SafeGuard DHMO High Plan - Risk Management

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000470056/SGC1033-FL-KIT-1
The Schedule of Benefits and the Exclusions and Limitations contained within this enrollment kit are provided to give you the details of your benefit plan. Also included is your Evidence of Coverage, which provides further information regarding plan benefits. Benefits provided by SafeGuard Health Plans, Inc. SafeGuard ® is a registered trademark of SafeGuard Health Enterprises, Inc.
Page 1 and 2: DentalDHMOSGC1033
Page 3 and 4: With MetLife's recent acquisition o
Page 5 and 6: SCHEDULE OF BENEFITS Benefits provi
Page 7 and 8: Code Service Co-payment D2510 Inlay
Page 9 and 10: Code Service Co-payment removal) D4
Page 11 and 12: Code Service Co-payment D6781 Crown
Page 13 and 14: Dental Terminology Definitions Thes
Page 15 and 16: Exclusions and Limitations (continu
Page 17 and 18: Evidence of Coverage and Disclosure
Page 19 and 20: Evidence of Coverage and Disclosure
Page 21 and 22: Your lawful spouse or domestic part
Page 23: SafeGuard Dental Plan Enrollment Fo
Page 26 and 27: Emergency Dental Services Emergency
Page 28 and 29: Organization, a member of the heir-
Page 30 and 31: month following notice of terminati
Page 32 and 33: If you are successful, the court ma
Page 34 and 35: The following definitions are used
Page 36 and 37: SAFEGUARD DENTAL & VISION HIPAA NOT
Page 38 and 39: Information to a coroner or medical
Page 40 and 41: electronically). The first list you
Page 46: DHMO-C

SafeGuard DHMO High Plan - Risk Management

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