2022DENTALCOMPANIONSilver, Silver Freedom, Platinum and Gold Freedom Plans1-866-535-8343 (TTY: 711)

YOUR DENTAL BENEFITS EXPLAINEDWe want to make sure you are smiling from ear to ear so KelseyCare Advantage has addednew coverage for 2022. Additionally, if you need more advanced services, there is coveragefor those services as well!All of our plans focus on the importance of preventive care so that’s why all plans includepreventive dental care coverage.Comprehensive Dental is included in the Silver, Silver Freedom, Platinum and Gold Freedomplans at no additional monthly premium. 1,500 25 0Annual Benefit Maximum for both Preventive andComprehensive services combinedper office visit copayAnnual deductibleNo Out-of-Network Benefits, No waiting periodsPercentage of Covered Benefits Per Policy Year:« 50% member cost-share for Type II and III servicesQuestions? Call 1-866-535-8343 (TTY: 711)

HERE’S WHAT’S COVEREDPREVENTIVE PROCEDURESOral Evaluation (0% Member Responsibility) Periodic Oral Evaluation- D0120, 2 per year Limited Oral Evaluation (focused)- D0140, 1 per year Comprehensive Oral Evaluation - D0150, 1 every 3 yearsImaging (0% Member Responsibility) Intraoral, Complete Series, includes Bitewings - D0210** (1 every 3 years) Panoramic Film - D0330** (1 per year)Bitewings (0% Member Responsibility) Two Films - D0272 Four Films - D0274Preventive Cleanings (0% Member Responsibility) Prophylaxis, Adult - D1110 (2 per year)**Panoramic Film (D0330) may be taken in place of Intraoral-Complete Series (D0210)Questions? Call 1-866-535-8343 (TTY: 711)

COMPREHENSIVE PROCEDURESFillings (Up to 4 total fillings per year) 50% Member Responsibility One surface - D2140 Two surfaces - D2150 Three surfaces - D2160 Four surfaces - D2161Resin-Based Composite Fillings (Up to 4 total fillings per year)50% Member Responsibility One surface, Anterior - D2330 Two surfaces, Anterior - D2331 Three surfaces, Anterior - D2332 Four or more surfaces, Anterior - D2335 One surface, Posterior - D2391 Two surfaces, Posterior - D2392 Three surfaces, Posterior - D2393 Four or more surfaces, Posterior - D2394Periodontal Scaling & Root Planing (50% Member Responsibility) 4 per Quadrant every 2 years - D4341 1-3 teeth per Quadrant every 2 years - D4342Full Mouth Debridement (50% Member Responsibility) Full Mouth Debridement - D4355Questions? Call 1-866-535-8343 (TTY: 711)

Simple Extractions (50% Member Responsibility) Erupted or Exposed Root - D7140Palliative (Emergency Care) (50% Member Responsibility) Palliative (emergency) Treatment of Dental Pain - D9110Denture Adjustments (50% Member Responsibility) Adjust complete denture, Maxillary - D5410 Adjust complete denture, Mandibular - D5411 Adjust Partial Denture, Maxillary - D5421 Adjust Partial Denture, Mandibular - D5422Denture Repair (50% Member Responsibility) Repair Broken Complete Denture Base, mandibular – D5511 Repair Broken Complete Denture Base, maxillary – D5512 Replace missing or broken teeth – Complete Denture – D5520 Repair Resin Denture Base, mandibular – D5611 Repair Resin Denture Base, maxillary – D5612 Replace Broken Teeth – Per Tooth – D5640*Total reimbursement does not include lab costs. Lab fees are the member’s responsibilityQuestions? Call 1-866-535-8343 (TTY: 711)

When scheduling an appointment:1Make sure you are seeing an in-network provider2Present your KelseyCare Advantage ID card to your FCL Dental provider3Discuss what services are covered on your KelseyCare Advantage planNeed help locating an in-network provider?1Call FCL dental at 1-877-493-6282 or KelseyCare Advantage at 1-866-535-8343 (TTY:711)Hours are 8:00 a.m. to 8:00 p.m. local time, seven days a week, from October 1 –March 31. From April 1 – September 30, Monday through Friday, hours are 8:00 8:00 p.m. local time.2Visit DENCMP22 C

COMPANION Silver, Silver Freedom, Platinum and Gold Freedom Plans. Questions? Call 1-866-535-8343 (TTY: 711) YOUR DENTAL BENEFITS EXPLAINED We want to make sure you are smiling from ear to ear so KelseyCare Advantage has added new coverage for 2022. Additional