Dental HMO Bene Ts - Houston Methodist Hospital
SafeGuard Group DentalDental HMO* BenefitsSavings, convenience and service. For healthier smiles.If I want to be at my best,a good dental planwill be refreshing.SafeGuard DHMOSGX 245-TXEnrollment KitBenefits provided by SafeGuard Health Plans, Inc., a MetLife company.EK SGX
A lot of emphasis has been put on healthy living, and oral health is an essential part of that. Thisdental benefits plan offers you valuable coverage that can help you and your family keep a healthyregimen. Plus, you’ll get service you can count on. Now that’s refreshing. Lower out-of-pocket costs on hundreds of dental procedures.1 Broad network of participating dentists. Hassle-free benefits. A commitment to your oral health.1 Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how often membersvisit the dentist and the cost of services rendered.
Table of ContentsAllow Us to Introduce OurselvesUnderstanding Your Dental PlanFrequently Asked QuestionsSchedule of BenefitsEvidence of CoverageThe Dental Education CenterWe're Here to HelpTemporary Identification Card
A good dental benefits plan can be an important part of good oral health. That’s why you haveaccess to this SafeGuard Dental HMO* plan — so you and your family can receive the dentalcoverage you need and get all of these valuable features: Lower out-of-pocket costs with co-payments on more than 340 procedures that will saveyou on out-of-pocket costs because they may be less than you would pay without the plan.**The co-payment for each covered procedure is listed in the Schedule of Benefits. Broad network of participating dentists and specialty care providers. Just logon towww.metlife.com/mybenefits to find a participating dentist. A commitment to your oral health means educational tools and resources that help you andyour dentist make informed choices. Hassle-free benefits that make your life easier with no deductibles or yearly maximums tokeep track of and no claim forms to complete.It’s easy to get this valuable dental benefits plan. Review your enclosed Dental Benefits Guide that contains details on the plan including theSchedule of Benefits and Evidence of Coverage. Please be sure to select two participating dentists. If your first choice is unable to accept newmembers at this time, you will have an alternate to help ensure your access to care is notdelayed. Each covered dependent may select different participating dentists. You may schedule an appointment with your dentist anytime after your effective date. Pleasebring a copy of the Schedule of Benefits with you to your first appointment to ensure yourdentist has all the necessary information about your plan.Be sure to take advantage of this important coverage.For more information, visit www.metlife.com/mybenefits or call 1-800-880-1800.Sincerely,SafeGuard, a MetLife companyBenefits provided by SafeGuard Health Plans, Inc., a MetLife company. Like most group benefit programs, benefit programsoffered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms forkeeping them in force. Please contact MetLife or your plan administrator for complete details.*Dental HMO plans are available in CA, FL and TX only, through a domestic company in the applicable state named SafeGuardHealth Plans, Inc. The SafeGuard companies are part of the MetLife family of companies. "Dental HMO” is used to refer toproducts that may differ by state of residence of the enrollee, including but not limited to: “Specialized Health Care Service Plans”in California; “Prepaid Limited Health Service Organizations” as described in Chapter 636 of the Florida statutes in Florida; and“Single Service Health Maintenance Organizations” in Texas.** Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how oftenparticipants visit the dentist and the cost of services rendered. 2009 MetLife, New York, NYL0609043639[exp0610][CA,FL,TX]
Understanding Your Dental BenefitsIt’s important to get the dental coverage you and your family need. This Dental HMO* plan offers youvaluable features that are sure to keep you smiling: Lower out-of-pocket costs.Broad network of participating dentists.A commitment to your oral health.Hassle-free benefits.Lower out-of-pocket costs on more than 340 procedures.This benefits plan provides you with access to essential dental care while helping to protect youagainst the rising costs of dental services. The co-payments may be considerably lower than yourcost would be without this dental plan. Here are some of the services included in this plan1 all ofwhich will help you lower your out-of-pocket dental care costs2: Preventive Services (exams, sealants, x-rays)White fillings on rear (posterior) teethPorcelain and titanium crownsAdult & child orthodonticsOsseous surgery, periodontal maintenanceRoot canals and retreatmentExtractions Bleaching treatment General anesthesia, IV sedation & nitrousoxide Up to 4 yearly cleanings Veneers Cancer screeningsPlus, many procedures that are not listed on the Schedule of Benefits are available at a reduced fee.For a full listing of all covered services and co-payments, please refer to the Schedule of Benefits.Broad network of participating dentists.Participating general dentists and specialists must meet well-established credentialing standards.Each dentist and specialist is pre-screened and subject to regular audits, including onsite visits to thedental offices. Remember that each enrolled family member may select a different participatinggeneral dentist.Commitment to your oral health.Because dental care can be an important part of good overall health, we provide you access tovaluable tools that can help you and your dentist make informed decisions about your dental benefitsand oral health.Today, the Academy of General Dentistry tells us that more than 90% of all diseases produce oralsigns and symptoms. Dentists can play a key role in screening for conditions such as cancer,diabetes, leukemia, heart disease, and kidney disease.3
Understanding Your Dental Benefits (continued)Hassle-free benefits.With this benefits plan, you don’t have to worry about deductibles, yearly maximums or filling outpaperwork for claims. All you have to do is select a participating dentist at enrollment. Then just call toschedule your appointment after your plan’s effective date. When you receive dental services fromyour selected dentist, you are only responsible for the co-payment for any covered services received.Plus, if you need specialty care, no problem. Your selected participating dentist will provide you withthe name of a participating specialist. Just call that specialist to schedule your appointment4. Any copayment amount for services is listed on your Schedule of Benefits. This co-payment applies whetherthe services are provided by your selected participating general dentist or by a participating specialist.Benefits provided by SafeGuard Health Plans, Inc., a MetLife company. Like most group benefit programs, benefit programsoffered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms forkeeping them in force. Please contact MetLife or your plan administrator for complete details.*Dental HMO plans are available in CA, FL and TX only, through a domestic company in the applicable state namedSafeGuard Health Plans, Inc. The SafeGuard companies are part of the MetLife family of companies. "Dental HMO” is used torefer to products that may differ by state of residence of the enrollee, including but not limited to: “Specialized Health CareService Plans” in California; “Prepaid Limited Health Service Organizations” as described in Chapter 636 of the Florida statutesin Florida; and “Single Service Health Maintenance Organizations” in Texas.1. Certain limitations apply to some services; please review your Schedule of Benefits for full details.2. Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how oftenparticipants visit the dentist and the cost of services rendered.3. Academy of General Dentistry. The Importance of Oral Health to Overall t.asp?IssID 320&Topic O&ArtID 1289#body, updated October 2008.4. In California, orthodontic and pedodontic specialty services require pre-approval. Your selected participating dentist willcontact SafeGuard for pre-approval. Once approved, your dentist will contact you with the name of a participating specialist.L0609043639[exp0610][CA,FL,TX]
DHMO* Frequently Asked QuestionsDo I need to select a dentist who participates in the network when I enroll?Yes. At the time of enrollment, you will select two participating dentists. This will help ensure you areable to receive the care you need if your first choice is unable to accept new members. Theparticipating dentist you select at enrollment will provide your routine dental care. You may schedulean appointment with your dentist anytime after your plan’s effective date.Who are the dentists who participate in your network?This plan’s network includes both private practice dentists and those who are in a clinic environment.Every dentist in the network has been thoroughly screened prior to acceptance. Participating dentistsare also subject to regular audits, including onsite visits to the dental offices. You can find the names,addresses, languages spoken and telephone numbers of participating dentists by searching ouronline “Find a Dentist” directory at www.metlife.com/mybenefits for the most up to date information.Can I change dentists?Yes. You and your enrolled dependents may each select different participating dentists and maychange dentists as often as once per month. You can change dentists for you and your enrolleddependents online at www.metlife.com/mybenefits or by calling Customer Service. Your transfer willbe effective the first of the following month. Please note: any requests made after the 25th of themonth will change effective the first of the following month (e.g., a facility request changed on March28th will go into effect on May 1st). Please note: you should ensure any dental work-in-progress iscompleted prior to transferring to a new dentist. Refer to your Evidence of Coverage included withyour enrollment materials for more information.What if I need emergency care?All participating dental offices in our network provide emergency access 24 hours a day, 7 days aweek. If you cannot reach your selected participating dentist, you may receive emergency care fromany licensed dental care professional. The definition of what is considered “emergency care” andother specifics can be found in the Evidence of Coverage located in your enrollment booklet.I noticed some dental offices in your directory appear to be closed to new members. What ifone of them is my current dentist?While these facilities cannot accept new patients, you may not have to change dentists if you arecurrently a patient in one of those offices. It is important that you contact Customer Service in order toensure that you can continue using your current facility under the plan.
DHMO* Frequently Asked Questions (continued)What if I need to see a specialist?This is a “direct referral” plan which means your selected participating dentist will refer you to aparticipating specialist in your area – there is no need to wait for approval.1 Any co-payment amountfor services is listed on your Schedule of Benefits. This co-payment applies whether the services areprovided by your selected participating general dentist or by a participating specialist.1. In California, orthodontic and pedodontic specialty services require pre-approval. Your selected participating dentist willcontact SafeGuard for pre-approval. Once approved, your dentist will contact you with the name of a participating specialist.Do these plans cover second opinions?Yes. Just contact Customer Service to let us know that you would like another clinical opinion and wewill provide the name of a dentist for you to see.If my dentist does not participate in my plan’s network, can he/she apply for participation?Yes. If your current dentist does not participate in the network, we will be happy to accept yournomination. Just call Customer Service, or to submit your nomination online, visit the MyBenefitswebsite at www.metlife.com/mybenefits and click the “Find a Dentist” link. Once submitted, we willcontact that dentist with an invitation to join our dental network.Benefits provided by SafeGuard Health Plans, Inc., a MetLife company. Like most group benefit programs, benefit programsoffered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms forkeeping them in force. Please contact MetLife or your plan administrator for complete details.*Dental HMO plans are available in CA, FL and TX only, through a domestic company in the applicable state namedSafeGuard Health Plans, Inc. The SafeGuard companies are part of the MetLife family of companies. "Dental HMO” is used torefer to products that may differ by state of residence of the enrollee, including but not limited to: “Specialized Health CareService Plans” in California; “Prepaid Limited Health Service Organizations” as described in Chapter 636 of the Florida statutesin Florida; and “Single Service Health Maintenance Organizations” in Texas.L0709047259[exp0710][CA,FL,TX]
SCHEDULE OF BENEFITSDirect Referral Dental PlanSGX245-TXThis Schedule of Benefits lists the services available to you under your SafeGuard plan, as wellas the co-payments associated with each procedure. There are other factors that impact howyour plan works and those are included here in the Exclusions and Limitations.During the course of treatment, your SafeGuard selected general dentist may recommend theservices of a dental specialist. Your selected general dentist may refer you directly to acontracted SafeGuard specialty care provider; no referral or pre-authorization from SafeGuard isrequired.In addition, non-listed services are available with your SafeGuard selected general dentist orspecialty care dentist at 75% of their usual and customary fees.Missed Appointments: If you need to cancel or reschedule an appointment, you should notifythe dental office as far in advance as possible. This will allow the dental office to accommodateanother person in need of attention.Benefits provided by SafeGuard Health Plans, Inc.CodeServiceCo-paymentDiagnostic TreatmentD0120Periodic oral evaluation – established patientD0140Limited oral evaluation – problem focusedD0145Oral evaluation for a patient under three years of age and counseling withprimary caregiverD0150Comprehensive oral evaluation – new or established patientD0160Detailed and extensive oral evaluation – problem focused, by reportD0170Re-evaluation – limited, problem focused (established patient; notpost-operative visit)D0180Comprehensive periodontal evaluation – new or established patientOffice visit - per visit (including all fees for sterilization and/or infection control) 0 0 5Radiographs/Diagnostic Imaging (X-rays)D0210Intraoral – complete series (including bitewings)D0220Intraoral – periapical first filmD0230Intraoral – periapical each additional filmD0240Intraoral – occlusal filmD0250Extraoral – first filmD0260Extraoral – each additional filmD0270Bitewing – single filmD0272Bitewings – two filmsD0273Bitewings – three filmsD0274Bitewings – four filmsD0277Vertical bitewings – 7 to 8 filmsD0330Panoramic filmD0350Oral/facial photographic images 0 0 0 0 0 0 0 0 0 0 0 0 0Tests and ExaminationsD0415Collection of microorganisms for culture and sensitivityD0425Caries susceptibility tests 0 0SG-SOB-SGXCustomer Service (800) 880-1800 0 0 0 0 010/12/20061/09
aymentAdjunctive pre-diagnostic test that aids in detection of mucosal abnormalitiesincluding premalignant and malignant lesions, not to include cytology or biopsyprocedures 50Pulp vitality tests 0Diagnostic casts 0Accession of tissue, gross examination, preparation and transmission of writtenreport 0Accession of tissue, gross and microscopic examination, preparation andTransmitssion of written report 0Accession of tissue, gross and microscopic examination, including assessmentof surgical margins for presence of disease, preparation and transmission ofwritten report 0Accession of brush biopsy sample, microscopic examination, preparation andtransmission of written report 0Preventive ServicesD1110Prophylaxis – adult*Additional-adult prophylaxis (maximum of 2 additional per year)D1120Prophylaxis – child*Additional-child prophylaxis (maximum of 2 additional per year)D1203Topical application of fluoride (prophylaxis not included) – child*D1204Topical application of fluoride (prophylaxis not included) – adult*D1206Topical fluoride varnish; therapeutic application for moderate to highcaries risk patients*D1310Nutritional counseling for control of dental diseaseD1320Tobacco counseling for the control and prevention of oral diseaseD1330Oral hygiene instructionsD1351Sealant – per toothD1510Space maintainer – fixed – unilateralD1515Space maintainer – fixed – bilateralD1520Space maintainer – removable – unilateralD1525Space maintainer – removable – bilateralD1550Recementation of space maintainerD1555Removal of fixed space maintainerRestorative TreatmentD2140Amalgam – one surface, primary or permanentD2150Amalgam – two surfaces, primary or permanentD2160Amalgam – three surfaces, primary or permanentD2161Amalgam – four or more surfaces, primary or permanentD2330Resin-based composite – one surface, anteriorD2331Resin-based composite – two surfaces, anteriorD2332Resin-based composite – three surfaces, anteriorD2335Resin-based composite – four or more surfaces or involving incisalangle (anterior)D2390Resin-based composite crown, anteriorD2391Resin-based composite – one surface, posteriorD2392Resin-based composite – two surfaces, posteriorD2393Resin-based composite – three surfaces, posteriorD2394Resin-based composite – four or more surfaces, posteriorSG-SOB-SGXCustomer Service (800) 880-1800 0 35 0 25 0 0 0 0 0 0 0 25 25 35 35 15 15 0 0 0 0 0 0 0 0 30 30 45 65 6510/12/20061/09
CodeServiceCo-paymentCrowns An additional charge, not to exceed 150 per unit, will be applied for any procedure usingnoble, high noble or titanium metal. There is a 75 co-payment per crown/bridge unit inaddition to regular co-payments for porcelain on molars. Cases involving seven (7) or more crowns and/or fixedbridge units in the same treatment planrequire an additional 125 co-payment per unit in addition to co-payment for each crown/bridgeunit.D2510Inlay – metallic – one surface 225D2520Inlay – metallic – two surfaces 235D2530Inlay – metallic – three or more surfaces 245D2542Onlay – metallic – two surfaces 245D2543Onlay – metallic – three surfaces 260D2544Onlay – metallic – four or more surfaces 270D2610Inlay – porcelain/ceramic – one surface 245D2620Inlay – porcelain/ceramic – two surfaces 245D2630Inlay – porcelain/ceramic – three or more surfaces 245D2642Onlay – porcelain/ceramic – two surfaces 245D2643Onlay – porcelain/ceramic – three surfaces 245D2644Onlay – porcelain/ceramic – four or more surfaces 245D2650Inlay – resin-based composite – one surface 245D2651Inlay – resin-based composite – two surfaces 245D2652Inlay – resin-based composite – three or more surfaces 245D2662Onlay – resin-based composite – two surfaces 245D2663Onlay – resin-based composite – three surfaces 245D2664Onlay – resin-based composite – four or more surfaces 245D2710Crown – resin-based composite (indirect) 245D2712Crown – ¾ resin-based composite (indirect) 245D2720Crown – resin with high noble metal 245D2721Crown – resin with predominantly base metal 245D2722Crown – resin with noble metal 245D2740Crown – porcelain/ceramic substrate 245D2750Crown – porcelain fused to high noble metal 245D2751Crown – porcelain fused to predominantly base metal 245D2752Crown – porcelain fused to noble metal 245D2780Crown – ¾ cast high noble metal 245D2781Crown – ¾ cast predominantly base metal 245D2782Crown – ¾ cast noble metal 245D2783Crown – ¾ porcelain/ceramic 245D2790Crown – full cast high noble metal 245D2791Crown – full cast predominantly base metal 245D2792Crown – full cast noble metal 245D2794Crown – titanium 245D2799Provisional crown 0D2910Recement inlay, onlay, or partial coverage restoration 0D2915Recement cast or prefabricated post and core 0D2920Recement crown 0D2930Prefabricated stainless steel crown – primary tooth 25D2931Prefabricated stainless steel crown – permanent tooth 25D2932Prefabricated resin crown 45D2933Prefabricated stainless steel crown with resin window 45D2940Sedative filling 0D2950Core buildup, including any pins 70D2951Pin retention – per tooth, in addition to restoration 10SG-SOB-SGXCustomer Service (800) 880-180010/12/20061/09
2971D2980ServiceCo-paymentPost and core in addition to crown, indirectly fabricated 50Each additional indirectly fabricated post – same tooth 50Prefabricated post and core in addition to crown 30Post removal (not in conjunction with endodontic therapy) 10Each additional prefabricated post – same tooth 30Labial veneer (resin laminate) – chairside 250Labial veneer (resin laminate) – laboratory 300Labial veneer (porcelain laminate) – laboratory 350Temporary crown (fractured tooth) 0Additional procedures to construct new crown under existing partial dentureframework 50Crown repair, by report 0EndodonticsAll procedures exclude final restoration.D3110Pulp cap – direct (excluding final restoration)D3120Pulp cap – indirect (excluding final restoration)D3220Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronalto the dentinocemental junction and application of medicamentD3221Pulpal debridement, primary and permanent teethD3222Partial pulpotomy for apexogenesis - permanent tooth with incomplete rootdevelopmentD3230Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding finalrestoration)D3240Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding finalrestoration)D3310Anterior (excluding final restoration)D3320Bicuspid (excluding final restoration)D3330Molar (excluding final restoration)D3331Treatment of root canal obstruction; non-surgical accessD3332Incomplete endodontic therapy; inoperable, unrestorable or fractured toothD3333Internal root repair of perforation defectsD3346Retreatment of previous root canal therapy – anteriorD3347Retreatment of previous root canal therapy – bicuspidD3348Retreatment of previous root canal therapy – molarD3351Apexification/recalcification – initial visit (apical closure/calcific repair ofperforations, root resorption, etc.)D3352Apexification/recalcification – interim medication replacement (apicalclosure/calcific repair of perforations, root resorption, etc.)D3353Apexification/recalcification – final visit (includes completed root canaltherapy – apical closure/calcific repair of perforations, root resorption, etc.)D3410Apicoectomy/periradicular surgery – anteriorD3421Apicoectomy/periradicular surgery – bicuspid (first root)D3425Apicoectomy/periradicular surgery – molar (first root)D3426Apicoectomy/periradicular surgery (each additional root)D3430Retrograde filling – per rootD3450Root amputation – per rootD3910Surgical procedure for isolation of tooth with rubber damD3920Hemisection (including any root removal), not including root canal therapyD3950Canal preparation and fitting of preformed dowel or postPeriodonticsD4210Gingivectomy or gingivoplasty – four or more contiguous teeth or boundedteeth spaces per quadrantD4211Gingivectomy or gingivoplasty – one to three contiguous teeth or boundedteeth spaces per quadrantSG-SOB-SGXCustomer Service (800) 880-1800 5 5 30 55 30 40 40 100 152 210 85 96 85 180 280 325 70 70 70 95 95 95 60 60 95 19 90 15 110 8310/12/20061/09
4342D4355D4381D4910ServiceCo-paymentGingival flap procedure, including root planing – four or more contiguousteeth or bounded teeth spaces per quadrant 150Gingival flap procedure, including root planing – one to three contiguousteeth or bounded teeth spaces per quadrant 113Apically positioned flap 165Clinical crown lengthening – hard tissue 150Osseous surgery (including flap entry and closure) – four or morecontiguous teeth or bounded teeth spaces per quadrant 300Osseous surgery (including flap entry and closure) – one to threecontiguous teeth or bounded teeth spaces per quadrant 225Bone replacement graft – first site in quadrant 180Bone replacement graft – each additional site in quadrant 95Biologic materials to aid in soft and osseous tissue regeneration 95Guided tissue regeneration – resorbable barrier, per site 215Guided tissue regeneration – nonresorbable barrier, per site (includesmembrane removal) 255Pedicle soft tissue graft procedure 245Free soft tissue graft procedure (including donor site surgery) 245Subepithelial connective tissue graft procedures, per tooth 75Distal or proximal wedge procedure (when not performed in conjunction withsurgical procedures in the same anatomical area) 100Soft tissue allograft 380Provisional splinting – intracoronal 95Provisional splinting – extracoronal 85Periodontal scaling and root planing – four or more teeth per quadrant 50Periodontal scaling and root planing – one to three teeth per quadrant 38Full mouth debridement to enable comprehensive evaluation and diagnosis 50Localized delivery of antimicrobial agents via a controlled release vehicle intodiseased crevicular tissue, per tooth, by report 65Periodontal maintenance (2 in a 12 month period) 40Additional periodontal maintenance procedures (beyond 2 per 12 months) 55Periodontal charting for planning treatment of periodontal disease 0Periodontal hygiene instruction 0Removable ProsthodonticsIncludes up to 3 adjustments within 6 months of delivery.D5110Complete denture – maxillaryD5120Complete denture – mandibularD5130Immediate denture – maxillaryD5140Immediate denture – mandibularD5211Maxillary partial denture – resin base (including any conventional clasps,rests and teeth)D5212Mandibular partial denture – resin base (including any conventional clasps,rests and teeth)D5213Maxillary partial denture – cast metal framework with resin denture bases(including any conventional clasps, rests and teeth)D5214Mandibular partial denture – cast metal framework with resin denture bases(including any conventional clasps, rests and teeth)D5225Maxillary partial denture – flexible base (including any clasps, rests and teeth)D5226Mandibular partial denture – flexible base (including any clasps, restsand teeth)SG-SOB-SGXCustomer Service (800) 880-1800 325 325 350 350 400 400 425 425 425 42510/12/20061/09
5820D5821D5850D5851D5862ServiceCo-paymentRemovable unilateral partial denture – one piece cast metal (includingclasps and teeth) 300Adjust complete denture – maxillary 10Adjust complete denture – mandibular 10Adjust partial denture – maxillary 10Adjust partial denture – mandibular 10Repair broken complete denture base 35Replace missing or broken teeth – complete denture (each tooth) 35Repair resin denture base 35Repair cast framework 35Repair or replace broken clasp 35Replace broken teeth – per tooth 35Add tooth to existing partial denture 35Add clasp to existing partial denture 35Replace all teeth and acrylic on cast metal framework (maxillary) 165Replace all teeth and acrylic on cast metal framework (mandibular) 165Rebase complete maxillary denture 75Rebase complete mandibular denture 75Rebase maxillary partial denture 75Rebase mandibular partial denture 75Reline complete maxillary denture (chairside) 65Reline complete mandibular denture (chairside) 65Reline maxillary partial denture (chairside) 65Reline mandibular partial denture (chairside) 65Reline complete maxillary denture (laboratory) 85Reline complete mandibular denture (laboratory) 85Reline maxillary partial denture (laboratory) 85Reline mandibular partial denture (laboratory) 85Interim complete denture (maxillary) 230Interim complete denture (mandibular) 230Interim partial denture (maxillary) 160Interim partial denture (mandibular) 170Tissue conditioning, maxillary 20Tissue conditioning, mandibular 20Precision attachment, by report 160Crowns/Fixed Bridges - Per Unit An additional charge, not to exceed 150 per unit, will be applied for any procedure usingnoble, high noble or titanium metal. There is a 75 co-payment per crown/bridge unit inaddition to regular co-payments for porcelain on molars. Cases involving seven (7) or more crowns and/or fixedbridge units in the same treatment planrequire an additional 125 co-payment per unit in addition to co-payment for each Crown/bridge unit.D6210Pontic – cast high noble metal 245D6211Pontic – cast predominantly base metal 245D6212Pontic – cast noble metal 245D6214Pontic – titanium 245D6240Pontic – porcelain fused to high noble metal 245D6241Pontic – porcelain fused to predominantly base metal 245D6242Pontic – porcelain fused to noble metal 245D6245Pontic – porcelain/ceramic 265D6250Pontic – resin with high noble metal 245D6251Pontic – resin with predominantly base metal 245SG-SOB-SGXCustomer Service (800) 880-180010/12/20061/09
6972D6973D6976D6977D6980ServiceCo-paymentPontic – resin with noble meta
dental bene ts plan offers you valuable coverage that can help you and your family keep a healthy regimen. Plus, you ll get service you can count on. Now that s refreshing. Lower out-of-pocket costs on hundreds of dental procedures. 1 Broad network of participating dentists. Hassle-free bene ts. A commitment to your oral health.
Oct 30, 2017 · Silver KP VA Silver 3000/30/Dental HMO 487.76 Gold KP VA Gold 1000/20/Dental HMO 494.14 Silver KP VA Silver 2000/30/Dental HMO 499.29 Gold KP VA Gold 0/20/Dental HMO 508.49 Silver KP VA Standard Silver 3500/30/Dental HMO 516.16 Platinum KP VA Platinum 0/5/Dental HMO 578.77 201
Medical-Only HMO, Keystone 65 Select Medical-Only HMO, and Keystone 65 Select Rx HMO have networks of doctors, hospitals, pharmacies, and other providers. Keystone 65 Basic Rx HMO, Keystone 65 Liberty Medical-Only HMO, Keystone 65 Select Medical-Only HMO, and Keystone 65 Select Rx HMO: If you use providers that are not in
Medical-Only HMO and Keystone 65 Preferred Rx HMO cover and what you pay. Keystone 65 Preferred Medical-Only HMO and Keystone 65 Preferred Rx HMO are Medicare Advantage HMO (Health Maintenance Organization) plans. With an HMO plan, members choose a family doctor, called a primary c
Para afiliados a Health Net Seniority Plus (HMO)*, Health Net Healthy Heart (HMO), Health Net Ruby Select (HMO), Health Net Gold Select (HMO), Health Net Jade (HMO SNP) y Health Net Seniority Plus (Employer HMO). Su examen de la vista de rutina está cubierto como un beneficio médico básico a través de su plan médico.
My Avatar - Financial Eligibility Guide . 10 Baycare Medical Group 44 HMO Insurance 11 BC Freedom Blue MDC HMO 42 HMO Insurance (MDC) 12 Benefit and Risk Management Services 45 HMO Insurance 13 Benesight 46 HMO Insurance 14 Blue Cross of CA 4 HMO Insurance (MDC) 15 Blue Shield Federal Emp Program 47 HMO Insurance
Karen S. Gerstner Houston Roderick O. Gibson Houston Reo Harris Houston Ronald N. Hayes Houston Isaac Henderson Houston Wesley J. Hocker Houston W. Ray Howard Houston Carl R. Hubert Houston Jon Jaworski Houston Stanford B. Kahn Houston Michael Kuhn Hous
What is the service area for the EmblemHealth Medicare HMO Dental Plan? This directory is for EmblemHealth Medicare HMO Dental Plan members residing in the following counties in New York State: Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Greene, Kings, Nassau, . You need to use dental network providers to get your dental services. If .
ANATOMI EXTREMITAS INFERIOR Tim Anatomi (Jaka Sunardi, dkk) FIK Universitas Negeri Yogyakarta. OSTEOLOGI. OS COXAE 1. Linea glutea posterior 2. Ala ossis ilii 3. Linea glutea anterior 4. Cristae illiaca (a) labium externum (b) lab. Intermedia (c) lab. Internum 5. Facies glutea 6. SIAS 7. Linea glutea inferior 8. SIAI 9. Facies lunata 10. Eminentia iliopectinea 11. Fossa acetabuli 12. Incisura .
