Guardian’s DHMO Plan

The Guardian DentalGuard DHMO plans allow you to choose to receive care from any participating licensed dentist in our DHMO network, and pay a set co-pay for your office visit. Under this plan, you must choose a primary care dentist. All of your dental care will be provided by, or arranged by, your primary care dentist.

Under the Affordable Care Act (ACA), insurers must provide coverage for 10 essential health benefits (EHBs). This plan includes the pediatric essential health benefit, which is a comprehensive set of dental services for children under 19. These services are covered without annual or lifetime limits as long as you receive care-in-network. Also included is coverage for medically necessary orthodontics.

Managed DentalGuard Family Plan—For Plan Years Beginning in 2016
In-Network Out-of-Network
You Pay (Average cost is illustrated below. Refer to detailed list on the following pages.)
Diagnosis & Preventive Care
-Members age 19 and older
-Members under age 19
*Exams, cleaning, x-rays

$0
$2
Not Covered
Basic Services
-Members age 19 and older
-Members under age 19

*Fillings, simple tooth extractions

$70
$65
Not Covered
Major Services
-Members age 19 and older
-Members under age 19
*Crowns, inlays, onlays, and cast restorations

$346
$348
Not Covered
Standard Orthodontic Coverage
(without verification of medical
necessity) D8080
*Comprehensive Orthodontic Treatment of the Adolescent
$2,500 Not Covered
Standard Orthodontic Coverage
(without verification of medical
necessity) D8090
*Comprehensive Orthodontic Treatment of the Adult
$2,800 Not Covered
Office Visit $15 Not Covered
Out of Pocket Maximum
(Individual / Family)

– Applies to child essential health benefits only)

$350 / $700
Not Covered
Annual Maximum None N/A

*Current Dental Terminology © 2013 American Dental Association (ADA). All rights reserved. Note: Procedures listed above under Preventive, Basic, Major and Orthodontics are for sample purposes only and do not encompass all covered services. For a list of co-payments for all covered services, please see the Covered Dental Services And Patient Charges on the following pages, and your policy contract for details. Limitations and exclusions apply. Plan documents are the final arbiter of coverage. FCW-GMC-FP-IL-15

Plan designs are not available in the following counties: Adams, Alexander, Bond, Boone, Brown, Bureau, Calhoun, Carroll, Cass, Christian, Clark, Clay, Clinton, Coles, Crawford, Cumberland, Dekalp, Dewitt, Douglas, Edgar, Edwards, Effingham, Fayette, Ford, Franklin, Fulton, Gallatin, Greene, Hamilton, Hancock, Hardin, Henderson, Henry, Iroquios, Jackson, Jasper, Jefferson, Jersey, Jo Daviess, Johnson, Knox, La Salle, Lawrence, Lee, Livingston, Logan, Macon, Maroupin, Marion, Marshall, Mason, Massac, Mcdonough, McLean, Menard, Mercer, Monroe, Montgomery, Morgan, Moultrie, Ogle, Perry, Piatt, Pike, Pope, Pulaski, Putnam, Randolph, Richland, Rock Island, Saline, Schuyler, Scott, Shelby, Stark, Stephenson, Tazewell, Union, Vermilion, Wabash, Warren, Washington, Wayne, White, Whiteside, Williamson, Woodford

Covered Dental Services and Patient Charges – U10ILI02

The services covered by this Policy are named in this list. If a service, treatment or procedure is not on this list, it is not a covered service. All services must be provided by the assigned Primary Care Dentist. The Member must pay the listed Patient Charge. The benefits We provide are subject to all of the terms of this Policy, including the Limitations and Conditions on Covered Dental Services and Exclusions.

There is a limit on the total amount of Patient Charges a Member who is under age 19 must pay each calendar year for pediatric essential health benefits as determined by Illinois. The limit is $350.00 for each such Member. Once this limit is reached the plan waives Patient Charges for such benefits for the rest of the calendar year for such Member. But if two or more such Members meet the limit of $700.00 in a calendar year, the plan waives the Patient Charges for such benefits for all other such Members for the rest of the calendar year.

The Patient Charges listed this section are only valid for covered services that are: (1) started and completed under this Policy, and (2) rendered by Participating Dentists in the State of Illinois.

Covered Services and Patient Charges
CDT Codes++ Plan Schedules – Patient Charges
D0100-D0999 I. DIAGNOSTIC
D0120 Periodic oral evaluation – established patient++++ $0
D0140 Limited oral evaluation – problem focused++++ 0
D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver++++ 0
D0150 Comprehensive oral evaluation – new or established patient++++ 0
D0170 Re-evaluation – limited, problem focused (established patient; not post-operative visit)++++ 0
D0180 Comprehensive periodontal evaluation – new or established patient++++ 0
D0210 Intraoral – complete series of radiographic images 0
D0220 Intraoral – periapical first radiographic image 0
D0230 Intraoral – periapical each additional radiographic image 0
D0240 Intraoral – occlusal radiographic image 0
D0270 Bitewing – single radiographic image 0
D0272 Bitewings – two radiographic images 0
D0273 Bitewings – three radiographic images 0
D0274 Bitewings – four radiographic images 0
D0277 Vertical bitewings – 7 to 8 radiographic images 0
D0330 Panoramic radiographic image 0
D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures 50
D0460 Pulp vitality tests 0
D0470 Diagnostic casts 0
D0999 Office visit during regular hours, general dentist only 15
D1000-D1999 II. PREVENTIVE
D1110 Prophylaxis – adult, for the first two services in any 12-month period+# 0
D1120 Prophylaxis – child, for the first two services in any 12-month period+# 0
D1999 Prophylaxis – adult or child, for each additional service in same 12-month period+# 60
D1203 Topical application of fluoride (prophylaxis not included) – child, for the first two services in any 12-month period+= 0
D1204 Topical application of fluoride (prophylaxis not included) – adult, for the first two services in any 12-month period+= 0
D1206 Topical application of fluoride varnish, for the first two services in any 12-month period+= 12
D1208 Topical application of fluoride+= 0
D2999 Topical fluoride (adult or child), each additional service in the same 12-month period+= 20
D1310 Nutritional counseling for control of dental disease 0
D1330 Oral hygiene instructions 0
D1351 Sealant – per tooth (molars)## 14
D9999 Sealant – per tooth (non-molars)## 35
D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent tooth## 14
D1510 Space maintainer – fixed – unilateral 75
D1515 Space maintainer – fixed – bilateral 110
D1525 Space maintainer – removable – bilateral 110
D1550 Re-cementation of space maintainer 13
D1555 Removal of fixed space maintainer 20
D2000-D2999 III. RESTORATIVE ###
D2140 Amalgam – one surface, primary or permanent 28
D2150 Amalgam – two surfaces, primary or permanent 39
D2160 Amalgam – three surfaces, primary or permanent 46
D2161 Amalgam – four or more surfaces, primary or permanent 57
D2330 Resin-based composite – one surface, anterior 36
D2331 Resin-based composite – two surfaces, anterior 44
D2332 Resin-based composite – three surfaces, anterior 58
D2335 Resin-based composite – four or more surfaces or involving incisal angle (anterior) 66
D2390 Resin-based composite crown, anterior 95
D2391 Resin-based composite – one surface, posterior 56
D2392 Resin-based composite – two surfaces, posterior 75
D2393 Resin-based composite – three surfaces, posterior 90
D2394 Resin-based composite – four or more surfaces, posterior 95
D2510 Inlay – metallic – one surface** 326
D2520 Inlay – metallic – two surfaces** 368
D2530 Inlay – metallic – three or more surfaces** 383
D2542 Onlay – metallic – two surfaces** 383
D2543 Onlay – metallic – three surfaces** 400
D2544 Onlay – metallic – four or surfaces** 420
D2610 Inlay – porcelain/ceramic – one surface 326
D2620 Inlay – porcelain/ceramic – two surfaces 368
D2630 Inlay – porcelain/ceramic – three or more surfaces 383
D2642 Onlay – porcelain/ceramic – two surfaces 383
D2643 Onlay – porcelain/ceramic – three surfaces 400
D2644 Onlay – porcelain/ceramic – four or more surfaces 420
D2740 Crown – porcelain/ceramic substrate 450
D2750 Crown – porcelain fused to high noble metal** 430
D2751 Crown – porcelain fused to predominately base metal 430
D2752 Crown – porcelain fused to noble metal 430
D2780 Crown – 3/4 cast high noble metal** 420
D2781 Crown – 3/4 cast predominately base metal 420
D2782 Crown – 3/4 cast noble metal 420
D2783 Crown – 3/4 porcelain/ceramic 420
D2790 Crown – full cast high noble metal** 430
D2791 Crown – full cast predominately base metal 430
D2792 Crown – full cast noble metal 430
D2794 Crown – titanium 430
D2910 Recement inlay, onlay, or partial coverage restoration 18
D2915 Recement cast or prefabricated post and core 18
D2920 Recement crown 18
D2929 Prefabricated porcelain/ceramic crown – primary tooth 135
D2930 Prefabricated stainless steel crown – primary tooth 110
D2931 Prefabricated stainless steel crown – permanent tooth 125
D2932 Prefabricated resin crown – anterior primary tooth 135
D2933 Prefabricated stainless steel crown with resin window – anterior primary tooth 135
D2934 Prefabricated esthetic coated stainless steel crown – primary tooth 145
D2940 Protective restoration 30
D2950 Core buildup, including any pins when required 113
D2951 Pin retention – per tooth, in addition to restoration 24
D2952 Post and core, in addition to crown, indirectly fabricated – includes canal preparation 160
D2953 Each additional indirectly fabricated post – same tooth – includes canal preparation 50
D2954 Prefabricated post and core in addition to crown – base metal post; includes canal preparation 130
D2957 Each additional prefabricated post – same tooth – base metal post; includes canal preparation 29
D2960 Labial veneer (resin laminate) – chairside 250
D2970 Temporary crown (fractured tooth) – palliative treatment only 100
D2971 Additional procedures to construct new crown under existing partial denture framework 125
D2990 Resin infiltration of incipient smooth surface lesions 5
D3000-D3999 IV. ENDODONTICS
D3110 Pulp cap – direct (excluding final restoration) 15
D3120 Pulp cap – indirect (excluding final restoration) 15
D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament 50
D3221 Pulpal debridement, primary and permanent teeth 50
D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development 50
D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) 88
D3240 Pulpal therapy (resorbable filling) -posterior, primary tooth (excluding final restoration) 90
D3310 Endodontic therapy, anterior tooth (excluding final restoration) 260
D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) 300
D3330 Endodontic therapy, molar (excluding final restoration) 400
D3331 Treatment of root canal obstruction, non-surgical access 0
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth 150
D3333 Internal root repair of perforation defects 120
D3346 Retreatment of previous root canal therapy – anterior 315
D3347 Retreatment of previous root canal therapy – bicuspid 370
D3348 Retreatment of previous root canal therapy – molar 445
D3410 Apicoectomy/periradicular surgery – anterior 265
D3421 Apicoectomy/periradicular surgery – bicuspid (first root) 300
D3425 Apicoectomy/periradicular surgery – molar (first root) 350
D3426 Apicoectomy/periradicular surgery – (each additional root) 110
D3430 Retrograde filling – per root 90
D3950 Canal preparation and fitting of preformed dowel or post 20
D4000-D4999 V. PERIODONTICS
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant 188
D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant 85
D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth 60
D4240 Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant 275
D4241 Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant 165
D4249 Clinical crown lengthening – hard tissue 285
D4260 Osseous surgery (including flap entry and closure) – four or more contiguous teeth or bounded teeth spaces per quadrant 410
D4261 Osseous surgery (including flap entry and closure) – one to three contiguous teeth or bounded teeth spaces per quadrant 350
D4268 Surgical revision procedure, per tooth 0
D4270 Pedicle soft tissue graft procedure 295
D4271 Free soft tissue graft procedure (including donor site surgery) 298
D4273 Subepithelial connective tissue graft procedures, per tooth 328
D4277 Free soft tissue graft procedure (including donor site surgery) first tooth or edentulous tooth position in a graft 298
D4278 Free soft tissue graft procedure (including donor site surgery) each additional contiguous tooth or edentulous tooth position in a graft 179
D4341 Periodontal scaling and root planing, four or more teeth per quadrant 50
D4342 Periodontal scaling and root planing, one to three teeth per quadrant 30
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis 35
D4910 Periodontal maintenance, for the first two services in any 12-month period+# 32
D4920 Unscheduled dressing change (by someone other than treating dentist) 25
D4999 Periodontal maintenance, each additional service in same 12-month period+# 60
D5000-D5999 VI. PROSTHODONTICS (removable)
D5110 Complete denture – maxillary 580
D5120 Complete denture – mandibular 580
D5130 Immediate denture – maxillary 620
D5140 Immediate denture – mandibular 620
D5211 Maxillary partial denture – resin base (including any conventional clasps, rests and teeth) 580
D5212 Mandibular partial denture – resin base (including any conventional clasps, rests and teeth) 580
D5213 Maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 620
D5214 Mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 620
D5225 Maxillary partial denture – flexible base (including any clasps, rests and teeth) 675
D5226 Mandibular partial denture – flexible base (including any clasps, rests and teeth) 675
D5410 Adjust complete denture – maxillary 27
D5411 Adjust complete denture – mandibular 27
D5421 Adjust partial denture – maxillary 27
D5422 Adjust partial denture – mandibular 27
D5510 Repair broken complete denture base 69
D5520 Replace missing or broken teeth – complete denture (each tooth) 66
D5610 Repair resin denture base 80
D5620 Repair cast framework 80
D5630 Repair or replace broken clasp 96
D5640 Replace broken teeth – per tooth 62
D5650 Add tooth to existing partial denture 81
D5660 Add clasp to existing partial denture 102
D5670 Replace all teeth and acrylic on cast metal framework (maxillary) 223
D5671 Replace all teeth and acrylic on cast metal framework (mandibular) 223
D5710 Rebase complete maxillary denture 230
D5711 Rebase complete mandibular denture 230
D5720 Rebase maxillary partial denture 230
D5721 Rebase mandibular partial denture 230
D5730 Reline complete maxillary denture (chairside) 130
D5731 Reline complete mandibular denture (chairside) 130
D5740 Reline maxillary partial denture (chairside) 125
D5741 Reline mandibular partial denture (chairside) 125
D5750 Reline complete maxillary denture (laboratory) 186
D5751 Reline complete mandibular denture (laboratory) 186
D5760 Reline maxillary partial denture (laboratory) 186
D5761 Reline mandibular partial denture (laboratory) 186
D5820 Interim partial denture (maxillary) 190
D5821 Interim partial denture (mandibular) 190
D5850 Tissue conditioning, maxillary 60
D5851 Tissue conditioning, mandibular 60
D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS – Medical Necessity
D5931 Obturator prosthesis, surgical #### 2,415
D5932 Obturator prosthesis, definitive #### 1,687
D5933 Obturator prosthesis, modification #### 245
D5936 Obturator prosthesis, interim #### 4,023
D6000-D6199 VIII. IMPLANT SERVICES – Not Covered
D6200-D6999 IX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit of fixed partial denture [bridge])###
D6210 Pontic – cast high noble metal** 400
D6211 Pontic – cast predominately base metal 400
D6212 Pontic – cast noble metal 400
D6214 Pontic – titanium 400
D6240 Pontic – porcelain fused to high noble metal** 400
D6241 Pontic – porcelain fused to predominately base metal 400
D6242 Pontic – porcelain fused to noble metal 400
D6245 Pontic – porcelain/ceramic 410
D6600 Inlay – porcelain/ceramic – two surfaces 368
D6601 Inlay – porcelain/ceramic – three or more surfaces 383
D6602 Inlay – cast high noble metal, two surfaces** 368
D6603 Inlay – cast high noble metal, three or more surfaces** 383
D6604 Inlay – cast predominantly base metal, two surfaces 368
D6605 Inlay – cast predominantly base metal, three or more surfaces 383
D6606 Inlay – cast noble metal, two surfaces 368
D6607 Inlay – cast noble metal, three or more surfaces 383
D6608 Onlay – porcelain/ceramic – two surfaces 383
D6609 Onlay – porcelain/ceramic – three or more surfaces 400
D6610 Onlay – cast high noble metal, two surfaces** 383
D6611 Onlay – cast high noble metal, three or more surfaces** 400
D6612 Onlay – cast predominantly base metal, two surfaces 383
D6613 Onlay – cast predominantly base metal, three or more surfaces 400
D6614 Onlay – cast noble metal, two surfaces 383
D6615 Inlay – cast noble metal, three or more surfaces 400
D6624 Inlay – titanium 368
D6634 Onlay – titanium 383
D6740 Crown – porcelain/ceramic 450
D6750 Crown – porcelain fused to high noble metal** 430
D6751 Crown – porcelain fused to predominately base metal 430
D6752 Crown – porcelain fused to noble metal 430
D6780 Crown – 3/4 cast high noble metal** 430
D6781 Crown – 3/4 cast predominately base metal 430
D6782 Crown – 3/4 cast noble metal 430
D6783 Crown – 3/4 porcelain/ceramic 430
D6790 Crown – full cast high noble metal** 430
D6791 Crown – full cast predominately base metal 430
D6792 Crown – full cast noble metal 430
D6794 Crown – titanium 430
D6930 Recement fixed partial denture 26
D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated 160
D6972 Prefabricated post and core in addition to fixed partial denture retainer 130
D6973 Core build up for retainer, including any pins 113
D6976 Each additional cast post – same tooth 50
D6977 Each additional prefabricated post – same tooth 29
D6999 Multiple crown and bridge unit treatment plan – per unit, six or more units per treatment plan### 125
D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY
D7111 Extraction, coronal remnants – deciduous tooth $20
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) 35
D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated 110
D7220 Removal of impacted tooth – soft tissue 145
D7230 Removal of impacted tooth – partially bony 180
D7240 Removal of impacted tooth – completely bony 215
D7241 Removal of impacted tooth – completely bony with unusual surgical complications 240
D7250 Surgical removal of residual tooth roots (cutting procedure) 110
D7261 Primary closure of a sinus perforation 250
D7280 Surgical access of an unerupted tooth 250
D7283 Placement of device to facilitate eruption of impacted tooth 35
D7285 Biopsy of oral tissue – hard (bone, tooth) 125
D7286 Biopsy of oral tissue – soft 85
D7288 Brush biopsy – transepithelial sample collection 65
D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant 53
D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant 26
D7320 Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant 92
D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant 65
D7450 Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25cm 200
D7451 Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25cm 260
D7460 Removal of nonodontogenic cyst or tumor – lesion diameter up to 1.25cm 406
D7461 Removal of nonodontogenic cyst or tumor – lesion diameter greater than to 1.25cm 406
D7471 Removal of lateral exostosis (maxilla or mandible) 215
D7472 Removal of torus palatinus 215
D7473 Removal of torus mandibularis 215
D7510 Incision and drainage of abscess – intraoral soft tissue 44
D7511 Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces) 48
D7610 Maxilla – open reduction (teeth immobilized, if present) #### 1,500
D7620 Maxilla – closed reduction (teeth immobilized, if present) #### 1,100
D7630 Mandible – open reduction (teeth immobilized, if present) #### 5,000
D7640 Mandible – closed reduction (teeth immobilized, if present) #### 2,200
D7710 Maxilla – open reduction #### 495
D7720 Maxilla – closed reduction #### 3,513
D7730 Mandible – open reduction #### 1,129
D7740 Mandible – closed reduction #### 1,020
D7955 Repair of maxillofacial soft and/or hard tissue defect #### 1,500
D7960 Frenulectomy – also known as frenectomy or frenotomy – separate procedure not incidental to another procedure. 100
D7963 Frenuloplasty 168
D8000-D8999 XI. ORTHODONTICS++
D8070 Comprehensive orthodontic treatment of the transitional dentition** 2,500
D8080 Comprehensive orthodontic treatment of the adolescent dentition** Child:
2,500
D8090 Comprehensive orthodontic treatment of the adult dentition** Adult:
2,800
D8660 Pre-orthodontic treatment visit (includes treatment plan, records, evaluation and consultation) 250
D8670 Periodic orthodontic treatment visit 0
D8680 Orthodontic retention (removal of appliances, construction and placement of removable retainers) 400
Broken appointment 25
D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICES
D9110 Palliative (emergency) treatment of dental pain – minor procedure 25
D9120 Fixed partial denture sectioning 30
D9215 Local anesthesia 0
D9220 Deep sedation/general anesthesia – first 30 minutes+++ 195
D9221 Deep sedation/general anesthesia – each additional 15 minutes+++ 75
D9230 Inhalation of nitrous oxide/analgesia, anxiolysis+++ #### 185
D9241 Intravenous conscious sedation/analgesia – first 30 minutes+++ 195
D9242 Intravenous conscious sedation/analgesia – each additional 15 minutes+++ 75
D9248 Non-intravenous conscious sedation #### 125
D9310 Consultation – diagnostic service provided by dentist or physician other than requesting dentist or physician 34
D9430 Office visit for observation (during regularly scheduled hours) – no other services performed 10
D9440 Office visit – after regularly scheduled hours 50
D9450 Case presentation, detailed and extensive treatment planning 0
D9610 Therapeutic drug injection, by report #### 79
D9951 Occlusal adjustment – limited 23
D9971 Odontoplasty – one to two teeth 23
D9972 Bleaching – per arch 165
D9975 Bleaching for home application, per arch; includes material and fabrication of custom trays 99
Broken appointment 25

Current Dental Termonology (CDT) @ American Dental Association (ADA)

+ The Patient Charges for codes D1110, D1120, D1203, D1204, D1206, D1208, and D4910 are limited to the first two services in any 12-month period. For each additional service in the same 12-month period, see codes D1999, D2999, and D4999 for the applicable Patient Charge.

++ Covered Services are subject to exclusions, limitations and Plan provisions as described in Member’s Plan booklet and the Manual (including the Quality Management retrospective review). Other codes may be used to describe Covered Services.

# Routine prophylaxis or periodontal maintenance procedure – a total of four services in any 12-month period. One of the covered periodontal maintenance procedures may be performed by a participating periodontal Specialist if done within three to six months following completion of approved, active periodontal therapy (periodontal scaling and root planing or periodontal osseous surgery) by a participating periodontal Specialist. Active periodontal therapy includes periodontal scaling and root planing or periodontal osseous surgery.

= Fluoride Treatment – a total of four services in any 12-month period.

## Sealants are limited to permanent teeth up to the 19th birthday.

** If high noble metal is used, there will be an additional Patient Charge for the actual cost of the high noble metal.

### The Patient Charge for these services is per unit.

#### Procedure code limited to dependent children under age 19.

+++ Procedure codes D9220, D9221, D9230, D9241, D9242 and D9248 are limited to a participating oral surgery Specialist. Additionally, these services are only covered in conjunction with other surgical services.

++++ Routine exams/evaluations – covered once every six months in a dental office setting and once every 12 months in a school setting

Plan schedule U10ILI02 is only valid for Covered Services rendered by Participating Dentists in the State of Illinois.

Underwritten by: First Commonwealth Insurance Company – (IL), First Commonwealth of Missouri – (MO), First Commonwealth Limited Health Services Corporation – (IN), First Commonwealth Limited Health Services Corporation of Michigan – (MI), Managed Dental Care – (CA), Managed DentalGuard, Inc. – (NJ, OH, TX), The Guardian Life Insurance Company of America – (CO, FL, NY and all PPO and Indemnity plans). All referenced companies are wholly owned subsidiaries of The Guardian Life Insurance Company of America, New York, NY.

The Policy Covers:

  • Orthodontic services as listed under Covered Dental Services and Patient Charges, limited to one (1) course of treatment per Member. We must preauthorize treatment, and it must be performed by a Participating Orthodontic Specialist Dentist.
  • Up to twenty-four (24) months of comprehensive treatment
  • Treatment plan and records, including initial records and any interim and final records.
  • Comprehensive orthodontic treatment, including the fixed banding appliances and related visits only.
  • Retention services following a course of comprehensive orthodontic treatment that was covered under this Plan
  • Orthodontic retention, including any and all necessary fixed and removable appliances and related visits.

This Policy Does Not Cover:

  • Any Procedure listed as an exclusion, in excess of Policy limitations, or as not covered under First Commonwealth.
  • Orthodontic treatment performed by any dentist other than a Participating Orthodontic Specialty Dentist.
  • Limited orthodontic treatment and Interceptive (Phase 1) treatment
  • Treatment beyond twenty-four (24) months. (The Member will be responsible for an additional charge for each additional month of treatment, based upon the Participating Orthodontic Specialists Dentist’s contracted fee.
  • Except as described under treatment in progress – orthodontic treatment, orthodontic services are not covered if comprehensive treatment begins before the Member is eligible for benefits under the Policy. If a Member’s coverage terminates after the fixed banding appliances are inserted, the Participating Orthodontist Specialty Care Dentist may prorate his or her usual fee over the remaining months of treatment.
  • Orthodontic services after a Member’s coverage terminates.
  • Any incremental charges for non-standard orthodontic appliances or those made with clear, ceramic, white or other optional material or lingual brackets.
  • Procedures, appliances or devices to (a) guide minor tooth movement or (b) to correct or control harmful habits.
  • Re-treatment of orthodontic cases, or changes in orthodontic treatment necessitated by any kind of accident.
  • Replacement or repair of orthodontic appliances damaged due to the neglect of the Member.
  •  Extractions performed solely to facilitate orthodontic treatment.
  • Orthognathic surgery (moving of teeth by surgical means) and associated incremental charges.
  •  If a Member transfers to another Participating Orthodontic Specialty Care Dentist after authorized comprehensive orthodontic treatment has started under this Policy, the Member will be responsible for any additional costs associated with the change in Orthodontic Specialty Care Dentist and subsequent treatment.
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