California Dental Network Plan Exclusions and Limitations: An Enrollment Application is a request for coverage, which, if approved by California Dental Network, becomes the enrollment form used to issue an identification card and Combined Evidence of Coverage and Disclosure Form. All benefits, limitations and exclusions are stated in full in the Combined Evidence of Coverage and Disclosure Form which is provided when coverage becomes effective. Members will have 30 days from receipt of the Combined Evidence of Coverage and Disclosure Form to cancel their enrollment and receive a full refund of their premiums if they have not utilized the Plan. You may obtain a copy of the Combined Evidence of Coverage and Disclosure Form from their Corporate Office before you enroll.

Limitations (1) Prophylaxis (cleaning) is limited to once every six months. (2) Fluoride treatment is covered once every 12 months for Members up to age 14. (3) Bitewing x-rays are limited to one series of four films every 12 months. (4) Full mouth x-rays are limited to once every 24 months. (5) Sealants are covered for Members up to the age of 14 and are limited to permanent first and second molars. (6) Periodontal treatments (subgingival curettage and root planing) are limited to one treatment per quadrant in any 12-month period. (7) Fixed bridgework will be covered only when a partial cannot satisfactorily restore the case.(8) Replacement of partial dentures is limited to once every five years. (9) Full upper and/or lower dentures are not to exceed one each in any five-year period. (10) Denture relines are limited to one per arch in any 12-month period.

Exclusions (1) General anesthesia, analgesia (nitrous oxide), intravenous sedation, or the services of an anesthesiologist. (2) Treatment of fractures or dislocations; congenital malformations; malignancies, cysts, or neoplasms; or Temporomandibular Joint Syndrome (TMJ). (3) Extractions or x-rays for orthodontic purposes. (4) Prescription drugs and over the counter drugs. (5) Any services involving implants or experimentalprocedures. (6) Any procedures performed for cosmetic, elective or aesthetic purposes. (7) Any procedure to replace or stabilize tooth structure lost by attrition, abrasion, erosion or grinding.

Not all general dentists are capable of performing each of the services listed herein and, based upon the Member’s condition, certain procedures may not be within the scope of practice or ability of a general dentist. In such cases, the general dentist will refer the Member to a California Dental Network participating dental specialist, who will give the Member a 30% discount from their regular fees during the first year of enrollment, and a 50% discount thereafter, for up to $1,000 in services per year. The ratio of premium costs to health services paid, for plan contracts with individuals and groups of 25 or fewer members, during the preceding fiscal year was 0%. * UCR means the dentist’s or specialist’s Usual, Customary & Reasonable fees. # Member is responsible for the payment shown plus the actual lab cost of gold. Orthodontists may charge Members additional fees for costs of cases over 24 months, based on the differences in UCR fees for the needed treatment periods less the UCR fees for a 24-month treatment period.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your Health Plan, you should first telephone your Health Plan at 1-714-479-0777 or toll-free 1-877-4-DENTAL and use your Health Plan’s grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your Health Plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a Health Plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes 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 site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.