LIST OF DENTAL PROCEDURES (LOW PLAN) PREVENTIVE PROCEDURES

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "LIST OF DENTAL PROCEDURES (LOW PLAN) PREVENTIVE PROCEDURES"

Transcription

1 LIST OF DENTAL PROCEDURES (LOW PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. PREVENTIVE PROCEDURES VISITS AND EVAULATIONS Periodic oral evaluation. $ Comprehensive oral evaluation - new or established patient Comprehensive periodontal evaluation - new or established patient (Two evaluations will be allowed in a Benefit Period. A 0120, 0150, or 0180 counts toward this maximum allowance and 0180 will be limited to once per provider.) 1110 Prophylaxis - adult Prophylaxis - child (Prophylaxis (cleaning) will be allowed twice in a Benefit Period. A 1110, 1120 or 1201 counts toward this maximum allowance. Periodontal maintenance may be substituted for a cleaning (see requirements under Basic section. Benefits will not be available if performed on the same date as periodontal services. An adult prophylaxis is considered for individuals age 14 and over. A child prophylaxis is considered for individuals age 13 and under.) 1201 Topical fluoride and prophylaxis Topical fluoride (separate code) in conjunction with prophylaxis - child ( : Coverage for fluoride treatment is limited to persons age 18 and under and to one treatment in a Benefit Period.) SPACE MAINTAINERS Fixed space maintainer, unilateral Fixed space maintainer, bilateral Removable space maintainer, unilateral Removable space maintainer, bilateral ( : Coverage is limited to space maintenance for unerupted teeth and following extraction of primary teeth. Allowance includes all adjustments within 6 months after installation.) 1550 Recementation of space maintainer Removable appliance therapy Fixed appliance therapy ( : Coverage is limited to the correction of thumb-sucking.) MISCELLANEOUS PREVENTIVE PROCEDURES 1351 Sealant - per tooth (1351: Coverage is limited to treatment of the occlusal surface of permanent molar teeth once during a 3-year period for persons age 16 and under.) GR Rev

2 PERSONAL AND DEPENDENT DENTAL CARE INSURANCE LIST OF DENTAL PROCEDURES (LOW PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. PREVENTIVE PROCEDURES RADIOGRAPHS Periapical radiograph - first film. $ Additional periapical film, each Intraoral - complete series (including bitewings) Panoramic film (0210 or 0330: Only one of these procedures will be allowed in any three year period.*) 0240 Intraoral, occlusal film Extraoral, first film Extraoral, each additional film Bitewing, single film Bitewing - two films Bitewing - four films Vertical bitewings - 7 to 8 films (Bitewing films are limited to 2 allowances in a Benefit Period. A 0270, 0272, 0274 or 0277 counts toward this maximum allowance. In addition, 0277 will be limited to once in a 3-year period.) *The frequency is measured forward from the last covered date of service for the procedure. GR Rev

3 PERSONAL AND DEPENDENT DENTAL CARE INSURANCE LIST OF DENTAL PROCEDURES (LOW PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. BASIC PROCEDURES VISITS AND EVAULATIONS Limited oral evaluation - problem focused $ Re-evaluation - limited, problem focused (Established patient; not post-operative visit) (0140 and 0170: Coverage is limited to accidental injury only. If not due to an accident, will be considered as a 0120 and count toward this maximum allowance.) 9440 Office visit after regularly scheduled hours (9440: Payment will be made on basis of services rendered or visit, whichever is greater.) 9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) (9310: Coverage is limited to one allowance per provider.) 9110 Palliative (emergency) treatment of dental pain - minor procedure (9110: Not covered in conjunction with other procedures, except diagnostic x-ray films.) 4355 Full mouth debridement to enable comprehensive evaluation and diagnosis (4355: Coverage is limited to once during a 5-year period.*) 4910 Periodontal maintenance (4910: This procedure is available in place of an eligible routine prophylaxis ( ) as listed above. Coverage is contingent upon evidence of full mouth active periodontal therapy and limited to 2 allowances in a Benefit Period (a 1110, 1120 or 1201 counts toward this maximum allowance Benefits will not be available if performed on the same date as other periodontal services.) 9911 Application of desensitizing resin for cervical and/or root surface, per tooth PATHOLOGY Biopsy of oral tissue - hard (bone, tooth) Biopsy of oral tissue - soft (all others) Accession of tissue, gross examination, preparation and transmission of written report *The frequency is measured forward from the last covered date of service for the procedure. GR Rev

4 BASIC PROCEDURES (Continued) (LOW PLAN) 0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report. $ Accession of tissue, gross and microscopic examination including assessment of surgical margins for presence of disease, preparation and transmission of written report ( : Coverage is limited to one examination per biopsy/excision.) RESTORATIVE DENTISTRY, excluding inlays, crowns and fixed partial dentures. Amalgam Restorations Amalgam - one surface, primary or permanent Amalgam - two surfaces, primary or permanent Amalgam - three surfaces, primary or permanent Amalgam - four or more surfaces, primary or permanent Resin Restorations Resin-based composite - one surface, anterior Resin-based composite - two surfaces, anterior Resin-based composite - three surfaces, anterior Resin-based composite - four or more surfaces or involving incisal angle, anterior Resin-based composite - one surface, posterior Resin-based composite - two surfaces, posterior Resin-based composite - three surfaces, posterior Resin-based composite - four or more surfaces, posterior ( : Coverage is limited to permanent bicuspid teeth.) Other Restorative Services Resin-based composite crown, anterior Prefabricated stainless steel crown - primary tooth Stainless steel crown - permanent tooth Prefabricated resin crown (2390, : Coverage is limited to persons age 18 and under. Please refer to Major procedures for persons age 19 and older.) 2951 Pin retention, per tooth, in addition to restoration (3 pins per tooth maximum) Recementation Inlay Crown Fixed Partial Denture GR Rev

5 BASIC PROCEDURES (Continued) (LOW PLAN) Full and Partial Denture Repairs, Acrylic. Repair of Complete Dentures Repair broken base. $ Replace missing or broken teeth - each tooth Repair of Partial Dentures Repair resin denture base Repair cast framework Repair or replace broken clasp Replace broken teeth (per tooth) Reline complete maxillary denture (chairside) Reline complete mandibular denture (chairside) Reline maxillary partial denture (chairside) Reline mandibular partial denture (chairside) Reline complete maxillary denture (laboratory) Reline complete mandibular denture (laboratory) Reline maxillary partial denture (laboratory) Reline mandibular partial denture (laboratory) ( : Coverage for relines is limited to service dates more than 6 months after installation.) ORAL SURGERY. Extractions. Includes local anesthesia, suturing, if needed, and routine postoperative care Coronal remnants - deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical Extractions. Includes local anesthesia, suturing, if needed, and routine postoperative care Surgical removal of erupted teeth Treatment of complications (post-surgical) - unusual circumstances, by report Impacted Teeth. Includes local anesthesia, suturing, if needed, and routine postoperative care Surgical removal of impacted tooth (soft tissue) Surgical removal of impacted tooth (partially bony) Surgical removal of impacted tooth (completely bony) Removal of impacted tooth (completely bony, with unusual surgical complications), by report Surgical removal of residual tooth roots (cutting procedure) Alveolar or Gingival Reconstruction Alveoplasty (without extractions) - per quadrant Alveoplasty (with extractions) - per quadrant Vestibuloplasty - ridge extension (secondary epithelialization) GR Rev

6 BASIC PROCEDURES (Continued) (LOW PLAN) 7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue). $ Cysts and Neoplasms Incision and drainage of abscess - intraoral soft tissue Incision and drainage of abscess - extraoral soft tissue Sialolithotomy Closure of salivary fistula Excision of benign lesion up to 1.25 cm Excision of benign lesion greater than 1.25 cm Excision of benign lesion, complicated Excision of malignant lesion up to 1.25 cm Excision of malignant lesion greater than 1.25 cm Excision of malignant lesion, complicated Excision of malignant tumor - lesion diameter up to 1.25 cm Excision of malignant tumor - lesion diameter greater than 1.25 cm Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm Destruction of lesion(s) by physical or chemical method, by report Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) Removal of reaction-producing foreign bodies - musculoskeletal system Radical resection of mandible with bone graft Maxillary sinusotomy for removal of tooth fragment or foreign body Oral antral fistula closure Partial ostectomy/sequestrectomy for removal of non-vital bone Miscellaneous Removal of foreign body, skin, or subcutaneous areolar tissue Frenulectomy (frenectomy or frenotomy) - separate procedure Suture of recent small wounds - up to 5 cm Complicated suture - up to 5 cm Complicated suture - greater than 5 cm Tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth Surgical access of an unerupted tooth Surgical exposure of impacted or unerupted tooth to aid eruption GR Rev

7 BASIC PROCEDURES (Continued) (LOW PLAN) 7970 Excision of hyperplastic tissue, per arch Primary closure of a sinus perforation Mobilization of erupted or malpositioned tooth to aid eruption Cytology sample collection Removal of lateral exostosis - (maxilla or mandible) Removal of torus palatinus Removal of torus mandibularis ( : A maximum of 5 allowances will be considered.) 7485 Surgical reduction of osseous tuberosity ANESTHESIA Deep sedation/general anesthesia - first 30 minutes Deep sedation/general anesthesia - each additional 15 minutes Intravenous conscious sedation/analgesia - first 30 minutes Intravenous conscious sedation/analgesia - each additional 15 minutes ( : Coverage is not available without a cutting procedure. Verification of the dentist s anesthesia permit and a copy of the anesthesia report is required. A maximum of two additional units (9221 or 9242) will be considered.) GR Rev

8 PERSONAL AND DEPENDENT DENTAL CARE INSURANCE LIST OF DENTAL PROCEDURES (LOW PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. BASIC PROCEDURES ENDODONTICS Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament. Limited to treatment of primary teeth. $ Pulpal debridement, primary and permanent teeth Pulpal therapy (resorbable filling) - anterior, primary tooth Pulpal therapy (resorbable filling) - posterior, primary tooth Root canal, anterior (excluding final restoration) Root canal, bicuspid (excluding final restoration) Root canal, molar (excluding final restoration) Incomplete endodontic therapy; inoperable or fractured tooth Internal root repair of perforation defects ( : Coverage is limited to permanent teeth. Allowance includes intraoperative films and cultures but excludes final restoration.) 3346 Retreatment of previous root canal therapy - anterior Retreatment of previous root canal therapy - bicuspid Retreatment of previous root canal therapy - molar ( : Coverage is limited to permanent teeth and to service dates more than 12 months after root canal therapy or a previous retreatment. Allowance includes intraoperative films and cultures but excludes final restoration.) 3351 Apexification/recalcification - initial visit Apexification/recalcification - interim medication replacement Apexification/recalcification - final visit Apicoectomy/periradicular surgery - anterior Apicoectomy/periradicular surgery - bicuspid (first root) Apicoectomy/periradicular surgery - molar (first root) Apicoectomy/periradicular surgery - each additional root Retrograde filling - per root Root amputation - per root Hemisection (including any root removal), not including root canal therapy PERIODONTICS. Surgical Procedures (including postoperative visits) Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant Gingivectomy or gingivoplasty - one to three teeth, per quadrant GR Rev

9 BASIC PROCEDURES (Continued) (LOW PLAN) 4240 Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant. $ Gingival flap procedure, including root planing - one to three teeth, per quadrant Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant Osseous surgery (including flap entry and closure) - one to three teeth, per quadrant Bone replacement graft - first site in quadrant Bone replacement graft - each additional site in quadrant Biologic materials to aid in soft and osseous tissue regeneration ( : Each procedure is eligible for consideration once in a 3-year period.*) 4270 Pedicle soft tissue graft procedure Free soft tissue graft procedure (including donor site) Subepithelial connective tissue graft procedures Soft tissue allograft Combined connective tissue and double pedicle graft ( , : A maximum of two sites per quadrant will be considered in a 3-year period. Coverage is limited to treatment of periodontal disease.*) 4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) Non-surgical Periodontal Procedures Periodontal scaling and root planing - four or more contiguous teeth or bounded teeth spaces per quadrant Periodontal scaling and root planing - one to three teeth, per quadrant ( : Each procedure is eligible for consideration once in a 2-year period.*) 4381 Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth (4381: A scaling and planing (4341) must be performed between 6 weeks and two years prior to treatment. A maximum of 2 sites per quadrant will be considered and the frequency is limited to once in any 2-year period.) 9951 Occlusal adjustment, limited Occlusal adjustment, complete ( : Coverage is limited to adjustment performed in conjunction with treatment of periodontal disease.) *The frequency is measured forward from the last covered date of service for the procedure. GR Rev

10 PERSONAL AND DEPENDENT DENTAL CARE INSURANCE LIST OF DENTAL PROCEDURES (LOW PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. MAJOR PROCEDURES RESTORATIVE. Inlays and crowns are covered only when necessitated by decay or traumatic injury. Inlays Resin-based composite crown, anterior. $ Inlay - metallic - one surface Inlay - metallic - two surfaces Inlay - metallic - three or more surfaces Onlay - metallic - two surfaces Onlay - metallic - three surfaces Onlay - metallic - four or more surfaces Inlay porcelain/ceramic - one surface Inlay porcelain/ceramic - two surfaces Inlay - porcelain/ceramic - three or more surfaces Onlay - porcelain/ceramic - two surfaces Onlay - porcelain/ceramic - three surfaces Onlay - porcelain/ceramic - four or more surfaces Inlay - resin-based composite composite/resin - one surface Inlay - resin-based composite composite/resin - two surfaces Inlay - resin-based composite composite/resin - three surfaces Onlay - resin-based composite composite/resin - two surfaces Onlay - resin-based composite composite/resin - three surfaces Onlay - resin-based composite composite/resin - four or more surfaces Crowns Resin (indirect) Resin with high noble metal Resin with predominantly base metal Resin with noble metal Porcelain/ceramic substrate Porcelain fused to high noble metal Porcelain fused to predominantly base metal Porcelain fused to noble metal Crown - 3/4 cast high noble metal Crown - 3/4 cast predominately base metal Crown - 3/4 cast noble metal Crown - 3/4 porcelain/ceramic Full cast high noble metal Full cast predominantly base metal Full cast noble metal GR Rev

11 MAJOR PROCEDURES (Continued) (LOW PLAN) 2930 Prefabricated stainless steel crown - primary tooth. $ Prefabricated stainless steel crown - permanent tooth Prefabricated resin crown ( : These procedures are limited to necessary placement resulting from decay or traumatic injury. Inlays will be reimbursed at the alternate allowance of an amalgam or composite restoration.) 2950 Core build-up, including any pins Cast post and core - in addition to crown Prefabricated post and core - in addition to crown Clinical crown lengthening, hard tissue PROSTHODONTICS - FIXED. Retainers (Abutments) 6545 Retainer - cast metal for resin bonded fixed prosthesis Retainer - porcelain/ceramic for resin bonded fixed prosthesis Inlay - porcelain/ceramic, two surfaces Inlay - porcelain/ceramic, three or more surfaces Inlay - cast high noble metal, two surfaces Inlay - cast high noble metal, three or more surfaces Inlay - cast predominantly base metal, two surfaces Inlay - cast predominantly base metal, three or more surfaces Inlay - cast noble metal, two surfaces Inlay - cast noble metal, three or more surfaces Onlay - porcelain/ceramic, two surfaces Onlay - porcelain/ceramic, three or more surfaces Onlay - cast high noble metal, two surfaces Onlay - cast high noble metal, three or more surfaces Onlay - cast predominantly base metal, two surfaces Onlay - cast predominantly base metal, three or more surfaces Onlay - cast noble metal, two surfaces Onlay - cast noble metal, three or more surfaces Crown - resin with high noble metal Crown - resin with predominantly base metal Crown - resin with noble metal Crown - porcelain/ceramic Crown - porcelain fused to high noble metal Crown - porcelain fused to predominantly base metal Crown - porcelain fused to noble metal Crown - 3/4 cast high noble metal Crown - 3/4 cast predominately base metal Crown - 3/4 cast noble metal Crown - 3/4 porcelain/ceramic Crown - full cast high noble metal Crown - full cast predominantly base metal Crown - full cast noble metal Stress breaker Cast post and core in addition to fixed partial denture retainer Cast post as part of fixed partial denture retainer Prefabricated post and core in addition to fixed partial denture retainer GR Rev

12 MAJOR PROCEDURES (Continued) (LOW PLAN) Implant Supported 6058 Abutment supported porcelain/ceramic crown Abutment supported porcelain fused to metal crown (high noble metal) Abutment supported porcelain fused to metal crown (predominantly base metal). $ Abutment supported porcelain fused to metal crown (noble metal) Abutment supported cast metal crown (high noble metal) Abutment supported cast metal crown (predominantly base metal) Abutment supported cast metal crown (noble metal) Implant supported porcelain/ceramic crown Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) Implant supported metal crown (titanium, titanium alloy, high noble metal) Abutment supported retainer for porcelain /ceramic FPD Abutment supported retainer for porcelain fused to metal FPD (high noble metal) Abutment supported retainer for porcelain fused to metal FPD (predominately base metal) Abutment supported retainer for porcelain fused to metal FPD (noble metal) Abutment supported retainer for cast metal FPD (high noble metal) Abutment supported retainer for cast metal FPD (predominately base metal) Abutment supported retainer for cast metal FPD (noble metal) Implant supported retainer for ceramic FPD Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) ( : Although implants are not a covered benefit, these procedures can qualify for benefits. Coverage is subject to the replacement and extraction provisions as defined under the limitations section of this contract.) Pontics Cast high noble metal Cast predominantly base metal Cast noble metal Porcelain fused to high noble metal Porcelain fused to predominantly base metal Porcelain fused to noble metal Porcelain/ceramic Resin with high noble metal Resin with predominantly base metal Resin with noble metal Repairs, crowns and fixed partial dentures Fixed partial denture repair, by report Crown repair, by report GR

13 MAJOR PROCEDURES (Continued) (LOW PLAN) PROSTHODONTICS - REMOVABLE. Partials and Dentures (Allowance for partial and complete dentures include adjustments within 6 months after installation. Precision attachments, implants, overdentures, specialized techniques and characterizations are considered optional and the additional expense for these shall be borne by the patient. All partial allowances include conventional clasps, rests and teeth.) 5110 Complete denture - maxillary. $ Complete denture - mandibular Immediate denture - maxillary Immediate denture - mandibular Maxillary partial denture - resin base Mandibular partial denture - resin base Maxillary partial denture - cast metal framework with resin denture bases Mandibular partial denture - cast metal framework with resin denture bases Removable unilateral partial denture - one piece cast metal Interim partial denture (maxillary) Interim partial denture (mandibular) Interim complete denture (maxillary) Interim complete denture (mandibular) Adjust complete denture - maxillary Adjust complete denture - mandibular Adjust partial denture - maxillary Adjust partial denture - mandibular ( : Coverage is limited to an adjustment with a date of service more than 6 months after installation.) 5850 Tissue conditioning, maxillary Tissue conditioning, mandibular Rebase - complete maxillary denture Rebase - complete mandibular denture Rebase - maxillary partial denture Rebase - mandibular partial denture Adding teeth to partial denture to replace extracted natural teeth Add tooth to existing partial denture Add clasp to existing partial denture Replace all teeth and acrylic on cast metal framework (maxillary) Replace all teeth and acrylic on cast metal framework (mandibular) ( : Prosthetic replacement limitation applies. See limitations section.) GR

14 PERSONAL AND DEPENDENT DENTAL CARE INSURANCE LIST OF DENTAL PROCEDURES (MIDDLE PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. PREVENTIVE PROCEDURES RADIOGRAPHS Periapical radiograph - first film. $ Additional periapical film, each Intraoral - complete series (including bitewings) Panoramic film (0210 or 0330: Only one of these procedures will be allowed in any three year period.*) 0240 Intraoral, occlusal film Extraoral, first film Extraoral, each additional film Bitewing, single film Bitewing - two films Bitewing - four films Vertical bitewings - 7 to 8 films (Bitewing films are limited to 2 allowances in a Benefit Period. A 0270, 0272, 0274 or 0277 counts toward this maximum allowance. In addition, 0277 will be limited to once in a 3-year period.) *The frequency is measured forward from the last covered date of service for the procedure. GR

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS.

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures for which benefits are payable under

More information

Cigna Dental - Low Plan Schedule for Class II and III Procedures Payment Basis - Maximum Covered Expense Benefit Period - Calendar Year.

Cigna Dental - Low Plan Schedule for Class II and III Procedures Payment Basis - Maximum Covered Expense Benefit Period - Calendar Year. Cigna Dental - Low Plan Schedule for Class II and III Procedures Payment Basis - Maximum Covered Expense Benefit Period - Calendar Year ADA Code Class II Maximum Covered ORAL PATHOLOGY/LABORATORY Procedure

More information

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS.

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures for which benefits are payable under

More information

PATIENT CHARGE SCHEDULE

PATIENT CHARGE SCHEDULE B1-05 Important Highlights PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. This Schedule applies only when covered dental services

More information

deltadentalins.com/usc

deltadentalins.com/usc Plan Benefit Highlights for: UNIVERSITY OF SOUTHERN CALIFORNIA STUDENT PLAN Group No: 05008 The Delta Dental PPO table plan provides you great dental benefits at a reasonable cost. With a table of allowance

More information

CCPOA PRIMARY DENTAL. CCPOA s Fee-for-Service. Procedure Code List

CCPOA PRIMARY DENTAL. CCPOA s Fee-for-Service. Procedure Code List CCPOA PRIMARY DENTAL CCPOA s Fee-for-Service Procedure Code List Effective May 2016 We have provided these payment allowances for informational purposes only and not as a guarantee of payment. All claims

More information

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS.

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures for which benefits are payable under

More information

Aetna Dental Plan Organization (DPO) Plan. 2015 New Jersey SHBP Active Employees Covered Services

Aetna Dental Plan Organization (DPO) Plan. 2015 New Jersey SHBP Active Employees Covered Services Aetna Dental Plan Organization (DPO) Plan 2015 New Jersey SHBP Active Employees Covered Services The following is a list of covered services and, if applicable, required copayments. Copayments are your

More information

General Dentist Fees

General Dentist Fees General Dentist Fees January 1, 2015 Not all codes are covered benefits. Please check the member s plan for verification and limitations. There are no fee increases for 2015, but new CDT codes have been

More information

DISCOUNT DENTAL PLAN COMPLETE LISTING OF MEMBER COPAYMENTS

DISCOUNT DENTAL PLAN COMPLETE LISTING OF MEMBER COPAYMENTS DISCOUNT DENTAL PLAN COMPLETE LISTING OF MEMBER COPAYMENTS 0120 PERIODIC ORAL EXAMINATION - ESTABLISHED PATIENT 20 0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED 33 0150 COMPREHENSIVE ORAL EVALUATION -

More information

Schedule B Indemnity plan People First Plan Code #4084

Schedule B Indemnity plan People First Plan Code #4084 : Calendar year deductible Waived for Type I preventive dental services Calendar year maximum Type I, II, III Waiting period Type I, II, III $50 individual $150 family (3 per family) $1,000 per covered

More information

PROVIDER CHOICE Plan PC - 5

PROVIDER CHOICE Plan PC - 5 The Dental Network Suite 200, 7400 York Road Towson, Maryland 21204 Telephone: (410) 847-9060 Fax: (410) 847-9062 Toll Free: (888) 833-8464 Website: www.thedentalnet.org Email: service@thedentalnet.org

More information

Delta Dental Patient Direct Schedule 19

Delta Dental Patient Direct Schedule 19 Delta Dental Patient Direct Schedule 19 ADA CODE DENTAL PROCEDURE /ADA CODE DESCRIPTION NORMAL FEE* MEMBER FEE YOU SAVE Diagnostic and Preventive Services (x-rays and cleanings) D0999 Routine office visit

More information

GROUP DENTAL PLAN WINSTON-SALEM/FORSYTH COUNTY SCHOOLS. Plan Number: 10-301002. Administered by:

GROUP DENTAL PLAN WINSTON-SALEM/FORSYTH COUNTY SCHOOLS. Plan Number: 10-301002. Administered by: GROUP DENTAL PLAN WINSTON-SALEM/FORSYTH COUNTY SCHOOLS Plan Number: 10-301002 Administered by: TABLE OF CONTENTS Name of Provision Page Number Schedule of Benefits Begins on 9040 Benefit Information,

More information

Dental Benefits Summary

Dental Benefits Summary PATIENT PAYS PATIENT PAYS CODE PROCEDURE CODE PROCEDURE Office Visit Copay $0 DIAGNOSTIC D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series X-rays D0330 Panoramic

More information

Dental Benefits Summary

Dental Benefits Summary CODE PROCEDURE Office Visit Copay PATIENT PAYS CODE $0 DIAGNOSTIC PROCEDURE PATIENT PAYS D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series Images D0330 Panoramic

More information

Network Plus Prepaid plan People First Plan Code #4004

Network Plus Prepaid plan People First Plan Code #4004 Selecting a dentist For participating dentist information you may visit our website at www.humanadental.com/custom/fl/ or call our dedicated Customer Care number at 1-800-943-6880. Once you become enrolled

More information

Dental Benefits Summary

Dental Benefits Summary CODE Office Visit Copay PATIENT PAYS CODE DIAGNOSTIC PATIENT PAYS D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series X-rays D0330 Panoramic X-Ray D0220-D0230 Periapicals

More information

Dental Benefits Summary

Dental Benefits Summary PATIENT PAYS PATIENT PAYS CODE PROCEDURE CODE PROCEDURE Office Visit Copay $5 DIAGNOSTIC D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series Images D0330 Panoramic

More information

DIRECT REFERRAL DENTAL PLAN HN VALUE DHMO 150 SCHEDULE OF BENEFITS

DIRECT REFERRAL DENTAL PLAN HN VALUE DHMO 150 SCHEDULE OF BENEFITS DIRECT REFERRAL DENTAL PLAN HN VALUE DHMO 150 SCHEDULE OF BENEFITS Benefits provided by Dental Benefit Providers of California, Inc. This document describes the Covered Services of this Health Net of California

More information

Humana Health Plans of Florida. Important:

Humana Health Plans of Florida. Important: Humana Health Plans of Florida Important: Dental discount membership in Florida is determined by viewing the member s ID card and verifying that the Humana Logo and Medicare name is listed with an effective

More information

2015 Dental Plan 5000S Benefit Information BALTIMORE CITY PUBLIC SCHOOLS. Baltimore City Public Schools 2015 Dental Options C1

2015 Dental Plan 5000S Benefit Information BALTIMORE CITY PUBLIC SCHOOLS. Baltimore City Public Schools 2015 Dental Options C1 2015 Dental Plan 5000S Benefit Information BALTIMORE CITY PUBLIC SCHOOLS Baltimore City Public Schools 2015 Dental Options C1 Important Information for 2015 The State of Maryland legalized same sex marriage

More information

2016 Buy Up Dental Care Plan Procedure List

2016 Buy Up Dental Care Plan Procedure List * This is in addition to the embedded Preventive Plan (see procedure list at deltadentalco.com/kp_preventive. BASIC SERVICES Minor Restorative Services D2140 Amalgam 1 surface, primary or permanent D2150

More information

SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Self-Referral Dental Plan

SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Self-Referral Dental Plan SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Self-Referral Dental Plan Univ II This Schedule of Benefits lists the services available to you under your SafeGuard

More information

SCHEDULE OF BENEFITS DIRECT REFERRAL DENTAL PLAN*

SCHEDULE OF BENEFITS DIRECT REFERRAL DENTAL PLAN* SCHEDULE OF BENEFITS DIRECT REFERRAL DENTAL PLAN* Nexus 150 This document describes the Covered Services of this dental plan, as well as Copayment requirements, Limitations of Benefits and Exclusions.

More information

Healthy Kids Evidence of Coverage (EOC) Errata Sheet

Healthy Kids Evidence of Coverage (EOC) Errata Sheet Healthy Kids Evidence of Coverage (EOC) Errata Sheet The information below is to replace the Section U.3. (Dental Services) of your current Handbook (EOC) for the benefit year from July 1, 2015 June 30,

More information

Staywell FL Child Medicaid Plan Benefits

Staywell FL Child Medicaid Plan Benefits The following is a complete list of the dental procedures for which benefits are payable under this Plan. on-listed procedures are not covered. This Plan does not allow alternate benefits. Members must

More information

DeltaCare USA. Getting to know your DeltaCare USA program. We keep you smiling SCNY(2005) NY14B_V5

DeltaCare USA. Getting to know your DeltaCare USA program. We keep you smiling SCNY(2005) NY14B_V5 DeltaCare USA Getting to know your DeltaCare USA program We keep you smiling SCNY(2005) Provided by: Delta Dental of New York, Inc. 575 Madison Avenue New York, New York 10022 NY14B_V5 DeltaCare USA Getting

More information

Procedure Description. Prophylaxis - adult. Periodic oral evaluation - established patient. Resin-based composite - three surfaces, posterior

Procedure Description. Prophylaxis - adult. Periodic oral evaluation - established patient. Resin-based composite - three surfaces, posterior Top ADA Dental Procedure Codes - Pediatric Patients Ranked by Contribution to Total Pediatric Dental Claim Costs based on 15 Milliman Health Cost Guidelines-Dental 12 08 13 51 74 91 71 93 03 12 06 Procedure

More information

Coverage with HMO Off-Marketplace Health Plans

Coverage with HMO Off-Marketplace Health Plans Adult Dental and Vision Coverage with HMO Off-Marketplace Health Plans Pam White We are your Health Net. Optional adult dental and vision coverage (ages 19 and older) with Health Net HMO Plus is available

More information

TEAMSTERSCARE DENTAL FEE SCHEDULE Effective: 01/01/ Delta Dental PPO Plus Premier National

TEAMSTERSCARE DENTAL FEE SCHEDULE Effective: 01/01/ Delta Dental PPO Plus Premier National Effective: 01/01/ - Delta Dental PPO Plus Premier National D0120 PERIODIC ORAL EXAMINATION $20.00 D0140 LIMITED EVAL PROBLEM FOCUS $37.00 D0145 ORAL EVALUATION FOR PATIENTS UNDER THREE YEARS OF AGE $20.00

More information

Cigna Dental Care (*DHMO) Patient Charge Schedule

Cigna Dental Care (*DHMO) Patient Charge Schedule A3O08 Cigna Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered

More information

A Dental Benefit Summary for Rice University

A Dental Benefit Summary for Rice University Aetna Dental presents A Dental Benefit Summary for Rice University CODE CODE Office Visit Copay $5 DIAGNOSTIC CROWNS/BRIDGES D0120 Exam-Periodic No Charge D2510 Inlay, Metallic, One surface $225 D0150

More information

Cigna Dental Care (*DHMO) Patient Charge Schedule

Cigna Dental Care (*DHMO) Patient Charge Schedule L1-08 Cigna Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered

More information

Dental Insurance Plan Highlights

Dental Insurance Plan Highlights Dental Insurance Plan Highlights Freedom of choice (Choose any dentist.) Personal ownership Benefits paid regardless of any other insurance No deductible No precertification Easy to understand Form A81075B1

More information

Keep your employees smiling

Keep your employees smiling Keep your employees smiling A guide to your dental benefits Base Level Point-of-Service Plan Good news! As a member of Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (hereafter Kaiser Permanente),

More information

MEDICAL ASSISTANCE PROGRAM DENTAL FEE SCHEDULE

MEDICAL ASSISTANCE PROGRAM DENTAL FEE SCHEDULE Dental General Payment Policies Children under 21 years of age are eligible for all medically necessary dental services. For children under 21 years of age who require medically necessary dental services

More information

Prepaid Dental. Good news about dental benefits for employees of. UMB Financial - Texas

Prepaid Dental. Good news about dental benefits for employees of. UMB Financial - Texas Prepaid Dental Good news about dental benefits for employees of UMB Financial - Texas A Dental Plan Means Healthy Smiles Because you are a valued employee, we are pleased to offer you the opportunity to

More information

Code Dental Procedure Description Pays CLINICAL ORAL EVALUATIONS

Code Dental Procedure Description Pays CLINICAL ORAL EVALUATIONS Schedule of Benefits SCHEDULE OF BENEFITS ADA Member Code Dental Procedure Description Pays CLINICAL ORAL EVALUATIONS D0120 Periodic oral evaluation...$0 D0140 Limited oral evaluation - problem focused...$0

More information

Cigna Dental Care (*DHMO) Patient Charge Schedule

Cigna Dental Care (*DHMO) Patient Charge Schedule Cigna Dental Care (*DHMO) Patient Charge Schedule This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Patient

More information

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC.

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. PEDIATRIC POLICY SCHEDULE This Pediatric Policy Schedule applies only to Covered Persons who are age 19 and under. Pediatric Dental Benefits end on the last

More information

USA provided by Delta Dental of California

USA provided by Delta Dental of California DeltaCare USA provided by Delta Dental of California Weʼll do whatever it takes and then some. Find a DeltaCare USA dentist Select from among the many conveniently located DeltaCare USA contracted general

More information

Texas. Use your HumanaOne Dental benefits. Choose HumanaOne dental benefits. HumanaOne Dental Prepaid HI215 Plan. Be healthy

Texas. Use your HumanaOne Dental benefits. Choose HumanaOne dental benefits. HumanaOne Dental Prepaid HI215 Plan. Be healthy HumanaOne Dental Prepaid HI215 Plan Texas Use your HumanaOne Dental benefits The HumanaOne Dental Prepaid HI215 plan has you covered for any circumstance. Whether you simply need quality routine dental

More information

4-1-2005. Dental Clinical Criteria and Documentation Requirements

4-1-2005. Dental Clinical Criteria and Documentation Requirements 4-1-2005 Dental Clinical Criteria and Documentation Requirements Table of Contents Dental Clinical Criteria Cast Restorations and Veneer Procedures... Pages 1-3 Crown Repair... Page 3 Endodontic Procedures...

More information

Your Summary of Benefits Dental Net Dental HMO Plan 2000A

Your Summary of Benefits Dental Net Dental HMO Plan 2000A Your Summary of s Dental Net Dental HMO Plan 2000A WELCOME TO YOUR DENTAL PLAN! This benefit summary outlines the basic components of Anthem s Dental Net DHMO Plans providing you with a quick reference

More information

DeltaCare Plan SCHEDULE OF DENTAL BENEFITS PATIENT

DeltaCare Plan SCHEDULE OF DENTAL BENEFITS PATIENT DeltaCare Plan SCHEDULE OF DENTAL BENEFITS CODE (D0100-D0999) DIAGNOSTIC Office visit, per visit (in addition to other services) No Cost D0120 Periodic oral evaluation No Cost D0140 Limited oral evaluation

More information

DentalBlue Gold SM INDIVIDUAL DENTAL POLICY OTHER INSURANCE REDUCES BENEFITS READ CAREFULLY

DentalBlue Gold SM INDIVIDUAL DENTAL POLICY OTHER INSURANCE REDUCES BENEFITS READ CAREFULLY DentalBlue Gold SM INDIVIDUAL DENTAL POLICY OTHER INSURANCE REDUCES BENEFITS READ CAREFULLY Attached is the Schedule of Benefits, showing name of Policyholder, Policy number, type of Policy (individual

More information

Dental Coverage. Hawai i. Coordinated Care Plans. H2491_H1015506_WCM_BRO_ENG CMS Approved 08022011 WellCare 2011 HI_07_11_WC

Dental Coverage. Hawai i. Coordinated Care Plans. H2491_H1015506_WCM_BRO_ENG CMS Approved 08022011 WellCare 2011 HI_07_11_WC Dental Coverage Coordinated Care Plans Hawai i Ohana is pleased to offer you dental coverage that focuses on the importance of preventive care. Taking care of your teeth and gums begins with regular checkups

More information

group dental & eye care For Cornell Employees and Their Families Ameritas Life Insurance Corp. of New York Coverage provided and underwritten by:

group dental & eye care For Cornell Employees and Their Families Ameritas Life Insurance Corp. of New York Coverage provided and underwritten by: group dental & eye care For Cornell Employees and Their Families 2015 Coverage provided and underwritten by: Ameritas Life Insurance Corp. of New York GR 6685 NY Rev. 9-14 Plan A+ $3,000 calendar year

More information

Schedule of Covered Services and Copayments Family Dental HMO SHOP Plan (CA-FD)

Schedule of Covered Services and Copayments Family Dental HMO SHOP Plan (CA-FD) Schedule of Covered Services and Copayments Family Dental HMO SHOP Plan (CA-FD) D9543 Diagnostic D0120 D0140 D0150 D0160 D0170 D0180 D0190 D0191 D0210 D0220 D0230 D0240 D0250 D0270 D0272 D0273 D0274 D0277

More information

2015 Dental Procedures Chart for Basic Dental Benefits

2015 Dental Procedures Chart for Basic Dental Benefits The dental procedures chart provides you with a list of the covered procedures and copayments for the Basic Dental benefits you receive as part of your CareMore Health Plan. Note: None of the procedures

More information

Aetna Life Insurance Company Hartford, Connecticut 06156

Aetna Life Insurance Company Hartford, Connecticut 06156 Aetna Life Insurance Company Hartford, Connecticut 06156 Extraterritorial Certificate Rider (GR-9N-CR1) Policyholder: Choctaw Enterprises Group Policy No.: GP-819977 Rider: Florida ET Dental (PPO) Issue

More information

Henrico County General Government and Public Schools 2016 Dental Plans

Henrico County General Government and Public Schools 2016 Dental Plans Henrico County General Government and Public Schools 2016 Dental Plans DeltaCare (DHMO) program Under this program, you select a DeltaCare (DHMO) panel dentist for your dental care. Delta Dental of Virginia

More information

2014 Preventive/Comprehensive. Dental HMO Plan. Health Net Medicare Advantage Plans. California. Josefina Bravo Health Net

2014 Preventive/Comprehensive. Dental HMO Plan. Health Net Medicare Advantage Plans. California. Josefina Bravo Health Net 2014 Preventive/Comprehensive Dental HMO Plan Health Net Medicare Advantage Plans California Josefina Bravo Health Net Material ID # H0562_2014_0289 CMS Accepted 09222013 1 2014 Preventive/Comprehensive

More information

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC.

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. PEDIATRIC POLICY SCHEDULE This Pediatric Policy Schedule applies only to Covered Persons who are age 19 and under. Pediatric Dental Benefits end on the last

More information

LIBERTY Dental Plan of California, Inc.

LIBERTY Dental Plan of California, Inc. LIBERTY Dental Plan of California, Inc. CA80 PLAN SCHEDULE OF BENEFITS Covered Benefits, Member Co-payments, Limitations & Exclusions No Annual Deductible No Annual Dollar Amount Maximum Provider office

More information

Attachment S: Benefits Covered - ADULTS - AGE 21 AND OVER

Attachment S: Benefits Covered - ADULTS - AGE 21 AND OVER Diagnostic services include the oral examinations and selected radiographs needed to assess the oral health, diagnose oral pathology and develop an adequate treatment plan for the Participant s oral health.

More information

Choosing your plan. We ll do whatever it takes and then some. Your Two Delta Dental Plan Options

Choosing your plan. We ll do whatever it takes and then some. Your Two Delta Dental Plan Options City of Sacramento Choosing your plan Your Two Delta Dental Plan Options The choice is yours. When it comes to dental health, you want benefits that provide you with the best balance of value and coverage.

More information

Union Security Insurance Company 2323 Grand Boulevard Kansas City, MO 64108-2670 800.443.2995 EVIDENCE OF COVERAGE

Union Security Insurance Company 2323 Grand Boulevard Kansas City, MO 64108-2670 800.443.2995 EVIDENCE OF COVERAGE Union Security Insurance Company 2323 Grand Boulevard Kansas City, MO 64108-2670 800.443.2995 EVIDENCE OF COVERAGE ARTICLE I DEFINITIONS 1.1 Agreement: The Group Dental Service Agreement between Group

More information

Keep Smiling. DeltaCare USA. provided by Alpha Dental Programs, Inc. Dental benefits made easy! Budget-friendly costs. Convenient services

Keep Smiling. DeltaCare USA. provided by Alpha Dental Programs, Inc. Dental benefits made easy! Budget-friendly costs. Convenient services Keep Smiling DeltaCare USA provided by Alpha Dental Programs, Inc. Dental benefits made easy! When you enroll in a DeltaCare USA 1 plan, you ll choose a primary care dentist from our network of carefully

More information

Cone Beam CT Capture and Interpretation with Field of View and One Full Dental Arch-Mandible D0366

Cone Beam CT Capture and Interpretation with Field of View and One Full Dental Arch-Mandible D0366 CDT Procedure Code HCBS-DD and SLS WAIVER PARTICIPANT Procedure Code Description New DIDD Rate D0120 Periodic Oral Evaluation 45.57 D0140 Limited Oral Evaluation Problem Focused 66.06 D0150 Comprehensive

More information

Dental Services Rider Harbor Choice Plus, a product of Harbor Health Plan, Inc.

Dental Services Rider Harbor Choice Plus, a product of Harbor Health Plan, Inc. Your Agreement gives You important information about Your health care benefits. This Dental Services Rider ( Rider ) is issued to You with Your Agreement because the plan you selected includes Other Dental

More information

Program Description. Services Covered

Program Description. Services Covered Provider Guide Program Description Delta Dental of Oregon (DDOR) and OEBB have partnered together to create a much needed program called The Children s Program. The program provides basic dental services

More information

Provider Toll Free Number: 855 812 9208

Provider Toll Free Number: 855 812 9208 UnitedHealthcare Community Plan DETAL PROVIDER BEEFITS MATRIX for APIPA members Dental services are limited to members under age 21 except for a limited set of services as indicated on the matrix.transplant

More information

AMS Premier Group Dental Insurance Plan

AMS Premier Group Dental Insurance Plan AMS Premier Group Dental Insurance Plan American Military Society Acceptance Guaranteed Comprehensive Coverage Economical Insurance Protection Choice of your own dentist You deserve more! AMS Premier Group

More information

Enroll in DeltaCare USA and you ll enjoy these features:

Enroll in DeltaCare USA and you ll enjoy these features: DeltaCare USA provided by Delta Dental of California We ll do whatever it takes and then some. Find a DeltaCare USA dentist Select from among the many conveniently located DeltaCare USA contracted general

More information

REQUIRED OUTLINE OF COVERAGE FOR BLUEEXTRA INDIVIDUAL SUPPLEMENTAL INSURANCE COVERAGE DENTAL, VISION AND HEARING AID BENEFITS

REQUIRED OUTLINE OF COVERAGE FOR BLUEEXTRA INDIVIDUAL SUPPLEMENTAL INSURANCE COVERAGE DENTAL, VISION AND HEARING AID BENEFITS REQUIRED OUTLINE OF COVERAGE FOR BLUEEXTRA INDIVIDUAL SUPPLEMENTAL INSURANCE COVERAGE DENTAL, VISION AND HEARING AID BENEFITS BASIC POLICY Issued by QCC Insurance Company* (Called the Company) *a subsidiary

More information

Base Level Point-Of-Service Plan

Base Level Point-Of-Service Plan Something TO SMILE ABOUT A GUIDE TO YOUR DENTAL S Base Level Point-Of-Service Plan In the event of ambiguity, or a conflict between this summary and the Evidence of Coverage, the Evidence of Coverage shall

More information

Managed Dental Plans. If I want to. be at my best, a good dental plan. will be refreshing.

Managed Dental Plans. If I want to. be at my best, a good dental plan. will be refreshing. Group Dental Managed Dental Plans Savings1, convenience and service. For healthier smiles. If I want to be at my best, a good dental plan will be refreshing. Dental HMO/Managed Care Plans MET 3768-FLORIDA

More information

Learn. dental plans: > Basic Plan. > My. Always. to enroll for. included withh. son is away. plan cover this?? radiation. please visit. dentist?

Learn. dental plans: > Basic Plan. > My. Always. to enroll for. included withh. son is away. plan cover this?? radiation. please visit. dentist? Cigna Dental Open Enrollment Brochure You and your family have the opportunity to receive dental care through one of the following State of Connecticut dental plans: > Basic Plan > Enhanced Plan > Dental

More information

PROVIDER MANUAL FOR DENTAL SERVICES. Published By:

PROVIDER MANUAL FOR DENTAL SERVICES. Published By: PROVIDER MANUAL FOR DENTAL SERVICES Published By: Division of Medical Services North Dakota Department of Human Services 600 E Boulevard Ave, Dept 325 Bismarck, ND 58505-0250 August 2013 ii TABLE OF CONTENTS

More information

Voluntary Group Dental Insurance

Voluntary Group Dental Insurance Voluntary Group Dental Insurance ENHANCED PLAN Employee Benefit Booklet BOARD OF SUPERVISORS OF LOUISIANA STATE UNIVERSITY AND AGRICULTURAL AND MECHANICAL COLLEGE F019004-0001 Products and services marketed

More information

Out-of- Network** $50 $50 Deductible (waived for Class I) $50 $50 Annual Maximum $1,500 Annual Maximum $1,500 Waiting Period

Out-of- Network** $50 $50 Deductible (waived for Class I) $50 $50 Annual Maximum $1,500 Annual Maximum $1,500 Waiting Period This summary of benefits, along with the exclusions and limitations describe the benefits of the Family Dental PPO Plan in California. Please review closely to understand all benefits, exclusions and limitations.

More information

CDT These changes take effect January 1, If you have questions, please feel free to contact:

CDT These changes take effect January 1, If you have questions, please feel free to contact: CDT 2016 Current Dental Terminology American Dental Association procedure codes (CDT codes) are the recognized dental codes set by the Federal Government. CDT codes are used for dental claim transactions

More information

SECURITY LIFE INSURANCE COMPANY OF AMERICA Minnetonka, Minnesota

SECURITY LIFE INSURANCE COMPANY OF AMERICA Minnetonka, Minnesota SECURITY LIFE INSURANCE COMPANY OF AMERICA Minnetonka, Minnesota COVERAGE SCHEDULE PREFERRED (In-Network) PROVIDER: WE WILL PAY BASED ON THE CONTRACTED FEE FOR SERVICE WITH THE PREFERRED PROVIDER ORGANIZATION

More information

HumanaDental State of Florida Employees

HumanaDental State of Florida Employees HumanaDental State of Florida Employees FLHHB32HH 0914 2 - HumanaDental Four plans to choose from Humana is pleased to offer you four dental plans to choose from this year. While some of the benefits are

More information

PWU REPRESENTED EMPLOYEES - ODA CODES COVERED UNDER THE KINECTRICS DENTAL PLAN (DRAFT) PROCEDURE

PWU REPRESENTED EMPLOYEES - ODA CODES COVERED UNDER THE KINECTRICS DENTAL PLAN (DRAFT) PROCEDURE PWU REPRESENTED EMPLOYEES - COVERED UNDER THE KINECTRICS DENTAL PLAN 01101 100% Class A Initial examination of a new patient 01102 100% Class A Initial examination of a new patient 01103 100% Class A Initial

More information

Employers Dental Services. Enrollment and Coverage Booklet

Employers Dental Services. Enrollment and Coverage Booklet Employers Dental Services Enrollment and Coverage Booklet EDS 700R W E U N D E R S T A N D W H A T Y O U R E W O R K I N G F O R SM Know? Did You About 80% of the population believes that a smile is very

More information

United Dental Care of Arizona, Inc. 2323 Grand Boulevard Kansas City, MO 64108-2670 800-443-2995 EVIDENCE OF COVERAGE

United Dental Care of Arizona, Inc. 2323 Grand Boulevard Kansas City, MO 64108-2670 800-443-2995 EVIDENCE OF COVERAGE United Dental Care of Arizona, Inc. 2323 Grand Boulevard Kansas City, MO 64108-2670 800-443-2995 EVIDENCE OF COVERAGE ARTICLE I DEFINITIONS 1.1 Agreement: The Group Dental Service Agreement between Group

More information

Keep Smiling. DeltaCare USA. provided by Delta Dental of California. Budget-friendly costs. Dental benefits made easy! Convenient services

Keep Smiling. DeltaCare USA. provided by Delta Dental of California. Budget-friendly costs. Dental benefits made easy! Convenient services Keep Smiling DeltaCare USA provided by Delta Dental of California Dental benefits made easy! When you enroll in a DeltaCare USA 1 plan, you ll choose a primary care dentist from our network of carefully

More information

Aetna Student Health Aetna PPO Dental Plan Design and Benefits Summary Policy Year: 2015 2016 Policy Number 867853

Aetna Student Health Aetna PPO Dental Plan Design and Benefits Summary Policy Year: 2015 2016 Policy Number 867853 Aetna Student Health Aetna PPO Dental Plan Design and Benefits Summary Policy Year: 2015 2016 Policy Number 867853 www.aetnastudenthealth.com (888) 238 4825 This Aetna Dental Preferred Provider Organization

More information

RETIREE DENTAL PLANS MEMBER HANDBOOK THE DENTAL PLAN ORGANIZATIONS AND THE DENTAL EXPENSE PLAN

RETIREE DENTAL PLANS MEMBER HANDBOOK THE DENTAL PLAN ORGANIZATIONS AND THE DENTAL EXPENSE PLAN STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS RETIREE DENTAL PLANS MEMBER HANDBOOK THE DENTAL PLAN ORGANIZATIONS AND THE DENTAL EXPENSE PLAN For Retired Group Members

More information

Dental HMO Plan. Evidence of Coverage and Health Service Agreement. Individual and Family Plan

Dental HMO Plan. Evidence of Coverage and Health Service Agreement. Individual and Family Plan Dental HMO Plan Evidence of Coverage and Health Service Agreement Individual and Family Plan An independent member of the Blue Shield Association (Intentionally left blank) Blue Shield of California Individual

More information

ONTARIO WORKS. Dentist Fee Schedule. Adult Emergency Dental Services (Age 18 and over) District of Muskoka

ONTARIO WORKS. Dentist Fee Schedule. Adult Emergency Dental Services (Age 18 and over) District of Muskoka ONTARIO WORKS Dentist Fee Schedule Adult Emergency Dental Services (Age 18 and over) District of Muskoka May 2012 The Canadian Dental Association is the owner of the copyright and other intellectual property

More information

Dental Benefits (866) 212-2743 A. Choice of Physician and Provider B. Scheduling Appointments C. Referrals to Specialists D. Changing Your Dentist

Dental Benefits (866) 212-2743 A. Choice of Physician and Provider B. Scheduling Appointments C. Referrals to Specialists D. Changing Your Dentist Dental Benefits Dental Benefits are provided through Delta Dental of California. Upon enrollment you will receive a dental provider directory that lists Delta Dental dentists participating in the Healthy

More information

TWO GREAT DENTAL PROGRAMS

TWO GREAT DENTAL PROGRAMS A REGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION TWO GREAT DENTAL PROGRAMS FOR 2015 KAISER PERMANENTE FEDERAL MEMBERS You must be enrolled in one of Kaiser Permanente s medical plans to elect fee-for-service

More information

Comprehensive Plan Benefits Booklet

Comprehensive Plan Benefits Booklet Comprehensive Plan Benefits Booklet For eligible Veterans and CHAMPVA beneficiaries Veterans Affairs Dental Insurance Program deltadentalvadip.org Comprehensive Plan Contact Information and Resources About

More information

2014 Dental Benefits Summary

2014 Dental Benefits Summary 2014 Dental Benefits Summary ICUBA Dental Benefit Options from HumanaDental The dental coverage is offered, so you and your family can receive the important dental care you need for good health. You can

More information

Your Dental Care Benefit Program BLUECARE DENTAL HMO PLAN NUMBER 705

Your Dental Care Benefit Program BLUECARE DENTAL HMO PLAN NUMBER 705 Your Dental Care Benefit Program BLUECARE DENTAL HMO PLAN NUMBER 705 GROUP CERTIFICATE RIDER REGARDING DEPENDENT LIMITING AGE For Dental Plans Changes in state or federal law or regulations or interpretations

More information

Anthem Blue Dental PPO Plan

Anthem Blue Dental PPO Plan Anthem Blue Dental PPO Plan For Individuals and Families Anthem Blue Cross and Blue Shield 700 Broadway Denver, Colorado 80273 anthem.com An independent licensee of the Blue Cross and Blue Shield Association.

More information

RETIREE DENTAL PLANS MEMBER HANDBOOK THE DENTAL PLAN ORGANIZATIONS AND THE DENTAL EXPENSE PLAN

RETIREE DENTAL PLANS MEMBER HANDBOOK THE DENTAL PLAN ORGANIZATIONS AND THE DENTAL EXPENSE PLAN STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS RETIREE DENTAL PLANS MEMBER HANDBOOK THE DENTAL PLAN ORGANIZATIONS AND THE DENTAL EXPENSE PLAN For Retired Group Members

More information

DENTAL PLAN ADMINISTERED BY MEDBEN

DENTAL PLAN ADMINISTERED BY MEDBEN DENTAL PLAN ADMINISTERED BY MEDBEN 2.9 SCHEDULE OF DENTAL BENEFITS This Schedule of Dental Benefits is intended to provide only a general description of a Covered Person s dental benefits under this Plan.

More information

Access PPO 1 Adults Maximum access, convenience and flexibility.

Access PPO 1 Adults Maximum access, convenience and flexibility. Access PPO 1 Adults Maximum access, convenience and flexibility. Benefit Features Deductibles: $50 ($150) per family Annual Maximum: $1,000 Waiting Periods: None Receive Care From: Any Dentist or Access

More information

healthy teeth healthy body arkansas medicaid s dental care for adults

healthy teeth healthy body arkansas medicaid s dental care for adults healthy teeth healthy body arkansas medicaid s dental care for adults eeping your teeth healthy can help your whole body stay well. If your mouth and teeth are clean, you might not get sick as much. That

More information

Managed DentalGuard Family Plan For Plan Years Beginning in 2016

Managed DentalGuard Family Plan For Plan Years Beginning in 2016 FAMILIES ON THE HEALTH INSURANCE EXCHANGE FOR NEW JERSEY Guardian s DHMO Plan The Guardian DentalGuard DHMO plans allow you to choose to receive care from any participating licensed dentist in the network,

More information

DeltaCare USA. Pediatric Basic Plan for Small Businesses. Dental plan administered and underwritten by Delta Dental Insurance Company

DeltaCare USA. Pediatric Basic Plan for Small Businesses. Dental plan administered and underwritten by Delta Dental Insurance Company DeltaCare USA Pediatric Basic Plan for Small Businesses Dental plan administered and underwritten by Delta Dental Insurance Company Available together with select medical plans offered through Florida

More information

Welcome to DeltaCare. Using Your Dental Plan. Emergency Dental Care. Choosing Your Primary Care Dentist

Welcome to DeltaCare. Using Your Dental Plan. Emergency Dental Care. Choosing Your Primary Care Dentist Welcome to DeltaCare DeltaCare is an innovative dental plan that provides you with comprehensive care at a significantly lower cost than most other dental plans which means great value for you. The plan

More information

MEDICAID DENTAL PROGRAMS CODING, POLICY AND RELATED FEE REVISION INFORMATION

MEDICAID DENTAL PROGRAMS CODING, POLICY AND RELATED FEE REVISION INFORMATION MEDICAID DENTAL PROGRAMS CODING, POLICY AND RELATED FEE REVISION INFORMATION Effective for dates of service on and after November 1, 2005, the following dental coding, policy and related fee revisions

More information

Dental Coverage Limitations By Program

Dental Coverage Limitations By Program Dental Coverage Limitations By Program Procedure or Service Common ADA Codes Program Coverage Periodic Oral Exam D0120 If you are less than 21 you may have an exam every 6 months. If you are 21 or older,

More information

LIBERTY Dental Plan of California, Inc.

LIBERTY Dental Plan of California, Inc. LIBERTY Dental Plan of California, Inc. CA50 PLAN SCHEDULE OF BENEFITS Covered Benefits, Member Co-payments, Limitations & Exclusions No Annual Deductible No Annual Dollar Amount Maximum Members must select,

More information