2022 Dental Benefits Vitality Plus (HMO) H0545, Plan 015 - Inter Valley Health Plan
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2022 Dental Benefits
Vitality Plus (HMO) H0545, Plan 015
Welcome to Delta Dental!
Inter Valley Health Plan partners with
Delta Dental to provide our members with
the option of enrolling in the Optional
Enhanced Dental Plan that will provide you
with routine and specialist coverage. Routine
dental is not a Medicare covered benefit.
This plan gives you comprehensive coverage
with no waiting periods or deductibles.
You will have a list of copayments for every
covered procedure, so you know all your costs
for preventive, basic, and major services.
This brochure is designed to help you
understand your dental benefits and
give you an idea of what to expect
when using your Optional Enhanced
Dental Plan.
Delta Dental is a registered mark of
Delta Dental Plans Association.
H0545_FUY2022_006_VP_C
HOW TO GET STARTED WITH YOUR DENTAL PLAN
If you have enrolled in the Optional Enhanced Do not consent to any dental treatment
Dental Plan and did not select a participating Provider if uncertain that the recommended
at the time of enrollment, call a Delta Dental, Customer procedures are covered.
Services Representative at 855-370-3801 (TTY 711) to
request a dental provider directory or go to Inter Valley What if you are referred
Health Plan’s website at ivhp.com to locate a dentist
to a specialist?
near you. Once you have selected your Delta Dental If you are referred to a dental specialist, your
Provider, call Delta Dental with your selection. You will participating dental provider will coordinate a
then be assigned to the dental office you selected. If pre-authorization referral.
you do not select a participating dentist, Delta Dental
What is a Regular Teeth Cleaning
will select a dentist for you.
(Prophylaxis)?
You will receive a dental identification card by A regular teeth cleaning (Procedure Code
mail. Please present your dental identification card to D1110-Prophylaxis)1 is for preventive purposes.
your dental provider when receiving services. A regular teeth cleaning removes plaque,
Where to locate your dental plan surface calculus, stains from the teeth and
benefits, exclusions and limitations. includes a polishing of the teeth. Members,
The details of your plan benefits are listed in the particularly those who have not kept up
Combined Evidence of Coverage (EOC) which is with their routine dental appointments (at
available on our website at ivhp.com or by calling least once every six (6) months) or have been
800-251-8191 (TTY 711) for a copy. Take your EOC diagnosed with periodontal disease, may find
with you to your dental visits as it will be needed to that they require services involving periodontal
confirm your dental plan copayments for covered scaling and root planing (Deep Cleaning).
dental procedures. Why do I need a deep cleaning (D4341²
What to expect at your first dental Periodontal scaling & root planing)?
appointment. Periodontal diseases are caused by plaque.
Plaque always forms on your teeth and contains
X-rays may need to be taken to complete your
bacteria that produces harmful toxins. If teeth
exam. Through this process, the dentist will determine
are not cleaned well, the toxins can irritate and
if there is any treatment needed.
inflame your gums.
You probably will not have a cleaning on your
Inflamed gums can pull away from your teeth
first appointment. Your dentist may diagnose root
and form spaces called pockets. These pockets
planing “deep cleaning” instead of a regular cleaning
trap plaque and bacteria under the gum line
depending on the condition of your teeth and gums.
which cannot be removed with brushing alone.
If at any time treatment is recommended, request The gums can become infected, and once
a proposed dental treatment plan in writing with the infected, if the pockets are not treated, the
ADA (American Dental Association) procedure codes disease can get worse, possibly damaging bone
to verify services are covered and the corresponding and other tissues that support your teeth.
copayments are correct as listed in your Combined
Evidence of Coverage (EOC).
Please call a Delta Dental Customer Services Representative at 855-370-3801 or for
hearing impaired TTY 711, who will be happy to help you.
OPTIONAL ENHANCED DENTAL PLAN
By enrolling in the Optional Enhanced Dental Plan, you will have routine general dentistry coverage and
specialist coverage with affordable copayments. Compare and see how much you can save:
Optional Enhanced Usual &
Dental Plan CAC06 Customary YOUR
Member Copay Fee in CA SAVINGS
CODE Procedure
D0150 Comprehensive Oral Evaluation $0 $129 $129
D0210 Intraoral-Complete series of radiographic images $0 $200 $200
D1110¹ Prophylaxis: adult $0 $110 $110
D2393 Resin-based composite – three surface, posterior $85 $350 $265
D2740 Crown-Porcelain / ceramic substrate $330 $1536 $1206
D2750 Crown-Porcelain fused to high noble metal $330 $1350 $1020
D2954 Prefabricated post and core in addition to crown $55 $375 $320
D2962 Labial veneer (porcelain laminate-laboratory) $320 $1346 $1026
D3330 Endodontic therapy, molar (excluding final restoration) $160 $1182 $1022
D3348 Retreatment of previous root canal therapy – molar $300 $1395 $1095
D4341² Periodontal scaling & root planing: per quadrant $40 $282 $242
per quadrant
D4910 Periodontal maintenance $40 $180 $140
D4921 Gingival irrigation per quadrant $35 $63 $28
per quadrant
D5110 Complete denture: Maxillary $220 $1976 $1756
D5213 Maxillary partial denture (upper) – cast metal $240 $2050 $1810
framework with resin denture bases
(including any conventional clasps, rests and teeth)
D6010 Surgical placement of implant body: endosteal implant $1500 $2500 $1000
D7210
Surgical removal of erupted tooth requiring removal $30 $313 $283
of bone and/or sectioning of tooth, and including
elevation of mucoperiosteal flap if indicated
D9975 External bleaching per arch, for home application, per $200 per arch $325 $125
arch; includes materials and fabrication of custom trays
¹D1110 Preventative: Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition.
It is intended to control local irritational factors.
²D4341 Periodontics: This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and
calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature.
Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by
calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as definitive
treatment in some stages of periodontal disease and/or part of pre-surgical procedures in others.
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the Plan.
Limitations, exclusions, copayments, and restrictions may apply. Benefits, premium and/or co-payments/co-insurance may change
on January 1 of each year.OPTIONAL ENHANCED DENTAL PLAN $14.80 PER MONTH
BOOST YOUR SAVINGS SELECT ONE PAYMENT OPTION
WITH A DENTAL PLAN PAYABLE TO INTER VALLEY HEALTH PLAN
Complete this form, include your payment Check or money order – annual payment
method, mail it to: Inter Valley Health Plan, Checking withdrawal – automatic monthly payments*
Att: Accounts Payable, 300 S. Park Ave, Credit card – annual payment
P.O. Box 6002, Pomona, CA 91769-6002. Credit card – automatic monthly payments*
This dental plan is available only to individual Inter Visa MasterCard Discover Amex
Valley Health Plan Members. The coverage term is *Monthly payments require an initial 2-month payment,
one year based on the plan year. The plan is on a with the second month’s premium held by Inter Valley Health
calendar year basis. The premium will be prorated Plan and used if automatic withdrawal is unavailable.
based on your effective date. CHECKING ACCOUNT
YES, ENROLL ME IN THE OPTIONAL ____________________ ________________________
ENHANCED DENTAL PLAN Routing Number Checking Account Number
By electing to enroll in the Optional Enhanced
Dental Plan, you agree to either a one-time
charge for the annual premium or recurring
charges for the stated monthly premium.
Coverage will remain in effect for a term of one Routing number Account number
year as stated above. Monthly memberships Please attach a voided check.
renew automatically. Annual memberships Your check will be processed electronically.
need to be manually renewed each year. CREDIT CARD INFORMATION
All other coverage agreements with Inter Valley _____________________________________________
Health Plan will remain unchanged. Credit Card Number
CHOOSE YOUR BILLING PREFERENCE ___/___/____ _______ ________________________
Monthly: $14.80 Annually: $177.60 Expiration Date 3 digit code Amount (Annual or 2 months’ premium)
Select Your Dentist: _____________________________________________
Dental office name & facility number Signature with the same name as it appears on the credit card
______________________________________/_____________________________________________
Your Name_________________________________________________________ Date of Birth____/____/______
Inter Valley Member number (If known) Vitality Plus HMO
______________________________________________________ Dental Plan Effective Date ____/____/______
Signature:________________________________________Date____/____/_____
Please call a Delta Dental, Customer Services Representative with any questions at 855-370-3801, TTY 711.
The Enrollment Period in the Optional Enhanced Dental Plan ends as of March 31, 2022. For new members, you
have the option of enrolling in these benefits up to 60 days after your effective date. Once you’ve enrolled, your
Optional Enhanced Dental benefits would become effective on the first of the following month if your enroll-
ment form is received before the 15th of the month.
If you decide you no longer want to be enrolled in the Optional Enhanced Dental Plan, please make sure to clarify that you
do not want to disenroll from the Medicare Advantage plan, just the optional supplemental benefits portion. Your statement
should include your name, Member ID number and signature. Any premium overpayments will be refunded to you. Once you
have disenrolled from these benefits, you will not be able to re-enroll until January of the next year and you will not have dental
coverage. All cancellations request received by the 15th of the month will take effect on the 1st of the following month.
Delta Dental is a registered mark of Delta Dental Plans Association. MED398VP 9/21
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