SafeGuard DHMO High Plan - Risk Management

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<strong>DHMO</strong>-C
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 44 and 45: 000470056/SGC1033-FL-KIT-1

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