discretion,determine whether any reimbursement to an insurance company or otherorganizations is warranted under these coordination of benefits provisions, andany such reimbursement will be deemed to be Benefits under this Program. PMIwill have the right to recover from a Dentist, Enrollee, insurance company orother organization, as PMI chooses, the amount of any Benefit paid by PMI whichexceeds its obligations under these coordination of benefit provisions.

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What if I need to change Contract Dentists?You may change your assigned Contract Dentist during an annual open enrollmentperiod. However, a transfer to another Contract Dentist will be allowed uponrequest directed to PMI if you have a change in residence, or fail to establish asatisfactory relationship with your assigned Contract Dentist. A change in ContractDentist must be requested before the 21st of the month to be effective on the firstday of the following month. If a facility is closed to further enrollment, or if aContract Dentist withdraws from the Program, PMI will provide written noticeand assign you to the Contract Dentist facility nearest your home.

All treatment in progress such as (a) partial or full dentures for which finalimpressions have been taken, (b) completion of root canals, and (c) delivery ofcrowns when teeth have been prepared, must be completed prior to a change indental facility assignment.

If your assigned Contract Dentist's contract with PMI terminates, that ContractDentist will complete (a) a partial or full denture for which final impressions havebeen taken, and (b) all work on every tooth upon which work has started (suchas completion of root canals in progress and delivery of crowns when teeth havebeen prepared).

Processing PoliciesPMI does not authorize or deny services provided by your assigned ContractDentist. All Benefits provided by your assigned Contract Dentist are inaccordance with Dental Care Guidelines which establish the standard of care forthe Program. PMI's processing policies and the Dental Care Guidelines arereviewed and updated as needed. You may contact PMI's Customer Servicedepartment at (800) 422-4234 for information regarding PMI's processing policies.

Who is eligible for coverage?Individual adults who meet the eligibility requirements defined by the Group areeligible for coverage under the DeltaCare Dental HMO Program. Dependentcoverage is not available under this Program.

Other ChargesYou must also pay any applicable Copayment (listed in Description of Benefits andCopayments) directly to the Contract Dentist or Contract Specialist who providestreatment. That Copayment is considered payment in full by you for the coveredBenefit; the Contract Dentist or Contract Specialist will not charge you for anyfees owed by PMI.

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You will be charged for broken appointments unless (a) the Contract Dentist orContract Specialist receives notice at least 24 hours in advance, or (b) an emergencyprevented such notice. Charges for broken appointments and for office visits afterregularly scheduled hours are shown in the Description of Benefits and Copayments.

Renewal and Termination of BenefitsThis Program renews on the anniversary of the contract term unless PMI providesnotice of a change in premiums or Benefits and the Group does not accept thechange. All Benefits terminate for any Enrollee as of the date that this Program isterminated, such person ceases to be eligible under the terms of this Program, orsuch person's enrollment is cancelled under the terms of this Program. PMI is notobligated to continue to provide Benefits to any such person in such event, exceptfor completion of treatment in progress commenced while this Program was ineffect.

Cancellation of EnrollmentSubject to any continued coverage option, an Eligible Employee’s or EligibleDependent’s enrollment under the Program may be cancelled, or renewal ofenrollment refused, in the following events:

1) Immediately

a) upon loss of eligibility as described in this Evidence of Coverage, or

2) Upon 15 days written notice if

a) an enrollee engages in conduct detrimental to safe operations andthe delivery of services while in a Contract Dentist’s facility;

b) the premiums are not paid by or on behalf of the Enrollee on thedate due. However the Enrollee may continue to receive Benefitsduring the 15-day period and may be reinstated during the term ofthis Program upon payment of any unpaid premium; or

c) the Enrollee knowingly commits or permits another person to commitfraud or deception in obtaining Benefits under the Program;

3) Upon 30 days written notice if

a) the Contract is terminated or not renewed;

b) the Enrollee fails to pay Copayments. However, the Enrollee may bereinstated during the term of this Program upon payment of alldelinquent charges.

Cancellation of a Primary Enrollee’s enrollment, as described above, shallautomatically cancel the enrollment of any of his or her Dependent Enrollees.Any cancellation is subject to the written notification requirements set forth inthis Contract.

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If you believe that enrollment has been cancelled or not renewed because of yourhealth status or requirements for health care services, (or that of your dependent(s),you may request a review by the Director of the California Department of ManagedHealth Care of the State of California. Please refer to Enrollee Complaint Procedure onpages 8–9.

Enrollee Complaint ProcedurePMI shall provide notification if any dental services or claims are denied, in wholeor in part, stating the specific reason or reasons for the denial of dental services.If you have any complaint regarding eligibility, the denial of services or claims, thepolicies, procedures or operations of PMI, or the quality of services performed bya Contract Dentist, you may call PMI’s Customer Service department at (800) 422-4234, or the complaint may be addressed in writing to:

PMI Quality Management DepartmentMS QM600

12898 Towne Center DriveCerritos, California 90703-8579

Written communication must include 1) the name of the patient, 2) the name,address, telephone number and identification number of the Primary Enrollee, 3)the name of the Applicant and 4) the Dentist’s name and facility location.

For complaints involving an adverse benefit determination (e.g. a denial,modification or termination of a requested benefit or claim) you must file arequest for review (a complaint) with PMI within 180 days after receipt of theadverse determination. PMI’s review will take into account all information,regardless of whether such information was submitted or considered initially.The review shall be conducted by a person who is neither the individual whomade the original benefit determination, nor the subordinate of such individual.Upon request and free of charge, PMI will provide you with copies of any pertinentdocuments that are relevant to the benefit determination, a copy of any internalrule, guideline, protocol, and/or explanation of the scientific or clinical judgmentif relied upon in making the benefit determination. If the review of a denial isbased in whole or in part on a lack of medical necessity, experimental treatment,or a clinical judgement in applying the terms of the Contract, PMI shall consultwith a Dentist who has appropriate training and experience. If any consultingDentist is involved in the review, the identity of such consulting Dentist will beavailable upon request.

Within five calendar days of the receipt of a complaint, including adverse benefitdeterminations as described above, the quality management coordinator willforward to you an acknowledgment of receipt of the complaint. Those complaintsrequiring professional expertise shall be referred to a licensed PMI dental consultantor dental director for review. Certain complaints may also require that you be

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referred to a regional Dentist for a clinical evaluation of the dental servicesprovided. PMI will forward to you a determination, in writing, within 30 days ofreceipt of a complaint. PMI will respond, within three days of receipt, to complaintsinvolving severe pain and/or imminent and serious threat to a patient’s dentalhealth.

If you have completed PMI’s grievance process, or you have been involved inPMI’s grievance procedure for more than 30 days, you may file a complaint withthe California Department of Managed Health Care. You may file a complaintwith the Department immediately in an emergency situation, which is one involvingsevere pain and/or imminent and serious threat to your health.

The California Department of Managed Health Care is responsible for regulatinghealth care service plans. If you have a grievance against your health plan, youshould first telephone your health plan at (800) 422-4234 and use your healthplan’s grievance process before contacting the Department. Utilizing this grievanceprocedure does not prohibit any potential legal rights or remedies that may beavailable to you. If you need help with a grievance involving an emergency, agrievance that has not been satisfactorily resolved by your health plan, or agrievance that has remained unresolved for more than 30 days, you may call theDepartment for assistance. You may also be eligible for an Independent MedicalReview (IMR)*. If you are eligible for IMR, the IMR process will provide animpartial review of medical decisions made by a health plan related to themedical necessity of a proposed service or treatment, coverage decisions fortreatments that are experimental or investigational in nature and paymentdisputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891)for the hearing and speech impaired. The department’s Internet Web sitehttp://www.hmohelp.ca.gov has complaint forms, IMR application formsand instructions online.

* IMR has limited application to your dental program. You may request IMR onlyif your dental claim concerns a life-threatening or seriously debilitating condition(s)and is denied or modified because it was deemed an experimental procedure.

If the group health plan is subject to the Employee Retirement Income Security Act of1974 (ERISA), you may contact the U.S. Department of Labor, Employee BenefitsSecurity Administration (EBSA) for further review of the claim or if you have questionsabout the rights under ERISA. You may also bring a civil action under section 502(a)of ERISA. The address of the U.S. Department of Labor is: U.S. Department of Labor,Employee Benefits Security Administration, 200 Constitution Avenue, N.W.Washington, D.C. 20210.

PremiumsThis Program requires premiums to be paid to PMI. If you are required to pay allor any portion of the premiums, you will be advised of the amount prior toenrollment. The Client will be responsible for sending all payments of premiums toPMI except payments you are requested to pay directly. Should you voluntarilycancel enrollment and subsequently desire to re-enroll, all premiums retroactiveto the date of cancellation (but not to exceed 12 months) must be paid before youcan re-enroll.

Standing Committee on Public PolicyA seven member committee, comprised of two providers, one of which is a Dentist,four representatives from the purchaser and subscriber community and one memberof the PMI Board of Directors, meets quarterly and participates in establishingpolicies to assure the comfort, dignity, and convenience of Enrollees and thepublic. Issues may be presented to this committee by writing to PMI's PublicPolicy Committee, c/o Professional Relations, at the address on the back of thisCombined Evidence of Coverage and Disclosure Form.

Governing LawThis Program is a health care service plan subject to the requirements ofChapter 2.2 of Division 2 of the California Health & Safety Code and Chapter 1of Division 1 of Title 28 of the California Code of Regulations. Any provisionrequired to be included in this Combined Evidence of Coverage and DisclosureForm by the above law and regulation binds this Program whether or not stated.

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The benefits shown below are performed as deemed appropriate by the attendingContract Dentist subject to the limitations and exclusions of the program. Pleaserefer to Schedule B for further clarification of benefits. Enrollees should discussall treatment options with their Contract Dentist prior to servicesbeing rendered.

Codes and/or text that appear in italics below are specifically intendedto clarify the delivery of benefits under the DeltaCare program andare not to be interpreted as CDT-4 procedure codes, descriptors ornomenclature which are under copyright by the American DentalAssociation.

SCHEDULE APlan KP CA578 KPSA (PMI CAM57)Description of Benefits and Copayments

ENROLLEECode Description PAYS

D0100-D0999 I. DiagnosticD0120 Periodic oral evaluation ......................................................................No CostD0140 Limited oral evaluation - problem focused ....................................No CostD0150 Comprehensive oral evaluation - new or established patient ...No CostD0160 Detailed and extensive oral evaluation - problem focused,

by report ............................................................................................No CostD0170 Re-evaluation - limited, problem focused

(established patient; not post-operative visit) ...........................No CostD0180 Comprehensive periodontal evaluation

- new or established patient ..........................................................No CostD0210 Intraoral radiographs - complete series (including bitewings)

- limited to 1 series every 36 months .............................................No CostD0220 Intraoral - periapical first film ...........................................................No CostD0230 Intraoral - periapical, each additional film .....................................No CostD0240 Intraoral - occlusal film .......................................................................No CostD0270 Bitewing radiograph - single film ........................................................No CostD0272 Bitewings radiographs - two films ......................................................No CostD0274 Bitewings radiographs - four films

- limited to 1 series every 6 months ................................................No CostD0330 Panoramic film - limited to 1 each 36 month period .......................No CostD0460 Pulp vitality tests ..................................................................................No CostD0470 Diagnostic casts ....................................................................................No CostD0472 Accession of tissue, gross examination, preparation and

transmission of written report ......................................................No CostD0473 Accession of tissue, gross and microscopic examination,

preparation and transmission of written report .......................No CostD0474 Accession of tissue, gross and microscopic examination,

including assessment of surgical margins for presenceof disease, preparation and transmission of written report ...No Cost

D0999 Unspecified diagnostic procedure, by report- includes office visit, per visit (in addition to other services) ........ $ 5.00

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ENROLLEECode Description PAYS

D1000-D1999 II. PreventiveD1110 Prophylaxis cleaning - adult - 1 per 6 month period ..................... $ 15.00D1310 Nutritional counseling for control of dental disease ...................No CostD1330 Oral hygiene instructions ..................................................................No Cost

D2000-D2999 III. RestorativeIncludes polishing, all adhesives and bonding agents, indirect pulp capping, bases, linersand acid etch procedures.* Optional is defined as any alternative procedure presented by the Contract Dentist

that satisfies the same dental need as a covered procedure, is chosen by the Enrollee,and is subject to the limitations and exclusions of the program. The applicablecharge to the Enrollee is the difference between the Contract Dentist’s “filed fee”for the Optional procedure and the “filed fee” for the covered procedure, plus anyapplicable Copayment for the covered procedure. “Filed fees” mean the ContractDentist’s fees on file with PMI. Questions regarding the DeltaCare program shouldbe directed to PMI’s Customer Service department at (800) 422-4234.

1 An amalgam is the benefit.2 Base or noble metal is the benefit. High noble metal (precious), if used, will be

charged to the Enrollee at the additional maximum cost to the Enrollee of $100.00per tooth. If a cast post and core is made of high noble metal, an additional fee upto $100.00 per tooth will be charged for the upgraded post and core.

3 Porcelain and other tooth-colored materials on molars are considered a materialupgrade with a maximum additional charge to the Enrollee of $75.00.

4 Replacement is subject to a limitation requiring the existing restoration to be 5+years old.

D2140 Amalgam - one surface, primary or permanent .......................... $ 27.00D2150 Amalgam - two surfaces, primary or permanent ......................... $ 32.00D2160 Amalgam - three surfaces, primary or permanent ...................... $ 37.00D2161 Amalgam - four or more surfaces, primary or permanent ....... $ 50.00D2330 Resin-based composite - one surface, anterior ............................ $ 55.00D2331 Resin-based composite - two surfaces, anterior .......................... $ 65.00D2332 Resin-based composite - three surfaces, anterior ....................... $ 75.00D2335 Resin-based composite - four or more surfaces or

involving incisal angle (anterior) ................................................. $ 85.00D2391 Resin-based composite - one surface, posterior 1 ....................... $ 75.00D2392 Resin-based composite - two surfaces, posterior 1 ..................... $ 80.00D2393 Resin-based composite - three surfaces, posterior 1 ................... $ 85.00D2394 Resin-based composite - four or more surfaces, posterior 1 .... $ 85.00D2510 Inlay - metallic - one surface 2,4 ........................................................ $ 260.00D2520 Inlay - metallic - two surfaces 2,4 ...................................................... $ 270.00D2530 Inlay - metallic - three or more surfaces 2,4 ................................... $ 280.00D2542 Onlay - metallic - two surfaces 2,4 ................................................... $ 278.00D2543 Onlay - metallic - three surfaces 2,4 ................................................. $ 290.00D2544 Onlay - metallic - four or more surfaces 2,4 .................................. $ 300.00D2610 Inlay - porcelain/ceramic - one surface * 4 ................................... OptionalD2620 Inlay - porcelain/ceramic - two surfaces * 4 .................................. Optional

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ENROLLEECode Description PAYS

D2630 Inlay - porcelain/ceramic - three or more surfaces * 4 .............. OptionalD2642 Onlay - porcelain/ceramic - two surfaces * 4 ............................... OptionalD2643 Onlay - porcelain/ceramic - three surfaces * 4 ............................ OptionalD2644 Onlay - porcelain/ceramic - four or more surfaces * 4 .............. OptionalD2650 Inlay - resin-based composite - one surface * 4 ........................... OptionalD2651 Inlay - resin-based composite - two surfaces * 4 ......................... OptionalD2652 Inlay - resin-based composite - three or more surfaces * 4 ...... OptionalD2662 Onlay - resin-based composite - two surfaces * 4 ....................... OptionalD2663 Onlay - resin-based composite - three surfaces * 4 .................... OptionalD2664 Onlay - resin-based composite - four or more surfaces * 4 ..... OptionalD2710 Crown - resin (indirect) 3,4 ................................................................ $ 125.00D2720 Crown - resin with high noble metal 3,4 ........................................ $ 395.00D2721 Crown - resin with predominantly base metal 3,4 ....................... $ 315.00D2722 Crown - resin with noble metal 3,4 .................................................. $ 350.00D2740 Crown - porcelain/ceramic substrate 3,4 ........................................ $ 300.00D2750 Crown - porcelain fused to high noble metal 3,4 ......................... $ 395.00D2751 Crown - porcelain fused to predominantly base metal 3,4 ........ $ 315.00D2752 Crown - porcelain fused to noble metal 3,4 .................................. $ 350.00D2780 Crown - ¾ cast high noble metal 4 ................................................ $ 335.00D2781 Crown - ¾ cast predominantly base metal 4 ............................... $ 300.00D2782 Crown - ¾ cast noble metal 4 ......................................................... $ 335.00D2790 Crown - full cast high noble metal 4 ............................................... $ 365.00D2791 Crown - full cast predominantly base metal 4 ............................. $ 300.00D2792 Crown - full cast noble metal 4 ........................................................ $ 335.00D2910 Recement inlay ..................................................................................... $ 20.00D2920 Recement crown ................................................................................. $ 20.00D2932 Prefabricated resin crown ................................................................. $ 60.00D2940 Sedative filling .......................................................................................No CostD2950 Core buildup, including any pins .................................................... $ 50.00D2951 Pin retention - per tooth, in addition to restoration .................. $ 25.00D2952 Cast post and core in addition to crown

- includes canal preparation 2 ........................................................... $ 95.00D2953 Each additional cast post - same tooth

- includes canal preparation 2 ........................................................... $ 95.00D2954 Prefabricated post and core in addition to crown

- base metal post; includes canal preparation ................................ $ 70.00D2957 Each additional prefabricated post - same tooth

- base metal post; includes canal preparation ................................ $ 70.00D2970 Temporary crown (fractured tooth) - palliative treatment only ...No CostD2980 Crown repair, by report .................................................................... $ 45.00

D3000-D3999 IV. Endodontics5 A benefit for permanent teeth only.D3220 Therapeutic pulpotomy (excluding final restoration)

- removal of pulp coronal to the dentinocementaljunction and application of medicament ....................................No Cost

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ENROLLEECode Description PAYS

D3221 Pulpal debridement, primary and permanent teeth .................... $ 35.00D3310 Root canal - anterior (excluding final restoration) 5 .................... $ 180.00D3320 Root canal - bicuspid (excluding final restoration) 5 ................... $ 230.00D3330 Root canal - molar (excluding final restoration) 5 ........................ $ 375.00D3346 Retreatment of previous root canal therapy - anterior 5 .......... $ 280.00D3347 Retreatment of previous root canal therapy - bicuspid 5 ......... $ 330.00D3348 Retreatment of previous root canal therapy - molar 5 .............. $ 475.00D3410 Apicoectomy/periradicular surgery - anterior 5 .......................... $ 270.00D3421 Apicoectomy/periradicular surgery - bicuspid (first root) 5 ..... $ 335.00D3425 Apicoectomy/periradicular surgery - molar (first root) 5 .......... $ 380.00D3426 Apicoectomy/periradicular surgery (each additional root) 5 ... $ 105.00D3430 Retrograde filling - per root 5 .......................................................... $ 25.00D3450 Root amputation, per root

- not covered in conjunction with procedure D3920 5 .................. $ 75.00

D4000-D4999 V. PeriodonticsIncludes preoperative and postoperative evaluations and treatment under a local anesthetic.D4210 Gingivectomy or gingivoplasty - four or more contiguous

teeth or bounded teeth spaces per quadrant .......................... $ 300.00D4211 Gingivectomy or gingivoplasty - one to three teeth,

per quadrant .................................................................................... $ 50.00D4240 Gingival flap procedure, including root planing

- four or more contiguous teeth orbounded teeth spaces per quadrant .......................................... $ 300.00

D4241 Gingival flap procedure, including root planing- one to three teeth, per quadrant .............................................. $ 300.00

D4260 Osseous surgery (including flap entry and closure)- four or more contiguous teeth orbounded teeth spaces per quadrant .......................................... $ 450.00

D4261 Osseous surgery (including flap entry and closure)- one to three teeth, per quadrant .............................................. $ 450.00

D4341 Periodontal scaling and root planing - four or morecontiguous teeth or bounded teeth spaces per quadrant- limited to 4 quadrants during any 12 consecutive months ........ $ 55.00

D4342 Periodontal scaling and root planing, one to three teeth,per quadrant - limited to 4 quadrantsduring any 12 consecutive months .................................................. $ 55.00

D4355 Full mouth debridement to enable comprehensive evaluationand diagnosis - limited to 1 treatmentin any 12 consecutive months ......................................................... $ 55.00

D4910 Periodontal maintenance- limited to 1 treatment each 6 month period .............................. $ 45.00

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ENROLLEECode Description PAYS

D5000-D5899 VI. Prosthodontics (removable)6 Includes after delivery adjustments and tissue conditioning, if needed, for the first six

months after placement, if the Enrollee continues to be eligible and the service isprovided at the Contract Dentist’s facility where the denture was originally delivered.

7 Limited to 1 per denture during any 12 consecutive months.8 Replacement is subject to a limitation requiring the existing denture to be 5+ years old.D5110 Complete denture - maxillary 6,8 ..................................................... $ 395.00D5120 Complete denture - mandibular 6,8 ................................................. $ 395.00D5130 Immediate denture - maxillary 6,8 .................................................... $ 495.00D5140 Immediate denture - mandibular 6,8 ................................................ $ 495.00D5211 Maxillary partial denture - resin base

(including any conventional clasps, rests and teeth) 6,8 ......... $ 300.00D5212 Mandibular partial denture - resin base

(including any conventional clasps, rests and teeth) 6,8 ......... $ 300.00D5213 Maxillary partial denture - cast metal framework with

resin denture bases (including anyconventional clasps, rests and teeth) 6,8 ..................................... $ 395.00

D5214 Mandibular partial denture - cast metal framework withresin denture bases (including anyconventional clasps, rests and teeth) 6,8 ..................................... $ 395.00

D5410 Adjust complete denture - maxillary 6 ........................................... $ 20.00D5411 Adjust complete denture - mandibular 6 ....................................... $ 20.00D5421 Adjust partial denture - maxillary 6 ................................................ $ 20.00D5422 Adjust partial denture - mandibular 6 ............................................ $ 20.00D5510 Repair broken complete denture base .......................................... $ 50.00D5520 Replace missing or broken teeth

- complete denture (each tooth) ................................................. $ 25.00D5610 Repair resin denture base ................................................................. $ 50.00D5620 Repair cast framework ....................................................................... $ 90.00D5630 Repair or replace broken clasp ....................................................... $ 45.00D5640 Replace broken teeth - per tooth ................................................... $ 25.00D5650 Add tooth to existing partial denture ............................................ $ 45.00D5660 Add clasp to existing partial denture ............................................ $ 45.00D5710 Rebase complete maxillary denture 7 ............................................ $ 130.00D5711 Rebase complete mandibular denture 7 ........................................ $ 130.00D5720 Rebase maxillary partial denture 7 .................................................. $ 130.00D5721 Rebase mandibular partial denture 7 .............................................. $ 130.00D5730 Reline complete maxillary denture (chairside) 7 ......................... $ 50.00D5731 Reline complete mandibular denture (chairside) 7 ..................... $ 50.00D5740 Reline maxillary partial denture (chairside) 7 ............................... $ 50.00D5741 Reline mandibular partial denture (chairside) 7 .......................... $ 50.00D5750 Reline complete maxillary denture (laboratory) 7 ....................... $ 150.00D5751 Reline complete mandibular denture (laboratory) 7 ................... $ 150.00D5760 Reline maxillary partial denture (laboratory) 7 ............................ $ 150.00D5761 Reline mandibular partial denture (laboratory) 7 ........................ $ 150.00

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ENROLLEECode Description PAYS

D5820 Interim partial denture (maxillary) - limited to initialplacement of interim partial denture /stayplateto replace extracted anterior teeth during healing 6 ...................... $ 55.00

D5821 Interim partial denture (mandibular) - limited to initialplacement of interim partial denture /stayplate toreplace extracted anterior teeth during healing 6 .......................... $ 55.00

D5850 Tissue conditioning, maxillary 6,7 ..................................................... $ 30.00D5851 Tissue conditioning, mandibular 6,7 ................................................. $ 30.00D5860 Overdenture - complete, by report * 6,8 ........................................ OptionalD5861 Overdenture - partial, by report * 6,8 ............................................. Optional

D5900-D5999 VII. Maxillofacial Prosthetics - Not Covered

D6000-D6199 VIII. Implant Services - Not Covered

D6200-D6999 IX. Prosthodontics, fixed (each retainer and each ponticconstitutes a unit in a fixed partial denture [bridge]).* Optional is defined as any alternative procedure presented by the Contract Dentist

that satisfies the same dental need as a covered procedure, is chosen by the Enrollee,and is subject to the limitations and exclusions of the program. The applicablecharge to the Enrollee is the difference between the Contract Dentist’s “filed fee”for the Optional procedure and the “filed fee” for the covered procedure, plus anyapplicable Copayment for the covered procedure. “Filed fees” mean the ContractDentist’s fees on file with PMI. Questions regarding the DeltaCare program shouldbe directed to PMI’s Customer Service department at (800) 422-4234.

2 Base or noble metal is the benefit. High noble metal (precious), if used, will becharged to the Enrollee at the additional maximum cost to the Enrollee of $100.00per tooth. If a cast post and core is made of high noble metal, an additional fee upto $100.00 per tooth will be charged for the upgraded post and core.

3 Porcelain and other tooth-colored materials on molars are considered a materialupgrade with a maximum additional charge to the Enrollee of $75.00.

9 Replacement is subject to a limitation requiring the existing bridge to be 5+ years old.D6210 Pontic - cast high noble metal 9 ...................................................... $ 365.00D6211 Pontic - cast predominantly base metal 9 ..................................... $ 300.00D6212 Pontic - cast noble metal 9 ................................................................ $ 300.00D6240 Pontic - porcelain fused to high noble metal 3,9 .......................... $ 395.00D6241 Pontic - porcelain fused to predominantly base metal 3,9 ......... $ 315.00D6242 Pontic - porcelain fused to noble metal 3,9 ................................... $ 350.00D6245 Pontic - porcelain/ceramic * 9 ......................................................... OptionalD6250 Pontic - resin with high noble metal 3,9 ......................................... $ 395.00D6251 Pontic - resin with predominantly base metal 3,9 ........................ $ 315.00D6252 Pontic - resin with noble metal 3,9 ................................................... $ 350.00D6600 Inlay - porcelain/ceramic, two surfaces * 9 ..................................... OptionalD6601 Inlay - porcelain/ceramic, three or more surfaces * 9 .................. Optional

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ENROLLEECode Description PAYS

D6602 Inlay - cast high noble metal, two surfaces 2,9 ............................... $ 270.00D6603 Inlay - cast high noble metal, three or more surfaces 2,9 ........... $ 280.00D6604 Inlay - cast predominantly base metal, two surfaces 9 ................ $ 270.00D6605 Inlay - cast predominantly base metal,

three or more surfaces 9 ................................................................ $ 280.00D6606 Inlay - cast noble metal, two surfaces 9 .......................................... $ 270.00D6607 Inlay - cast noble metal, three or more surfaces 9 ....................... $ 280.00D6608 Onlay - porcelain/ceramic, two surfaces * 9 .................................. OptionalD6609 Onlay - porcelain/ceramic, three or more surfaces * 9 ............... OptionalD6610 Onlay - cast high noble metal, two surfaces 2,9 ............................ $ 290.00D6611 Onlay - cast high noble metal, three or more surfaces 2,9 ........ $ 290.00D6612 Onlay - cast predominantly base metal, two surfaces 9 ............. $ 290.00D6613 Onlay - cast predominantly base metal,

three or more surfaces 9 ................................................................ $ 290.00D6614 Onlay - cast noble metal, two surfaces 9 ....................................... $ 290.00D6615 Onlay - cast noble metal, three or more surfaces 9 .................... $ 290.00D6720 Crown - resin with high noble metal 3,9 ........................................ $ 395.00D6721 Crown - resin with predominantly base metal 3,9 ....................... $ 315.00D6722 Crown - resin with noble metal 3,9 .................................................. $ 350.00D6740 Crown - porcelain/ceramic * 9 ........................................................ OptionalD6750 Crown - porcelain fused to high noble metal 3,9 ......................... $ 395.00D6751 Crown - porcelain fused to predominantly base metal 3,9 ........ $ 315.00D6752 Crown - porcelain fused to noble metal 3,9 .................................. $ 350.00D6780 Crown - ¾ cast high noble metal 9 ................................................ $ 335.00D6781 Crown - ¾ cast predominantly base metal 9 ............................... $ 300.00D6782 Crown - ¾ cast noble metal 9 ......................................................... $ 335.00D6790 Crown - full cast high noble metal 9 ............................................... $ 365.00D6791 Crown - full cast predominantly base metal 9 ............................. $ 300.00D6792 Crown - full cast noble metal 9 ........................................................ $ 335.00D6930 Recement fixed partial denture ....................................................... $ 30.00D6940 Stress breaker 9 .................................................................................... $ 50.00D6970 Cast post and core in addition to fixed partial

denture retainer - includes canal preparation 2 ........................... $ 95.00D6971 Cast post as part of fixed partial denture retainer

- includes canal preparation 2 ........................................................... $ 95.00D6972 Prefabricated post and core in addition to fixed partial

denture retainer - base metal post; includes canal preparation . $ 85.00D6973 Core buildup for retainer, including any pins .............................. $ 50.00D6976 Each additional cast post - same tooth

- includes canal preparation 2 ........................................................... $ 95.00D6977 Each additional prefabricated post - same tooth

- base metal post; includes canal preparation ................................ $ 85.00D6980 Fixed partial denture repair, by report ......................................... $ 45.00

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ENROLLEECode Description PAYS

CAM57

D7000-D7999 X. Oral and Maxillofacial SurgeryIncludes preoperative and postoperative evaluations and treatment under local anesthetic.D7111 Coronal remnants - deciduous teeth (extraction) ........................ $ 35.00D7140 Extraction, erupted tooth or exposed root

(elevation and/or forceps removal) ............................................ $ 35.00D7210 Surgical removal of erupted tooth requiring elevation

of mucoperiosteal flap and removalof bone and/or section of tooth .................................................. $ 65.00

D7220 Removal of impacted tooth - soft tissue ........................................ $ 75.00D7230 Removal of impacted tooth - partially bony ................................. $ 100.00D7240 Removal of impacted tooth - completely bony ........................... $ 140.00D7241 Removal of impacted tooth - completely bony,

with unusual surgical complications .......................................... $ 160.00D7250 Surgical removal of residual tooth roots (cutting procedure) . $ 65.00D7286 Biopsy of oral tissue - soft (all others)

- does not include pathology laboratory procedures ...................... $ 60.00D7310 Alveoloplasty in conjunction with extractions - per quadrant ..... $ 50.00D7320 Alveoloplasty not in conjunction with extractions

- per quadrant ................................................................................. $ 105.00D7471 Removal of lateral exostosis - (maxilla or mandible) ................. $ 200.00D7510 Incision and drainage of abscess - intraoral soft tissue ............. $ 35.00D7960 Frenulectomy (frenectomy or frenotomy)

- separate procedure ...................................................................... $ 75.00

D8000-D8999 XI. Orthodontics - Not Covered

D9000-D9999 XII. Adjunctive General ServicesD9110 Palliative (emergency) treatment of dental pain

- minor procedure .......................................................................... $ 35.00D9211 Regional block anesthesia ..................................................................No CostD9212 Trigeminal division block anesthesia ................................................No CostD9215 Local anesthesia ....................................................................................No CostD9310 Consultation (diagnostic services provided by a dentist or

physician other than practitioner providing treatment) ............ $ 35.00D9430 Office visit for observation (during regularly scheduled hours)

- no other services performed ..................................................... $ 5.00D9440 Office visit - after regularly scheduled hours ............................... $ 50.00D9999 Unspecified adjunctive procedure, by report

- includes failed appointment without 24 hour notice- per 15 minutes of appointment time ........................................... $ 10.00

Procedures not listed above are not covered however may be available at theContract Dentist’s “filed fees”.

“Filed fees” mean the Contract Dentist’s fees on file with PMI. Questions regardingthese fees should be directed to PMI’s Customer Service department at (800) 422-4234.

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SCHEDULE BLIMITATIONS OF BENEFITS

1. Full mouth x-rays are limited to one set every 36 consecutive months andinclude any combination of periapicals, bitewings and/or panoramic film;

2. Bitewing x-rays are limited to not more than one series of four films in anysix month period;

3. Diagnostic casts are limited to aid in diagnosis by the Contract Dentist forcovered benefits;

4. If a biopsy is preauthorized by PMI to an oral surgeon, then examination ofthe resulting biopsy specimen is covered under D0472, D0473 or D0474and available at no additional cost;

5. Prophylaxis or periodontal maintenance therapy is limited to one procedureeach six month period;

6. A filling is a benefit for the removal of decay, for minor repairs of toothstructure or to replace a lost filling;

7. A crown is a benefit when there is insufficient tooth structure to support afilling or to replace an existing crown that is nonfunctional or nonrestorableand meets the five year limitation (see Limitation #11);

8. A covered metallic inlay or onlay using base or noble metal is available forlisted Copayment(s). If the Enrollee elects to have high noble metal usedinstead, the maximum additional cost of this material upgrade is $100.00per tooth. For a cast post and core, the benefit is for base or noble metal. Ifthe Enrollee elects to have a high noble metal cast post and core instead, themaximum additional cost of this material upgrade is $100.00 per tooth;

9. For molars, a covered crown or unit of a fixed partial denture (bridge) is afull cast metal restoration without porcelain or other tooth-colored material.If the Enrollee elects to have porcelain, porcelain-fused-to-metal, resin orresin-with-metal used instead, the maximum additional cost for this tooth-colored material upgrade is $75.00 per molar;

10. If a porcelain margin is also chosen by the Enrollee for a porcelain-fused-to-metal crown, the maximum additional cost for this laboratory upgrade is $75.00;

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11. The replacement of an existing inlay, onlay, crown, fixed partial denture(bridge) or a removable full or partial denture is covered when:a. The existing restoration/bridge/denture is no longer functional and

cannot be made functional by repair or adjustment, andb. Either of the following:

- The existing non-functional restoration/bridge/denture was placedfive or more years prior to its replacement, or

- If an existing partial denture is less than five years old, but must bereplaced by a new partial denture due to the loss of a natural tooth,which cannot be replaced by adding another tooth to the existingpartial denture;

12. A therapeutic pulpotomy on a permanent tooth is limited to palliative treatmentwhen the Contract Dentist is not performing root canal therapy;

13. Periodontal scaling and root planing are limited to four quadrants duringany 12 month period;

14. Full mouth debridement (gross scale) is limited to one treatment in any 12month period;

15. The benefit for the replacement of a missing posterior tooth (or teeth) is aremovable partial denture. Coverage for the placement of a fixed partialdenture (bridge) is optional except in the following cases:- The sole tooth to be replaced in the arch is a permanent anterior tooth,

provided that it is not in conjunction with a partial denture on the samearch. A cantilever bridge is a benefit at the professional discretion ofthe Contract Dentist for the replacement of one missing permanentanterior tooth only; or

- The new bridge would replace an existing, nonfunctional bridge utilizingthe same abutment teeth with no additional abutments or pontics withthe exception of posterior cantilever bridges (see Limitation #11); or

- The abutment teeth are not being crowned solely for the purpose ofsupporting a pontic (each abutment tooth to be crowned must meetLimitation #7);

16. Relines, tissue conditioning and rebases are limited to one per denture duringany 12 consecutive months;

17. Interim partial dentures (stayplates), in conjunction with fixed or removableappliances, are limited to:- The replacement of extracted anterior teeth for adults during a healing

period when the teeth cannot be added to an existing partial denture;

18. Excision of the frenum is a benefit only when it results in limited mobility ofthe tongue, it causes a large diastema between teeth or it interferes with aprosthetic appliance;

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19. In cases of accidental injury, benefits available are described in Schedule B,Accident Injury Benefit. Damages to the hard and soft tissues of the oralcavity from normal masticatory (chewing) function, exclusive attrition andnormal wear, will be covered as described in Schedules A, Description ofBenefits and Copayments; and B, Limitations and Exclusions of Benefits;

20. Soft tissue management programs include but are not limited to the followingcovered services: periodontal pocket charting, root planing, scaling, curettage,oral hygiene instruction, periodontal maintenance and/or prophylaxis. If anEnrollee declines non-covered services within a soft tissue managementprogram, it does not eliminate or alter the benefit for covered services;

21. A new removable partial, complete or immediate denture includes after deliveryadjustments and tissue conditioning at no additional cost for the first sixmonths after placement if the Enrollee continues to be eligible and the serviceis provided at the Contract Dentist’s facility where the denture was originallydelivered;

22. An Optional procedure is defined as any alternative procedure presentedby the Contract Dentist that satisfies the same dental need as a coveredprocedure to an Enrollee, and is subject to the Limitations and Exclusions ofthe program. The applicable charge to the Enrollee is the difference betweenthe Contract Dentist’s “filed fee” for the Optional procedure and the “filedfee” for the covered procedure, plus any applicable Copayment. Optionaltreatment does not apply when alternative treatment choices are also benefits.Optional procedures include:- The use of a tooth-colored material when restoring a posterior tooth

with a filling, inlay or onlay; and- Units in a fixed partial denture (bridge) made of porcelain/ceramic, which

is not fused to and supported by underlying cast metal.

“Filed fee” means the Contract Dentist’s fees on file with PMI. Questions regardingthese fees should be directed to PMI’s Customer Service department at (800) 422-4234.

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EXCLUSIONS OF BENEFITS

1. Any procedure that is not specifically listed under Schedule A, Description ofBenefits and Copayments;

2. Dental conditions arising out of and due to Enrollee’s employment for whichWorker’s Compensation is paid. Services that are provided to the Enrolleeby state government or agency thereof, or are provided without cost to theEnrollee by any municipality, county or other subdivision, except as providedin Section 1373(a) of the California Health and Safety Code;

3. All related fees for admission, use, or stays in a hospital, out-patient surgerycenter, extended care facility, or other similar care facility;

4. Loss or theft of full or partial dentures, space maintainers, crowns and fixedpartial dentures (bridges);

5. Dental expenses incurred in connection with any dental procedures startedafter termination of eligibility for coverage;

6. Dental expenses incurred in connection with any dental procedure startedbefore the Enrollee’s eligibility with the DeltaCare program. Examples include:teeth prepared for crowns, root canals in progress;

7. Congenital malformations (e.g. congenitally missing teeth, supernumeraryteeth, enamel and dentinal dysplasias, etc.);

8. Dispensing of drugs not normally utilized in the delivery of dental services;

9. Any procedure that in the professional opinion of the Contract Dentist:a. has poor prognosis for a successful result and reasonable longevity

based on the condition of the tooth or teeth and/or surroundingstructures, or

b. is inconsistent with generally accepted standards for dentistry;

10. Dental services received from any dental facility other than the assignedContract Dentist including the services of a dental specialist, unless expresslypreauthorized in writing by PMI or as cited under “Out of Area EmergencyTreatment”. To obtain written authorization, the Enrollee should call PMI’sCustomer Service department at (800) 4224234;

11. Consultations for non-covered benefits;

12. Implant placement or removal, appliances placed on or services associatedwith implants, including but not limited to prophylaxis and periodontaltreatment;

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13. Restorations placed solely due to cosmetics, abrasions, attrition, erosion,restoring or altering vertical dimension, congenital or developmentalmalformation of teeth or the anticipation of future fractures;

14. Appliances or restorations necessary to increase vertical dimension, replaceor stabilize tooth structure loss by attrition, realignment of teeth, periodontalsplinting, gnathologic recordings, equilibration or treatment of disturbancesof the temporomandibular joint (TMJ);

15. An initial treatment plan which involves the removal and reestablishment ofthe occlusal contacts of 10 or more teeth with crowns, onlays, fixed partialdentures (bridges), or any combination of these is considered to be fullmouth construction under the DeltaCare program. Crowns, onlays andfixed partial dentures associated with such a treatment plan are not coveredbenefits. This exclusion does not eliminate services for any other benefits;

16. Precious metal for removable appliances, metallic or permanent soft basesfor complete dentures, porcelain denture teeth, precision abutments forremovable partials or fixed partial dentures (overlays, implants, and appliancesassociated therewith) and personalization and characterization of completeand partial dentures;

17. Extraction of teeth, when teeth are asymptomatic/non-pathologic (no signsor symptoms of pathology or infection), including but not limited to theremoval of third molars and orthodontic extractions;

18. Treatment or extraction of retained primary teeth;

19. A Maryland bridge is considered a specialized technique and is not a Benefit.Recementation, repair or replacement of an existing Maryland bridge is not a Benefit.

ACCIDENT INJURY BENEFIT

An accident injury is damage to the hard and soft tissue of the mouth causeddirectly and independently of all other causes by external forces. Damage to thehard and soft tissue of the mouth from normal chewing function is coveredunder Schedule A, Description of Benefits and Copayments.

PMI will pay up to 100% of the Contract Dentist’s “filed fees”, for expenses anEnrollee incurs for an accident injury, less any applicable Copayment(s), up to aMaximum of $1,600.00 in any 12 month period.

Accident injury benefits include the following procedure in addition to thoselisted in Schedule A, Description of Benefits and Copayments.

CODE D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or

displaced tooth and/or alveolus - includes splinting and/or stabilization.

Payment of accident injury benefits is subject to Schedule B, Limitations andExclusions of Benefits, in addition to the following provisions:

MAXIMUMAccident injury benefits will be provided for each Enrollee up to a maximum of$1,600.00 in any 12 month period.

LIMITATIONAccident injury benefits are limited to services provided as a result of an accidentwhich occurred (a) while the Enrollee was covered under the DeltaCare program,or (b) while the Enrollee was covered under another DeltaCare program, and ifthe benefits for the expenses incurred would have been paid if the Enrollee hadremained covered under that program.

EXCLUSIONSIn addition to Schedule B, Limitations #12, #17, and #19 and Exclusions #1-9,#11-14 and #17-19, the following exclusions apply:1. Prophylaxis;2. Extra-oral grafts (grafting of tissues from outside the mouth to oral tissue);3. Replacement of existing restorations due to decay;4. Orthodontic services (treatment of malalignment of teeth and/or jaws);5. Replacement of existing restorations, crowns, bridges, dentures and otherdental or orthodontic appliances damaged by accident injury.

“Filed fees” means the Contract Dentist’s fees on file with PMI. Questions regardingthese fees should be directed to PMI’s Customer Service department at (800) 422-4234.

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Organ and Tissue DonationDonating organs and tissue provides many societal benefits. Organ and tissuedonation allows recipients of transplants to go on to lead fuller and moremeaningful lives. Currently, the need for organ transplants far exceedsavailability. If you are interested in organ donation, please speak with yourphysician. Organ donation begins at the hospital, when a patient ispronounced brain dead and identified as a potential organ donor. An organprocurement organization will become involved to coordinate the activities.

If you have any questions or needadditional information call or write:

12898 Towne Center DriveCerritos, CA 90703-8579

(800) 422-4234www.deltadentalca.org/pmi

03/04 7104002012

Did you know you could refer to our web site fora listing of DeltaCare Dentists?Visit www.deltadentalca.org/pmi and click on theDentist Directory, DeltaCare Dentists and AllStates. You can also change your facility assignment,change your mailing address, request ID cards oran Evidence of Coverage booklet online. From thehome page, simply click on Contact Us, CustomerService and the Online Customer Service Requestfor DeltaCare (administered by PMI).

In California, PMI Dental Health Plan administers the DeltaCare and DeltaVision programs forDelta Dental of California.