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Page 1 of 2 Dental Open Access Choice Plan Douglas County January 1, 2010 The following summarizes your HealthPartners coverage. For exact terms and conditions, consult the Group Membership Contract or Summary Plan Description, or call the Member Services Information Line at (952) 883-5000 or call toll free at 1-[PHONE REDACTED]. HealthPartners Network Care from a network provider Out-of-Network Care from an out-of-network provider Annual Maximum Annual maximums are combined in and out-of-network Annual maximum $1,000 per calendar year $1,000 per calendar year Implant maximum included in annual maximum $500 per calendar year $500 per calendar year Deductible Deductibles are combined in and out-of-network Applies to Basic Care, Special Care & Prosthetics $50 per person; $150 per family per calendar year $50 per person; $150 per family per calendar year Preventive and Diagnostic Care Teeth cleaning, exams, dental x-rays, fluoride treatments and sealants 100% coverage 100% coverage Basic Care Basic Care I Fillings (amalgam and anterior composite) 80% coverage 80% coverage Posterior composite (white) fillings 50% coverage 50% coverage Simple extractions 80% coverage 80% coverage Non-surgical periodontics 80% coverage 80% coverage Endodontics (root canal therapy) 50% coverage 50% coverage Basic Care II Surgical periodontics 50% coverage 50% coverage Complex oral surgery 50% coverage 50% coverage Special Care Restorative crowns & onlays 50% coverage 50% coverage Prosthetics Bridges, dentures & partial dentures Dental implants 50% coverage 50% coverage 50% coverage 50% coverage Emergency Care Refer to the Group Dental Member Contract for coverage of emergency dental services. This is a benefit summary sheet only. This dental plan may not cover all your dental care expenses. For complete information about benefits and services, ask your employer or call the Member Services Information Line at (952) 883-5000 or call toll free at 1-[PHONE REDACTED]. ---PAGE BREAK--- Page 2 of 2 Benefit Limitations: Coverage for dental exams limited to twice each calendar year. Coverage for dental cleanings (prophylaxis or periodontal maintenance) limited to twice each calendar year. Sealants limited to one application per tooth once every three years. Coverage for professionally applied topical fluoride limited to once each calendar year, for members under age 19. Coverage for bitewing x-rays limited to once each calendar year. Full mouth or panoramic x-rays limited to once every three years. Oral hygiene instruction limited to once per enrollee per lifetime. Coverage for space maintainers limited to replacement of prematurely lost primary teeth for dependent members under age 19. Replacement of crowns and fixed or removable prosthetic appliances limited to once every five years. Certain limitations apply to repair, rebase and relining of dentures. Dental services related to the replacement of any teeth missing prior to the member’s effective date are covered when services are performed by a provider in the HealthPartners Dental Open Access Network. Non-surgical and surgical periodontics limited to once in two years. Read your Group Membership Contract or Summary Plan Description and Appendix carefully to determine which expenses are covered. Our mission is to improve the health of our members, our patients and the community. 2008, HealthPartners