NEVADA D 350 B S The following copayments apply only when treatment is performed at a participating PacifiCare Plan Dental Office. Prescription drugs are covered by your PacifiCare Medical Plan per your medical plan benefits. ADA ADA Codes Description Copay Codes Description CopayType I Covered Services (GP Care Only) – 02161 Amalgam, four surfaces permanent $40No waiting period 02330 Resin – one surface anterior $30 02331 Resin – two surfaces anterior $35 Diagnostic Services 02332 Resin – three surfaces anterior $40 00120 Periodic oral evaluation $5 02335 Resin – four surfaces anterior $45 00140 Limited oral exam – (problem focused) $5 Oral Surgery (12-month waiting 00150 Comprehensive oral evaluation $5 period for specialist care) 00210 Intraoral/bitewings – full mouth X-rays $10 00220 Intraoral – periapical X-rays, first film $5 07110 Simple extraction $35 00230 Intraoral – periapical X-rays, additional $5 07120 Additional extraction (same quadrant) $30 00240 Occlusal X-ray $5 07210 Surgical extraction $75 00270 Bitewing X-ray, 1 film $5 07220 Impacted (soft tissue) $95 00272 Bitewing X-ray, 2 films $5 07230 Impacted (partially bony) $110 00274 Bitewing X-ray, 4 films $5 07240 Impacted (completely bony) $175 00330 Panorex film $10 07250 Root removal, surgical $110 00470 Diagnostic casts $10 07310 Alveolectomy (with extractions) $110 07510 I & D of abscess, intraoral $60 Preventive Services Endodontic Services (12-month 01110 Adult prophylaxis (cleaning) – waiting period for specialist care) every 6 months $10 01120 Child prophylaxis (cleaning) – 03110 Direct pulp capping (EXL FN RES) $25 every 6 months $5 03120 Indirect pulp capping including 01201 Prophylaxis with fluoride child $5 temporary restoration $20 01203 Fluoride w/o prophy child $5 03220 Pulpotomy, primary $75 01330 Oral hygiene instructions $5 03310 Root canal, anterior $265 01351 Sealant, per tooth $5 03320 Root canal, bicuspid $280 01515 Fixed, lingual/palatal bar $60 03330 Root canal, molar $400 03346 Retreatment of rct-anterior Adjunctive Services (pre-existing exclusion) $265 09110 Palliative emergency treatment $25 03347 Retreatment of rct-bicuspid 09310 Consultation (specialist only – (pre-existing exclusion) $280 12-month waiting period) $35 03348 Retreatment of rct-molar 09430 Office for observation – (pre-existing exclusion) $400 regular business hours 03425 Apicoectomy, molar $270 (no other procedures performed) $25 03426 Apicoectomy, additional root $270 09440 Office visit after hours $30 03430 Retrograde filling $205 Basic Restorative Services Periodontal Services (12-month waiting period for specialist care) 02110 Amalgam, one surface primary $25 02120 Amalgam, two surfaces primary $30 04211 Gingivectomy/tooth $65 02130 Amalgam, three surfaces primary $30 04260 Osseous Surgery/per qt. $405 02131 Amalgam, four surfaces primary $35 04341 Scale/root planing per quadrant $50 02140 Amalgam, one surface permanent $25 04355 Full mouth debridement $45 02150 Amalgam, two surfaces permanent $30 04910 Perio maintenance procedure $55 02160 Amalgam, three surfaces permanent $30
Type II Covered Services – GP & Specialty Care(Covered after 12 months of continuouscoverage under dental plan) ADA Codes Description Copay Advanced Restorative Services (excludes gold unless noted*) 02750 Porcelain with gold crown* $325 02751 Crown Porc FU Predom Bas $310 02752 Porcelain semiprecious crown $300 02790 Full gold crown $300 02920 Recement Crown $30 02930 Prefab stain st. crown pri $70 02940 Sedative fillings $20 02950 Crown buildup inc. pins $65 02951 Pin retent per tooth rest $20 02954 Preformed post & core add $90 Removable Prosthodontics 05110 Immediate denture – upper $395 05120 Immediate denture – lower $395 05130 Upper partial, resin base $430 05140 Lower partial, resin base $430 05213 Partial metal base – upper $420 05214 Partial metal base – lower $420 05421 Partial adjustment, upper $35 05422 Partial adjustment, lower $35 05510 Repair acrylic saddle or base (no teeth involved) $40 05520 Replace miss teeth complete per tooth $30 05610 Repair acrylic saddle $60 05620 Repair framework $63 05640 Repair/replace tooth p/p $55 05650 Add tooth to existing partial $55 05750 Reline complete denture, upper (lab) $110 05751 Reline complete denture, lower (lab) $110 05820 Interim partial – upper including clasp/rest $95 05821 Interim partial – lower, including clasp/rest $95 Fixed Prosthodontics (excludes gold) 06240 Porcelain to gold pontic $335 06241 PFM porcelain fused to pred. Metal $285 06242 Pontic porcelain semiprecious $300 06250 Pontic resin high noble metal $400 06251 Plastic process to metal $350 06252 Pontic resin to semiprecious $380 06750 Pontic resin high noble metal $365 06751 Plastic process to metal $280 06752 Pontic resin to semiprecious $305 * plus the cost of gold
350 Plan Limitations and Exclusions • Full or partial replacement of dentures will be made only if existing dentures are unsatisfactory and cannot Emergency Care (In Area) be made satisfactory, and then the following would • In emergency situations, PacifiCare Primary Care apply: Dentists shall furnish such care as needed 1. Charges for full or partial dentures, fixed bridges or immediately or, if appropriate, not more than tooth additions to existing denture, if required 24 hours after the request. Dental emergencies are because of loss of natural teeth, are covered by the defined as conditions where hemorrhage, acute pain Plan. Replacement of an existing prosthesis or infection of dental origin exists. (denture, partial and crown) that is over five years old and cannot be made serviceable is also covered. Emergency Care (Out-of-Area) 2. Charges for repairing and rebasing existing • In emergency situations, PacifiCare Primary Care denture which have not been replaced by a new Dentists shall furnish such care as needed immediately denture are also covered by the Plan. or, if appropriate, not more than 24 hours after the request. Dental emergencies are defined as unexpected 3. Covered charge for both a temporary and a conditions where hemorrhage, acute pain or infection permanent prosthesis will be limited to the of dental origin exists. (For emergencies to sound charges for a permanent one only. Charges for natural teeth, refer to medical Evidence of Coverage.) specialized techniques involving precision attachments, personalization or characterization, • Coverage is limited to palliative treatment of infection precious metal for removable appliances, overlays and pain. Definitive treatment is not covered. The out- and implants and additional charges for of-area coverage reimburses the usual and customary adjustments within six months of installation are fee up to a maximum of $100 per occurrence. not included as covered benefits. PacifiCare must be notified within 30 days. • Full mouth X-rays and panographs are limited to only Service Fees once every thirty-six (36) months. • If you do not keep an appointment and fail to notify • Procedures for root planing are allowable only when the dental office of cancellation 24 hours in advance, the need can be demonstrated radiographically and/or you may be assessed a $25 service charge. For by written explanation and only two quadrants are emergency care requiring an after-hours appointment, allowable at an appointment with a maximum of four you may be assessed a $30 visit charge in addition to quads per year. any copayment. • One course of sealant treatment every twenty-four Dental Plan Limitations (24) months. Limited to primary molars and 1st and 2nd permanent molars only. • There is a $1,000 annual maximum benefit on • Full mouth debridement is limited to one every specialty care. Specialty services require twenty-four (24) months. Root planing per quad predetermination of benefits. limited to one course of treatment every three years. • Specialty care is covered after twelve (12) months • Relines of dentures are limited to only twice per year. continuous coverage under dental plan. • Replacement of missing teeth with complete or partial • Routine teeth cleaning is limited to not more than dentures, or fixed bridges, using standard procedures, once every 6 months. (Does not include limited is covered. However, treatment involving the oral/emergency exams). following procedures is considered optional and, if • Treatment of dental emergencies is limited to care performed, member should be advised of his/her that will alleviate acute symptoms and does not responsibility for the additional fee. include definitive restorative treatment such as root canal treatment, crowns, etc. Dental Plan Exclusions • Crowns will be covered only if there is not enough • Major surgery and treatment of malignancies. Cysts or retentive quality left in tooth to hold a filling, i.e. buccal benign tumors not within the scope of usual or lingual walls either fractured or decayed to the comprehensive dental care. Odontogenic cysts extent that they do not hold a filling. Veneers, posterior exceeding 1.25 cm in diameter. Procedures, to the second bicuspid, are considered purely cosmetic appliances, or restorations to correct or replace soft dentistry. Allowance will be made for cast full crown. If or hard tissue defects resulting from such treatment. performed, patient must pay the additional fee. There Procedures, appliances or restorations to correct will be an additional charge to the member for the use congenital or developmental malformations including, of gold or other precious metals. but not limited to, cleft palate, enamel hypoplasia, • Correction of occlusion is not a separate benefit, but fluorosis, jaw malformations and anodontia. it is considered a part of the completed restoration or • Procedures or surgery which are undertaken primarily fixed prosthesis. for cosmetic reasons or to correct congenital malformations composite restorations beyond second biscuspid are considered cosmetic.