400N Enrollment Form - Dental Alternatives Insurance Services Inc

Dental HMO
SmileSaver Individual 400N
Enrollment Kit

This plan will provide you with excellent dental benefits and
save you money. You know how important it is to maintain
good oral health and this plan helps with low or no
co-payments for preventive services. But there is more than
just preventive care … restorative treatment is also covered
at co-payments considerably lower than what you might
expect to pay without this plan.
About this plan …
• No waiting periods, claims forms, deductibles or maximums
• You will access care through a network of pre-screened
general dentists. You and each enrolled dependent may
select a different network dentist.
• Emergency care is available (see Evidence of Coverage
within this booklet).
• Specialty care is covered; review the enclosed Schedule of
Benefits to find out more.

SmileSaver dental and vision plans are provided by
SafeGuard Health Plans, Inc. SafeGuard has been a
leader in the dental benefits industry for 30 years. Our
continued success is due to excellent service, quality
products and the fact that, at SafeGuard, our members
are our first priority. Member satisfaction is monitored
to ensure we meet our goals and your expectations.
This booklet contains important information about your
benefit plan – including your Schedule of Benefits and
Evidence of Coverage. You will receive an ID card after
your enrollment has been processed; in the meantime,
you may use the temporary card below.
Temporary Identification Card
PRINT NAME
SIGNATURE
This card is not required to obtain services

SafeGuard Network Dentists
SafeGuard contracts with dentists who meet our high quality
standards, ensuring you the best dental care available. Each
dentist is pre-screened and each office is thoroughly evaluated
prior to being accepted into our network.
Online Directory Instructions
Before you enroll...
Select a general dentist from the Directory of SafeGuard
Participating Dentists
You and each of your enrolled dependents may select different
general dentists
Online Dentist Listing
The most current network information can be found in our online
directory at www.safeguard.net.
Click on “Dental & Vision Directories”
Choose "Visitor" and then select “Dental HMO” and state.
Select your plan from the scroll down menu (check the
Schedule of Benefits in this booklet for the name of your plan).
You will be able to search by city, county, zip code, or by a
particular dentist's name.
After enrollment...
To access the directory once you are enrolled, log in to our website
and use your Family ID number, Group ID number, or social security
number (Family and Group ID numbers are provided on your ID card).
If you have any questions, you can call Customer
Service at 800.880.1800 or log on to our
website at www.safeguard.net/contact.html to
email us your questions.

DIRECT REFERRAL DENTAL PLAN*
Diagnostic Treatment
• Bitewings are limited to 1 per 12 months.
• Full mouth x-rays are limited to 1 per 3 years.
• Panoramic x-rays are limited to 1 per 3 years.
• Orthodontic x-rays are not covered.
SCHEDULE OF BENEFITS
D0120 Periodic oral evaluation - established patient
D0140 Limited (problem focused) oral evaluation
D0145 Oral evaluation for a patient under three years
of age and counseling with primary caregiver
D0150 Comprehensive oral evaluation - new or
established patient
D0180 Comprehensive periodontal evaluation - new or
established patient
SmileSaver 400 North
Principal Benefits and Coverages: The following services are the principal benefits to
which Members are entitled. Only these procedures are provided for, either partially or
totally by the Plan. The Member may be responsible for a co-payment for these procedures.
Please reference your Evidence of Coverage to fully understand what is meant by Coverage
for a given procedure. If a service is requested and provided to a Member and the procedure
is not listed in this Schedule of Benefits, the Member shall pay the dentist his or her usual
and customary fee for the treatment received. There may be some procedures that are
listed in this document that may not be available at all locations due to individual dentist's
scope of practice.
Other Charges: The Member is responsible for the Co-payments for services listed in the
following Schedule of Benefits. Services not listed will be billed to the Member at the
dentist's usual and customary fee (U&C).
Specialty Care Information: During the course of treatment, your SafeGuard selected
general dentist may recommend the services of a dental specialist.
*Your SafeGuard selected general dentist is responsible for coordinating your dental care,
and if necessary, referring you to a SafeGuard contracted specialist, and will submit all
required documentation for any necessary referral.
Pedodontics: Pedodontic services are available at a Specialist at 75% of that provider’s
usual fee for this service for children under the age of six (6) when referred by a SafeGuard
selected general dentist.
•If you choose to receive this service from a SafeGuard contracted specialty care provider
(periodontics, oral surgery, endodontics, orthodontics), your co-payment will be 75% of that
provider’s usual fee for this service.
Code
Benefit Summary for Specialty Care
Calendar Year Limit
$1,000/Person
Limit per Lifetime
$2,000/Person
Service
Benefits provided by SafeGuard Health Plans, Inc.
Co-payment When
Services Performed
by Contracted
General Dentist
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09
$5
$5
$5
$5
$5
Co-payment When
Services Performed
by Contracted
Specialist
•
$50
$50
$50
$5

Code
D0210
D0220
D0230
D0240
D0270
D0272
D0273
D0274
D0330
D0460
D0470
Service
Office visit - per visit (including all fees for
sterilization and/or infection control)
X-rays intraoral - complete series - including
bitewings (not including ortho x-rays)
X-rays intraoral - periapical - first film
X-rays intraoral - periapical - each additional film
X-rays intraoral - occlusal film
X-rays bitewing - single film
X-rays bitewings - two films
X-rays bitewings - three films
X-rays bitewings - four films
X-rays panoramic film
Pulp vitality tests
Diagnostic casts
Co-payment When
Services Performed
by Contracted
General Dentist
$0
$6
$0
$0
$0
$0
$0
$0
$0
$0
$0
$5
Co-payment When
Services Performed
by Contracted
Specialist
$0
$37
$14
$6
•••••
$25
••
•
•
•
Preventive Services
• Prophylaxis are limited to 2 per 12 months.
• Fluoride treatments are limited to 2 per 12 months for children under age 18.
• Space maintainers are limited to children under age 14.
D1110
D1120
D1203
D1206
D1330
D1351
D1510
D1515
D1520
D1525
D1550
D1555
Restorative Treatment
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2391
D2392
D2393
D2394
Prophylaxis - adult
Prophylaxis - child
Topical application of fluoride (excluding
prophylaxis) - child
Topical fluoride varnish; therapeutic application
for moderate to high caries risk patients
Oral hygiene instructions
Sealant - per tooth
Space maintainer - fixed - unilateral
Space maintainer - fixed - bilateral
Space maintainer - removable - unilateral
Space maintainer - removable - bilateral
Recementation of space maintainer
Removal of fixed space maintainer
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-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
$15
$10
$5
$5
$0
$10
$40
$80
$40
$90
$10
$10
$11
$17
$27
$30
$24
$30
$36
$42
$73
$103
$121
$149
•
•
•
•
•
•
•
•
•
•
•
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09

Code
Crowns
• Cost of Noble or High Noble Metal (gold, etc.) is included in the co-payments shown.
• There is an additional $145 co-payment per crown/bridge unit in addition to regular
co-payments for porcelain on posterior teeth (molars or bicuspids).
• Procedures noted with * are subject to a six month waiting period.
D2750 Crown - porcelain fused to high noble metal* $310 •
• The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth
is $480, including any applicable porcelain co-payment.
• Elective procedures are not subject to the six month waiting period.
D2751 Crown - porcelain fused to predominantly base
metal*
$250 •
• The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth
is $420, including any applicable porcelain co-payment.
• Elective procedures are not subject to the six month waiting period.
D2752 Crown - porcelain fused to noble metal*
$290 •
• The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth
is $460, including any applicable porcelain co-payment.
• Elective procedures are not subject to the six month waiting period.
D2780
$240 •
D2781
$180 •
D2782
$220 •
D2790
$235 •
D2791
$175 •
D2792
$215 •
D2910
D2915
D2920
D2930
D2931
D2940
D2950
D2951
D2952
D2954
D2961
D2962
D2970
D2971
Service
Crown - 3/4 cast high noble metal*
Crown - 3/4 cast predominantly base metal*
Crown - 3/4 cast noble metal*
Crown - full cast high noble metal*
Crown - full cast predominantly base metal*
Crown - full cast noble metal*
Recement inlay, onlay, or partial coverage
restoration
Recement cast or prefabricated post and core
Recement crown
Prefabricated stainless steel crown - primary tooth
Prefabricated stainless steel crown - permanent
tooth
Sedative filling
Core build up, including any pins
Pin retention - per tooth, in addition to restoration
Post and core in addition to crown, indirectly
fabricated
Prefabricated post and core in addition to crown
Labial veneer - resin laminate, laboratory*
Labial veneer - porcelain laminate, laboratory*
Temporary crown (fractured tooth)
Additional procedures to construct new crown
under existing partial dental framework
Endodontics
D3110 Pulp cap - direct (excluding final restoration)
D3120 Pulp cap - indirect (excluding final restoration)
D3220 Therapeutic pulpotomy (excluding final restoration)
D3310 Root canal - anterior, per tooth (excluding final
restoration)
D3320 Root canal - bicuspid, per tooth (excluding final
restoration)
Co-payment When
Services Performed
by Contracted
General Dentist
$14
$14
$14
$48
$48
$0
$0
$0
$50
$30
$400
$425
$0
$113
$5
$5
$15
$125
$190
Co-payment When
Services Performed
by Contracted
Specialist
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09
•
•
•
•
•
•
•
•
•
•
•

Code
D3330
D3351
D3352
D3353
D3410
D3421
D3425
D3426
D3430
D3450
D3920
Service
Root canal - molar, per tooth (excluding final
restoration)
Apexification/recalcification - initial visit
Apexification/recalcification - interim visit
Apexification/recalcification - final visit
Apicoectomy/periradicular surgery - anterior
Apicoectomy/periradicular surgery - bicuspid,
1st root
Apicoectomy/periradicular surgery - molar, 1st
root
Apicoectomy/periradicular surgery - each
additional root
Retrograde filling - per root
Root amputation - per root
Hemisection - including root removal
(excluding root canal therapy)
Periodontics
D4210 Gingivectomy or gingivoplasty - four or more
contiguous teeth or bounded teeth spaces per
quadrant
D4211 Gingivectomy or gingivoplasty - one to three
contiguous teeth or bounded teeth spaces per
quadrant
D4260 Osseous surgery (including flap entry and
closure) - four or more contiguous teeth or
bounded teeth spaces per quadrant
D4261 Osseous surgery (including flap entry and
closure) - one to three contiguous teeth or
bounded teeth spaces per quadrant
D4341 Periodontal scaling and root planing - four or
more teeth - per quadrant
D4342 Periodontal scaling and root planing - one to
three teeth, per quadrant
D4355 Full mouth debridement to enable
comprehensive evaluation and diagnosis
D4381 Localized delivery of antimicrobial agents via a
controlled release vehicle into diseased
crevicular tissue, per tooth, by report
D4910 Periodontal maintenance procedures - following
active periodontal therapy
Initial perio charting for moderate to advanced
cases
Co-payment When
Services Performed
by Contracted
General Dentist
$250
$12
$12
$12
$125
$125
$125
$125
$30
U&C
• Procedures noted with * are subject to a six month waiting period.
D5110
D5120
D5130
D5140
Complete upper denture*
Complete lower denture*
Immediate upper denture*
Immediate lower denture*
$275
$275
$330
$330
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09
U&C
$90
$30
$250
$200
$45
$36
$45
$40
$45
$5
Co-payment When
Services Performed
by Contracted
Specialist
•
•
•
•
•
•
•
•
•
•
•
$80
•
•
•
•
$64
•
•
$55
•
Removable Prosthodontics
• Removable Prosthodontics - Includes all adjustments for up to six (6) months post-delivery.
•
•
•

Code
D5211
D5212
D5213
D5214
D5225
D5226
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5820
D5821
D5850
D5851
Service
Upper partial - resin base (including clasps,
rests and teeth)*
Lower partial - resin base (including clasps,
rests and teeth)*
Upper partial - cast metal base with resin
saddles (including clasps, rests and teeth)*
Lower partial - cast metal base with resin
saddles (including clasps, rests and teeth)*
Maxillary partial denture - flexible base
(including any clasps, rests and teeth)*
Mandibular partial denture - flexible base
(including any clasps, rests and teeth)*
Adjust complete denture - upper
Adjust complete denture - lower
Adjust partial denture - upper
Adjust partial denture - lower
Repair broken complete denture base
Replace missing or broken teeth
Repair resin denture base
Repair cast framework
Repair or replace broken clasp
Replace broken teeth - per tooth
Add tooth to existing partial denture
Add clasp to existing partial denture
Rebase complete upper denture
Rebase complete lower denture
Rebase upper partial denture
Rebase lower partial denture
Reline complete upper denture (chairside)
Reline complete lower denture (chairside)
Reline upper partial denture (chairside)
Reline lower partial denture (chairside)
Reline complete upper denture (laboratory)
Reline complete lower denture (laboratory)
Reline upper partial denture (laboratory)
Reline lower partial denture (laboratory)
Interim partial denture - upper
Interim partial denture - lower
Tissue conditioning - upper
Tissue conditioning - lower
Co-payment When
Services Performed
by Contracted
General Dentist
$215
$215
$275
$275
$215
$215
$8
$8
$8
$8
$30
$22
$28
$44
$44
$22
$22
$50
$75
$75
$75
$75
$33
$33
$33
$33
$70
$70
$70
$70
$80
$80
$20
$20
• Procedures noted with * are subject to a six month waiting period.
D6210 Pontic - cast high noble metal*
D6211 Pontic - cast predominantly base metal*
D6212 Pontic - cast noble metal*
$240
$180
$220
Co-payment When
Services Performed
by Contracted
Specialist
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Fixed Prosthodontics
• Cost of Noble or High Noble Metal (gold, etc.) is included in the co-payments shown.
• There is an additional $145 co-payment per crown/bridge unit in addition to regular
co-payments for porcelain on posterior teeth (molars or bicuspids).
•
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09

Code
D6240 Pontic - porcelain fused to high noble metal* $310 •
• The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth
is $480, including any applicable porcelain co-payment.
• Elective procedures are not subject to the six month waiting period.
D6241 Pontic - porcelain fused to predominantly base
metal*
$250 •
• The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth
is $420, including any applicable porcelain co-payment.
• Elective procedures are not subject to the six month waiting period.
D6242 Pontic - porcelain fused to noble metal*
$290 •
• The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth
is $460, including any applicable porcelain co-payment.
• Elective procedures are not subject to the six month waiting period.
D6750 Crown - porcelain fused to high noble metal* $310 •
• The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth
is $480, including any applicable porcelain co-payment.
• Elective procedures are not subject to the six month waiting period.
D6751 Crown - porcelain fused to predominantly base
metal*
$250 •
• The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth
is $420, including any applicable porcelain co-payment.
• Elective procedures are not subject to the six month waiting period.
D6752 Crown - porcelain fused to noble metal*
$290 •
• The co-payment per crown/bridge unit for elective procedures on anterior or posterior teeth
is $460, including any applicable porcelain co-payment.
• Elective procedures are not subject to the six month waiting period.
D6780
$240 •
D6781
$180 •
D6782
$220 •
D6790
$240
D6791
$180
D6792
$220
D6930
$20 •
D6970
$50 •
D6972
D6973
Service
Crown - 3/4 cast high noble metal*
Crown - 3/4 cast predominantly base metal*
Crown - 3/4 cast noble metal*
Crown - full cast high noble metal*
Crown - full cast predominantly base metal*
Crown - full cast noble metal*
Recement bridge
Post and core in addition to fixed partial
denture retainer, indirectly fabricated
Prefabricated post and core in addition to
bridge retainer
Core build up for retainer, including any pins
Co-payment When
Services Performed
by Contracted
General Dentist
$30
$30
Co-payment When
Services Performed
by Contracted
Specialist
•
Oral Surgery
D7111
D7140
D7210
D7220
D7230
D7240
Extraction, coronal remnants - deciduous tooth
Extraction - erupted tooth or exposed root
(elevation and/or forceps removal)
Surgical removal of erupted tooth
Extraction - removal of impacted tooth - soft
tissue
Extraction - removal of impacted tooth -
partially bony
Extraction - removal of impacted tooth -
completely bony
$14
$15
$25
$40
$60
$75
$30
$40
$70
$110
$135
$160
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09

Code
D7250
D7510
D7530
D7550
D7910
D7960
D7963
D7970
Service
Surgical extraction - removal of residual tooth
roots
Incision and drainage of abscess - intraoral
soft tissue
Removal of foreign body from mucosa, skin,
or subcutaneous alveolar tissue
Partial ostectomy/sequestrectomy for
removal of non-vital bone
Suture of recent small wounds up to 5 cm
Frenulectomy (frenectomy or frenotomy) -
separate procedure
Frenuloplasty
Excision of hyperplastic tissue, per arch
Co-payment When
Services Performed
by Contracted
General Dentist
$25
U&C
U&C
U&C
U&C
$50
$50
U&C
Co-payment When
Services Performed
by Contracted
Specialist
•
•
•
•
•
$50
$50
•
Orthodontics
D8030
D8040
D8080
D8090
D8210
D8220
D8660
D8670
D8680
D8693
Adjunctive General Services
D9110
D9120
D9215
D9310
D9430
D9440
D9450
D9930
D9941
Limited orthodontic treatment of the
adolescent dentition (child)
Limited orthodontic treatment of the adult
dentition (adult)
Comprehensive orthodontic treatment of the
adolescent dentition (up to 24 months) (child)
Comprehensive orthodontic treatment of the
adult dentition (up to 24 months) (adult)
Minor treatment to control harmful habits -
removable appliance therapy
Minor treatment to control harmful habits -
fixed appliance therapy
Pre-orthodontic treatment visit
Periodic orthodontic treatment visit (as part of
contract)
Retention phase (removal of appliances,
construction and placement of retainers)
Rebonding or recementing; and/or repair, as
required of fixed retainers
Palliative (emergency) treatment of dental pain -
minor procedure
Fixed partial denture sectioning
Local anesthesia
Consultation - diagnostic service provided by
dentist or physician other than requesting
dentist or physician (other than orthodontist)
Office visit for observation (during regularly
scheduled hours) - no other services performed
Office visit - after regularly scheduled hours
Case presentation, detailed and extensive
treatment planning
Treatment of complications (post-surgical) -
unusual circumstances, by report
Fabrication of athletic mouthguard
U&C
U&C
U&C
U&C
$75
$95
U&C
$0
U&C
U&C
$15
U&C
$0
$50
$5
$30
$5
U&C
$140
$1,450
$1,550
$2,100
$2,250
•
•
$45
$0
$175
$0
$15
•
$0
$50
•
•
$5
$0
•
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09

Code
D9942
D9951
D9972
Service
Repair and/or relining of an occlusal guard
Occlusal adjustment - limited (per visit)
External bleaching - per arch
Missed appointments - without twenty-four (24)
hour prior notice
Record transfer - transfer of all materials with
less than a full mouth x-ray
Record transfer - transfer of all materials with a
full mouth x-ray
Co-payment When
Services Performed
by Contracted
General Dentist
$30
$12
$175
Current Dental Terminology © American Dental Association
•If you choose to receive this service from a SafeGuard contracted specialty care provider
(periodontics, oral surgery, endodontics, orthodontics), your co-payment will be 75% of that
provider’s usual fee for this service.
$20
$10
$20
Co-payment When
Services Performed
by Contracted
Specialist
•
$0
•
$22
$10
$20
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09

Dental Terminology Definitions
These definitions are designed to give you a “layman’s understanding” of some dental
terminology in order for you to better understand your plan; they are not full descriptions.
Amalgam:
Anterior:
Bicuspid:
Bridge:
Crown:
Endodontics:
Oral Surgery:
Orthodontics:
Periodontics:
Posterior:
Primary Teeth:
Prophylaxis:
Prosthodontics:
Quadrant:
Resin-based
Composite:
A silver filling
Teeth that are in the front of the mouth
Most people have eight bicuspid teeth; they are located immediately
preceding the molar teeth with two in each quadrant of the mouth.
A replacement for one or more missing teeth that is permanently attached
to the teeth adjacent to the empty space(s).
A covering created to place over a tooth to strengthen and/or replace
tooth structure. A crown can be made of different materials (noble, high
noble), base metal, porcelain or porcelain and metal.
Procedures that treat the nerve or the pulp of the tooth due to injury or
infection.
Surgery to remove teeth, reshape portions of the bone in the mouth, or
biopsy suspect areas of the mouth.
Braces and other procedures to straighten the teeth.
Procedures related to treatment of the supporting structures of the
teeth (gums, underlying bone).
Teeth that set towards the back of the mouth, including molars and
bicuspids (premolars).
The first set of teeth (“baby” teeth).
Scaling and polishing of teeth by removal of the plaque above the gum
line.
The restoration of natural and/or the replacement of missing teeth
with artificial substitutes.
One of the four equal sections into which your mouth can be divided (some
procedures like periodontics are done in quadrants).
Tooth-colored (white) fillings
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09

Principle Exclusions and Limitations on Benefits
Limitations
The limitations listed below apply to your dental plan. However, you may elect to have any
treatment performed at the dentist's regular fee:
1. Services performed by a general dentist or specialty care dentist, not contracted
with SafeGuard, without prior approval by SafeGuard (except for out of area emergency
services).
2. Major restorative work (i.e., crowns, bridgework or dentures) requires a six (6)
month wait from the current effective date of coverage for the member (patient).
These procedures are noted in the Schedule of Benefits with an asterisk.
3. Routine and periodic examinations are limited to two (2) per twelve (12) months, per
enrolled Member.
4. Routine prophylaxis procedures are limited to two (2) per twelve (12) months.
5. Bitewing radiographs (x-rays) in conjunction with periodic examinations are limited
to one (1) series of films in any twelve (12) consecutive month period. Full mouth
radiographs (x-rays), in conjunction with periodic examinations, are limited to once
every three (3) years. Panoramic films are limited to once every three (3) years.
6. Fluoride treatment is limited to enrolled Members under the age of eighteen (18)
years, and two (2) per twelve (12) months.
7. Periodontal scaling and root planing, and/or gingival curettage, and periodontal
maintenance procedures are limited to one (1) course of therapy during any twelve
(12) month period.
8. Space maintainers are limited to enrolled Members under the age of fourteen (14)
years.
9. Partial Dentures are not eligible for replacement within three (3) years of original
placement unless required as a result of tooth loss which cannot be restored by
modification of the existing partial denture. Crowns, bridges, and/or complete
dentures are not eligible for replacement within five (5) years of original placement.
10. Complete upper and/or lower dentures are covered only once within any five (5) year
period. Replacement will be provided for an existing denture only if it is unsatisfactory
and cannot be made satisfactory. Complete or partial upper and/or lower dentures
are limited to the benefit level for a standard procedure. If a more personalized or
specialized treatment (such as precision attachments, overlays, implants,
personalization or characterization) is chosen by the patient and the dentist, the
patient will be responsible for all additional charges.
11. Complete and/or partial denture relines are limited to one (1) per denture during a
twelve (12) month period.
12. Endodontic retreatment of previous root canal therapy is not a covered benefit.
13. Pedodontic services are available to eligible Members under the age of six (6)
years, if his or her assigned Participating General Dentist requests the referral to
the participating Specialist after examining the patient. Pedodontic benefits are
available at a reduced rate from participating dental offices.
14. Plan Contribution towards the cost of specialty care as a result of an approved
referral is limited to a maximum of $1,000 per contract year. Lifetime maximum of
$2,000.
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09

Principle Exclusions and Limitations on Benefits
Exclusions
The following dental services and procedures are not included in this dental plan and
there is no coverage for these items. However, you may elect to have any treatment
performed at the dentist's regular fee:
1. Any procedure not specifically listed as a covered benefit.
2. Any condition for which benefits of any nature are recovered or found to be
recoverable, whether by adjudication or settlement, medical health insurance,
worker's compensation or occupational disease law, even if the patient did not
claim those benefits.
3. Care or treatment which is obtained from, or for which payment is made by, any
Federal, State, County, Municipal, or other governmental agency, including any foreign
government.
4. Disease contracted or injuries sustained as a result of a major disaster, war, declared
or undeclared, epidemic conditions, or from exposure to nuclear energy, whether or
not the result of war.
5. Any illness, injury, or condition for which a third party may be liable or legally
responsible by reason of negligence, an intentional act or breach of any legal
obligation on the part of such third party is not covered.
6. Dental treatment or expenses incurred or in connection with any dental procedures
started prior to the Member's effective date under this Plan or after termination of
the Member's coverage. Example: teeth prepared for crowns, root canal treatment
in progress, orthodontic treatment in progress.
7. Dispensing of drugs not normally supplied in the dental office.
8. Hospital and associated physician charges or any kind of charges for any dental
treatment or costs associated with treatment as a result of an accident. This plan
does not provide emergency medical care to its members, except, if applicable, in
certain specifically identified instances. Members are encouraged to use the 911
emergency response system in areas where the system is established and operating
when the Member has an emergency medical condition that requires an emergency
response.
9. All treatment of fractures and dislocations.
10. Extractions for orthodontic purposes.
11. General anesthesia, inhalation sedation, intravenous sedation, or intramuscular
sedation.
12. Dental treatment or expenses incurred in conjunction with the correction of congenital
or developmental malformations.
13. Histopathological exams, treatment and/or removal of cysts, tumors, neoplasms,
malignancies and foreign bodies.
14. Tooth implantation or transplantation, orthognathic surgery, soft tissue or osseous
grafts, alveoloplasty, vestibuloplasty, or osteotomy procedures.
15. Charges for any dental treatment, because the Member is unwilling or incapable of
having treatment performed in the assigned general dentist or specialist office.
16. Dental procedures and charges incurred as part of implants (placement or removal)
and prosthetic devices placed on implants (fixed or removable, example: bridges,
crowns, dentures).
17. Replacement of lost or stolen dentures, crown and bridgework, or other dental
appliances.
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09

Principle Exclusions and Limitations on Benefits
18. Precision attachments and stress breakers.
19. Crown lengthening surgical procedures.
20. Periodontal irrigation procedures, when available, are provided at the doctor's regular
fee.
21. Dental treatment or procedures required in conjunction with altering vertical
dimension, replacing tooth structure lost by attrition, erosion or abrasion.
22. Dental treatment or procedures requiring or associated with fixed prosthodontic
restorations when part of extensive oral rehabilitation or reconstruction (more than
six (6) units of crown and/or bridgework in one (1) arch or more than ten (10) units
total). Extensive oral rehabilitation or reconstruction is available at the dentist's
regular fee.
23. Diagnosis or treatment by any method of any condition related to the jaw joint,
temporomandibular joint (TMJ) or associated musculature, nerves and other tissues.
24. Oral physio-therapy, dietary or saliva analysis and dietary instruction.
25. The treating dentist shall have the right to discontinue further treatment of a
Member who continually fails to keep appointments or who fails to follow their
prescribed course of treatment.
26. A dental treatment plan which in the opinion of the Participating Dentist, is not
dentally necessary, will not produce a beneficial result, or has a poor prognosis.
27. Any corrective treatment required as a result of dental services performed by a
non-participating dentist while this coverage is in effect, and any dental services
started by a non-participating dentist will not be the responsibility of the participating
dental office or the Plan for completion or compensation.
Orthodontic Exclusions & Limitations
Limitations
A. Child co-payments apply only to those members up to age nineteen (19). Age
nineteen (19) and older are considered adults and are subject to adult co-payments.
Age is determined on the date bands are placed.
B. Treatment co-payments are for twenty-four (24) months of treatment. Treatment in
excess of twenty-four (24) months (extended treatment) is available at usual and
customary fees, payable until treatment is completed (retainers are placed). If the
patient is in active treatment and the member elects to change providers, the
member may incur additional expenses.
C. Member and his or her eligible dependent must remain on the Plan during the
period of time the member or his or her eligible dependent is undergoing
orthodontic treatment. An early termination will result in usual and customary
charges for all unfinished work.
D. Orthodontic treatment must be provided by participating Orthodontist.
Exclusions
A. The following are not benefits included as orthodontia:
1. Study models
2. X-rays for orthodontic purposes
3. Tracings and photographs
4. Phase I orthodontic treatment (prior to full mouth banding)
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09

Principle Exclusions and Limitations on Benefits
B. Treatment in progress started prior to a Member's eligibility under this plan.
C. Surgical procedures for orthodontic treatment.
D. Severe or mutilated malocclusions.
E. Retreatment of orthodontic cases.
F. Changes in treatment necessitated by accident of any kind.
G. Hospital charges, or treatment in a hospital.
H. Dispensing of drugs not normally supplied in a dental office.
I. Treatment of temporomandibular joint (TMJ) disturbances, hormonal imbalances,
cleft palate, micrognathia, macroglossia, and myofunctional therapies are excluded
services.
J. Replacement of lost or broken appliances.
K. Extractions for orthodontic purposes.
Language Assistance
As a SafeGuard member you have a right to free language assistance services, including
interpretation and translation services. SafeGuard collects and maintains your language
preferences, race, and ethnicity so that we can communicate more effectively with our
members. If you require language assistance or would like to inform SafeGuard of your
preferred language, please contact SafeGuard at (800) 880-1800.
Como miembro de SafeGuard usted tiene derecho a recibir servicios gratuitos de asistencia
en idiomas. Esto incluye servicios de interpretación y traducción. SafeGuard recaba la
información sobre sus preferencias de idioma, raza, y etnia de manera que nos podamos
comunicar eficazmente con nuestros afiliados. Si necesita asistencia en su idioma o
quiere informarle a SafeGuard sobre su idioma de preferencia, comuníquese con SafeGuard
al (800) 880-1800.
SM-400N-IDP-SOB Customer Service (800) 880-1800
1/09

Evidence of Coverage
and Disclosure Statement
Individual Dental Plan
SG-INDIV-EOC 1
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Evidence of Coverage and Disclosure Statement
This Evidence of Coverage provides a detailed summary of how your SafeGuard
dental plan operates, your entitlements, and the plan’s restrictions and
limitations. However, this combined Evidence of Coverage and
Disclosure Statement constitutes only a summary of the
health plan. The health plan contract must be consulted to
determine the exact terms and conditions of coverage.
This Evidence of Coverage and Disclosure Statement is subject to Chapter
2.2 of Division 2 of the California Health and Safety Code (commonly referred
to as the Knox-Keene Act) and the regulations issued thereto by the
Department of Managed Health Care. Should either the law or the regulations
be amended, such amendments shall automatically be deemed to be a part
of this document and shall take precedence over any inconsistent provision
of this contract. Any provision required to be in this Evidence of Coverage and
Disclosure Statement by either law or the regulation shall automatically bind
SafeGuard.
Entire Contract
SafeGuard typically contracts with an Individual, such as yourself to provide
benefits. Your application, Enrollment Form, this Evidence of Coverage and
any attachments or inserts including the Schedule of Benefits with Exclusions
and Limitations, constitutes the entire agreement between the parties. To
be valid, any change in the contract must be approved by an officer of
SafeGuard and attached to it. No agent may change the Contract or waive
any of the provisions. Should any provision herein not conform to applicable
laws, it shall be construed as if it were in full compliance thereof.
SG-INDIV-EOC 2
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Evidence of Coverage and Disclosure Statement
Table of Contents
Who May Enroll .................................................................................. 4
Service Area ...................................................................................... 4
Dependent Coverage .......................................................................... 4
When Coverage Begins ...................................................................... 4
Choice of Provider .............................................................................. 5
Facilities ........................................................................................... 5
New Patient and Routine Services ...................................................... 5
Making an Appointment ...................................................................... 5
Uniform Health Plan Benefits and Coverage Matrix ............................... 6
Specialist Referrals ............................................................................ 6
Changing Your Selected General Dental Office ...................................... 6
Second Opinions ................................................................................ 7
Prepayment Fee ................................................................................. 8
Co-payments ..................................................................................... 8
Other Charges ................................................................................... 8
Coordination of Benefits ..................................................................... 8
Customer Service .............................................................................. 8
Emergency Dental Services ................................................................ 8
Grievance Procedures ....................................................................... 10
Arbitration ....................................................................................... 11
Termination of Benefits .................................................................... 11
Renewal Provisions .......................................................................... 12
Reinstatement ................................................................................ 12
Current Members ............................................................................. 13
New Members ................................................................................. 13
Member Rights ................................................................................ 14
Member Responsibilities .................................................................. 14
Language Assistance ....................................................................... 15
Definitions. ...................................................................................... 16
SG-INDIV-EOC 3
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Who May Enroll
You may enroll yourself and your dependents, provided each meets eligibility
requirements and/or the Service Area and Dependent Coverage requirements
listed below.
Service Area
The Service Area is the geographical area in which SafeGuard has a panel of
Selected General Dentists and Specialists who have agreed to provide care
to SafeGuard members. To enroll in the SafeGuard plan, you must reside, live,
or work in the Service Area, and the permanent legal residence of any enrolled
dependents must be:
• The same as yours;
• In the Service Area with the person having temporary or permanent
conservatorship or guardianship of such dependents, where the Subscriber
has legal responsibility for the health care of such dependents;
• In the Service Area under other circumstances where you are legally
responsible for the health care of such dependents; or
• In the Service Area with your spouse.
Dependent Coverage
SafeGuard defines eligible dependents to be:
• Your lawful spouse or registered domestic partner.
• Your unmarried children or grandchildren up to age 25 for whom you
provide care (including adopted children, step-children, or other children
for whom you are required to provide dental care pursuant to a court or
administrative order).
• Your children who are incapable of self-sustaining employment and support
due to a developmental disability or physical handicap.
When Coverage Begins
Coverage for you and your enrolled dependents will begin on the date in your
enrollment materials. Newborn children are covered the first day of the month
following the date of birth and legally adopted children, foster children and
stepchildren are covered the first day of the month following placement as
long as SafeGuard is notified within thirty (30) days and any prepayment fee
is paid within that period.
SG-INDIV-EOC 4
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Choice of Provider
When you enroll in the SafeGuard plan, you and each enrolled family member
must choose a Selected General Dental Office from our SafeGuard network.
Each family member may select a different dental office. Please refer to the
Directory of Participating Dentists for a complete listing of Selected General
Dental Offices. Or you may access our website at www.safeguard.net to view
SafeGuard General Dentists in your home or work zip codes.
Facilities
A complete list of contracted facilities is contained in the Directory of Participating
Dentists.
New Patient and Routine Services
As a SafeGuard member, you have the right to expect that the first available
appointment time for new patient or routine dental care services is within four
(4) weeks of your initial request. If your schedule requires that an appointment
be scheduled on a specific date, day of the week, or time of day, the Selected
General Dentist may need additional time to meet your special request.
Making an Appointment
Once your coverage begins, you may contact the Selected General Dental
Office you selected at enrollment to schedule an appointment. SafeGuard
Selected General Dental Offices are open in accordance with their individual
practice needs. When scheduling an appointment, please identify yourself as
a SafeGuard member. Your Selected General Dental Office will also need to
know your chief dental concern and basic personal data. Arrive early for your
first appointment to complete any paperwork. There is an office visit co-payment
on some plans and also be aware that there is a charge for missing your
appointment. Your first visit to your dentist will usually consist of x-rays and an
examination only. By performing these procedures first, your dentist can
establish your treatment plan according to your overall health needs.
We recommend that you take this brochure with you on your appointment,
along with the enclosed Schedule of Benefits. Remember, only dental services
listed as covered benefits in the Schedule of Benefits and provided by a
SafeGuard Dentist are covered.
SG-INDIV-EOC 5
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8/08

SmileSaver Individual & Family Enrollment Application
To ensure that you’re correctly enrolled in the plan(s) you have selected, make sure to fill the form out completely. We cannot guarantee
access to care if information is missing. With these plans, care is provided by a network dentist ... make sure you include the facility
number for the providers you’ve chosen.
Broker #: General Agent #: Master General #:
Last Name
First Name
MI
Subscriber SS#
- -
Home Address
Apt. #
City
State
Zip Code
Male/Female Date of Birth
Home Telephone ( )
Work Telephone ( )
Ext.
Plan
Selected:
Dental: SM400 SM600
Must be completed to enroll:
Facility # - 1 st Choice Facility # - 2 nd Choice
Dependent Information:
Select up to 3 dentists, 3 orthodontists and 1 vision care provider per family
Last Name First Name MI Sex Birthdate Facility # - 1 st Choice Facility # - 2 nd Choice
Spouse
Child #1
Child #2
Child #3
Child #4
Must be completed to enroll in plan(s)
Step 1. Select a rate
Step 2. Select a payment option
Annual Rates:
Annual by check made payable to SmileSaver (include with application)
Dental SM400 SM600
Subscriber Only $ 192.96 $ 69.96
Subscriber + One $ 288.96 $ 114.96
Subscriber + Family $ 397.92 $ 141.00
Monthly by credit card Annual by credit card
Please charge my: VISA MasterCard Discover American Express
Credit Card Number Expiration Date CID #
One-time application fee (non-refundable) +$16.00
Name as it appears on credit card:
_____ / ____ ______
Total Amount $ __________
I hereby authorize credit card payment in the amount indicated on this application:
Monthly Rates:
Signature: Date:
Dental SM400 SM600
Subscriber Only $ 17.00 $ 6.65
Subscriber + One $ 25.20 $ 10.40
Subscriber + Family $ 34.50 $ 13.00
One-time application fee (non-refundable) +$16.00
Total Amount $__________
Monthly by checking account (Include check for first month’s payment.
This is the account number we will use for your monthly bank debit.)
Automatic Bank Account payments are deducted on or about the 20th of each month.
I hereby authorize SafeGuard Health Plans, Inc., to debit the designated prepayment
fee each month from my bank account. This authorization will remain in effect until I
notify SafeGuard, in writing, 30 days prior to termination. My bank is authorized to
make any necessary corrections.
Signature: Date:
Use and Disclosure of Personal Health Information:
Agreement - I understand that any dispute or controversy which may arise between SafeGuard Health Plans, Inc., a California Corporation and myself, may
be submitted to binding arbitration in lieu of a jury or court trial.
Authorization to release dental/vision records - I hereby authorize the release and disclosure to review, or to obtain a copy of, any and all dental records
which pertain to me or any member of my family, maintained by my chosen selected provider and/or specialist, to SafeGuard and/or any designated agent
or representative for the purposes of dental treatment, care and for SafeGuard’s quality assessment and utilization reviews, which will be kept strictly
confidential. This authorization shall remain valid for the term of this coverage.
I understand that the initial term of the plan contract is for one year.
Signature: Date:
Mail this application to: SmileSaver - DAIS
3720 S. Susan St. #200
Santa Ana, CA 92704
Visit SafeGuard’s website at www.safeguard.net for current provider listings
SmileSaver sm
Dental & Vision products are provided by SafeGuard Health Plans, Inc.
SM-IND-FAM-EF 4/07

Effective Dates of Coverage
The date your SmileSaver coverage becomes effective is based on when we receive your application and payment. If you have
questions after reviewing the following information, call us at 800.445.8119.
Annually by check or credit card: If your application and payment is received by the 20th of the month, you will be able to use your
benefits on the first day of the following month (e.g. received by March 20, your benefits will be effective April 1).
Monthly bank draft: If your application and payment is received by the 10th of the month, you will be able to use your benefits on
the first day of the following month (e.g. received by March 10, your benefits will be effective April 1. After the 10th of March, your
benefits will be effective May 1).
Monthly credit card draft: If your application and payment is received by the 20th of the month, you will be able to use your
benefits on the first day of the following month (e.g. received by March 20, your benefits will be effective April 1. After the 20th
of March, your benefits will be effective May 1).

Uniform Health Plan Benefits and Coverage Matrix
This matrix is designed to help you compare covered benefits and is a summary
only. Please review this Evidence of Coverage and the Schedule of Benefits
for a detailed description of covered benefits, exclusions and limitations.
Category
Co-payments and Limitations
Deductibles
Your plan may have a deductible
(co-payment) for services listed in your
plan’s Schedule of Benefits.
Lifetime Maximums
Not applicable.
Professional Services Covered professional services are
provided by Participating Dentists.
Emergency Health Coverage Not applicable.
Ambulance Services
Not applicable.
Prescription Drug Coverage Not applicable.
Durable Medical Equipment Not applicable.
Mental Health Services Not applicable.
Chemical Dependency Services Not applicable.
Home Health Services Not applicable.
Other
Please review your plan’s Schedule of
Benefits for more details on covered
services.
Specialist Referrals
During the course of treatment, you may require the services of a Specialist.
Your Selected General Dental Office will submit all required documentation
to SafeGuard and SafeGuard will advise you of the name, address, and
telephone number of the Specialist who will provide the required treatment.
These services are available only when the dental procedure cannot be
performed by the Selected General Dental Office due to the severity of the
problem. Some SafeGuard plans require that specialty referrals be authorized
in writing from SafeGuard while others incorporate a direct or self-referral
process. Full information is contained in your plan Schedule of Benefits.
Changing Your Selected General Dental Office
You have control over your choice of dental offices, and you can make changes
at any time. If you would like to change your Selected General Dental Office,
please contact Customer Service at (800) 880-1800. Our associates will
help you locate a dental office most convenient to you. The transfer will be
effective on the first day of the month following the transfer request. You
must pay all outstanding charges owed to your dentist before you transfer to
a new dentist. In addition, you may have to pay a fee for the cost of duplicating
your x-rays and dental records.
SG-INDIV-EOC 6
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Second Opinions
You may request a second opinion if you have unanswered questions about
diagnosis, treatment plans, and/or the results achieved by such dental
treatment. Contact SafeGuard’s Customer Service Department either by calling
(800) 880-1800 or sending a written request to the following address:
SafeGuard
c/o Customer Service
PO Box 3594
Laguna Hills, CA 92654-3594
In addition, your Selected General Dentist or SafeGuard may also request a
second opinion on your behalf. There is no second opinion consultation charge
to you. You will be responsible for the office visit co-payment as listed on your
Schedule of Benefits.
Reasons for a second opinion to be provided or authorized shall include, but
are not limited to, the following:
(1) If you question the reasonableness or necessity of recommended
surgical procedures.
(2) If you question a diagnosis or plan of care for a condition that threatens
loss of life, loss of limb, loss of bodily function, or substantial
impairment, including, but not limited to, a serious chronic condition.
(3) If the clinical indications are not clear or are complex and confusing,
a diagnosis is in doubt due to conflicting test results, or the treating
dentist is unable to diagnose the condition, and the enrollee requests
an additional diagnosis.
(4) If the treatment plan in progress is not improving your dental condition
within an appropriate period of time given the diagnosis and plan of
care, and you request a second opinion regarding the diagnosis or
continuance of the treatment.
Requests for second opinions are processed within five (5) business days of
receipt by SafeGuard of such request, except when an expedited second opinion
is warranted; in which case a decision will be made and conveyed to you
within 24 hours. Upon approval, SafeGuard will contact the consulting dentist
and make arrangements to enable you to schedule an appointment. All second
opinion consultations will be completed by a contracted dentist with
qualifications in the same area of expertise as the referring dentist or dentist
who provided the initial examination or dental care services. You may obtain a
copy of the second dental opinion policy by contacting SafeGuard’s Customer
Service Department by telephone at the toll-free number indicated above, or
by writing to SafeGuard at the above address.
SG-INDIV-EOC 7
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No co-payment is required for a second opinion consultation. Some plans do
require a co-payment for an office visit.
Your Financial Responsibility:
Prepayment Fee
Your prepayment fee is the amount you pay SafeGuard for your dental benefits.
It is due and payable either annually or by monthly bank draft, according to
your agreement with SafeGuard. Please refer to the co-payment section, below,
for information relating to your co-payments under this plan. The prepayment
fee is not the same as a co-payment.
Co-payments
When you receive care from either a Selected General Dentist or Specialist, you
will pay the co-payment described on your Schedule of Benefits enclosed with this
Evidence of Coverage. When you are referred to a Specialist, your co-payment may
be either a fixed dollar amount, or a percentage of the dentist’s usual and customary
fee. Please refer to the Schedule of Benefits for specific details. When you have
paid the required co-payment, if any, you have paid in full. If SafeGuard fails to pay
the contracted provider, you will not be liable to the provider for any sums owed by
SafeGuard. If you choose to receive services from a non-contracted provider, you
may be liable to the non-contracted provider for the cost of services unless
specifically authorized by SafeGuard or in accordance with emergency care
provisions. SafeGuard does not require claim forms.
Other Charges
All other charges you may be required to pay under this plan are listed in the
Schedule of Benefits.
Coordination of Benefits
SafeGuard does not coordinate benefits with any other carrier. If you have
coverage with another carrier, please contact that carrier to determine whether
coordination of benefits is available.
Customer Service
SafeGuard provides toll-free access to our Customer Service Associates to
assist you with benefit coverage questions, resolving problems or changing
your dental office. SafeGuard’s Customer Service can be reached Monday
through Friday at (800) 880-1800 from 5:00 a.m. to 6:00 p.m. Pacific Time.
Automated service is also provided after hours for eligibility verification and
dental office transfers.
Emergency Dental Services
Emergency dental services are dental procedures administered in a dentist’s
office, dental clinic, or other comparable facility, to evaluate and stabilize
SG-INDIV-EOC 8
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dental conditions of a recent onset and severity accompanied by excessive
bleeding, severe pain, or acute infection that would lead a reasonably prudent
lay person possessing average knowledge of dentistry to believe that
immediate care is needed.
All Selected General Dental Offices provide emergency dental services twentyfour
(24) hours a day, seven (7) days a week and SafeGuard encourages you
to seek care from your Selected General Dentist. If you require emergency
dental services, you may go to any dental provider, go to the closest
emergency room, or call 911 for assistance, as necessary. Prior Authorization
for emergency dental services is not required.
Your reimbursement from SafeGuard for emergency dental services, if any, is
limited to the extent the treatment you received directly relates to emergency
dental services – i.e. to evaluate and stabilize the dental condition. All
reimbursements will be allocated in accordance with your plan benefits, subject
to any exclusions and limitations. Hospital charges and/or other charges for
care received at any hospital or outpatient care facility that are not related to
treatment of the actual dental condition are not covered benefits.
If you receive emergency dental services, you will be required to pay the
charges to the dentist and submit a claim to SafeGuard for a benefits
determination. If you seek emergency dental services from a provider located
more than 25 miles away from your Selected General Dentist, you will receive
emergency benefits coverage up to a maximum of $50, less any applicable
co-payments.
To be reimbursed for emergency dental services, you must notify Customer
Service within forty-eight (48) hours after receiving such services. If your
physical condition does not permit such notification, you must make the
notification as soon as it is reasonably possible to do so. Please include
your name, family ID number, address and telephone number on all requests
for reimbursement. In the event of a dental emergency and you are within 25
miles of your Selected General Dental Office, simply contact your dentist who
will make reasonable arrangements for such emergency dental care. If your
dentist isn’t available, you must contact SafeGuard’s Customer Service
Department at (800) 880-1800 for assistance.
If you are more than twenty-five (25) miles from your chosen Selected General
Dental Office, or you cannot reach your dentist or SafeGuard’s Customer
Service, you may obtain emergency dental services from any licensed dentist.
To be reimbursed for a dental emergency, you must notify Customer Service
within forty-eight (48) hours after receiving dental emergency care services.
If your physical condition does not permit such notification within the
SG-INDIV-EOC 9
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prescribed time, the member must make the notification as soon as it is
reasonably possible to do so.
If you do not require emergency dental services and a delay in receiving
treatment would not be detrimental to your health, please contact your
Selected General Dental Office or SafeGuard’s Customer Service Department
at (800) 880-1800 to make reasonable arrangements for your care.
Grievance Procedures
If you or one of your eligible dependents has a grievance with us or your
dentist, you may orally submit such grievance by calling our Customer Service
Department at (800) 880-1800. We will permit grievances which are filed
within 180 days of the occurrence or incident that is the subject of the grievance.
You may also submit a completed written grievance form (available by calling
the Customer Service number) or a detailed summary of your grievance to:
SafeGuard
c/o Quality Management Department
PO Box 3532
Laguna Hills, CA 92654-3532
You may also file a written grievance via our website at www.safeguard.net.
Please click on Members, then Forms to Print, and then Grievance Forms.
Please be sure to include your name (patient’s name, if different), Member
Identification Number, facility (or Selected General Dental Office) name and
number on all written correspondence.
We agree, subject to our Complaint Procedure, to duly investigate and
endeavor to resolve any and all complaints received from Members regarding
the plan. We will confirm receipt of your complaint in writing within five (5)
calendar days of receipt. We will resolve the complaint and communicate the
resolution in writing within thirty (30) calendar days.
The California Department of Managed Health Care is
responsible for regulating health care service plans. If you
have a grievance against your health plan, you should first
telephone your health plan at 1-800-880-1800 and use your
health plan’s grievance process before contacting the
department. Utilizing this grievance procedure does not
prohibit any potential legal rights or remedies that may be
available to you. If you need help with a grievance involving
an emergency, a grievance that has not been satisfactorily
resolved by your health plan, or a grievance that has
remained unresolved for more than 30 days, you may call
the department for assistance. You may also be eligible for
SG-INDIV-EOC 10
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an Independent Medical Review (IMR). If you are eligible
for IMR, the IMR process will provide an impartial review of
medical decisions made by a health plan related to the
medical necessity of a proposed service or treatment,
coverage decisions for treatments that are experimental or
investigational in nature and payment disputes for emergency
or urgent medical services. The department also has a tollfree
telephone number (1-888-HMO-2219) and a TDD line
(1-877-688-9891) for the hearing and speech impaired. The
department’s Internet Web Site http://www.hmohelp.ca.gov
has complaint forms, IMR application forms and instructions
online.
In the event of an urgent grievance, which involves an imminent and serious
threat to your health, including, but not limited to, severe pain, potential loss of
life, limb or major bodily function, you are not required to participate in SafeGuard’s
grievance process and may directly contact the California Department of Managed
Health Care, as referenced above, for review of the urgent grievance.
Arbitration
Each and every disagreement, dispute or controversy which remains unresolved
concerning the construction, interpretation, performance or breach of this
contract, or the provision of dental services under this contract after exhausting
SafeGuard’s complaint procedures, arising between the organization, a member
or the heir-at-law or personal representative of such person, as the case may
be, and SafeGuard, its employees, officers or directors, or participating dentist
or their dental groups, partners, agents, or employees, may be voluntarily
submitted to arbitration in accordance with the American Arbitration Association
rules and regulations, whether such dispute involves a claim in tort, contract
or otherwise. This includes, without limitation, all disputes as to professional
liability or malpractice, that is as to whether any dental services rendered
under this contract were unnecessary or unauthorized or were improperly,
negligently or incompetently rendered. It also includes, without limitation, any
act or omission which occurs during the term of this contract but which gives
rise to a claim after the termination of this contract. Arbitration shall be initiated
by written notice to the President, SafeGuard Health Plans, Inc., P.O. Box 30900,
Laguna Hills, California 92654-0900.The notice shall include a detailed
description of the matter to be arbitrated.
Changes To Your Coverage:
Termination of Benefits
Your coverage may be cancelled for any reason, after not less than 60 days
written notice by either you or SafeGuard.
Your coverage may be cancelled after not less than 30 days written notice for:
• Non-payment of amounts due under the contract, except no written notice
will be required for failure to pay premium.
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• Failure to establish a satisfactory dentist-patient relationship and if it is
shown that SafeGuard has, in good faith, provided you with the opportunity
to select an alternative dentist.
• Neither residing, living, or working in the service area or area for which
SafeGuard is authorized to do business.
Your coverage may be cancelled after not less than 15 days written notice for:
• An intentional misrepresentation, except as limited by statute.
• Fraud in the use of services or facilities.
• Such other good cause as is agreed upon in the contract.
Your coverage may be cancelled immediately:
• Subject to continuation of coverage and conversion privilege provisions, if
applicable, if you do not meet eligibility requirements other than the
requirements that you live or work in the service area.
• For any misconduct detrimental to safe plan operations and the delivery
of services.
If you fail to pay the prepayment fees through and including the final month of
the contract, all coverage may be terminated at the end of the grace period,
and you may be responsible for the usual and customary fees for any services
received from your Selected General Dentist or Specialist during the period
the prepayment fees went unpaid, including the grace period.
Enrollment will be cancelled as of the last day for which payment has been
received, subject to compliance with notice requirements.
Orthodontic treatment is governed by the orthodontic limitations listed on
your schedule of benefits. If you terminate coverage from the plan after the
start of orthodontic treatment, you will be responsible for any additional incurred
charges for any remaining orthodontic treatment.
Renewal Provisions
You have contracted with SafeGuard to provide services for the time period
specified in the contract. Your coverage under the plan is guaranteed for that
time period so long as you meet the eligibility requirements under the plan.
When the contract expires, it may be renewed. If renewed, it is possible that
the terms of the plan may have been changed. If changes to benefits, copayments
or premiums have been made to a renewed contract, you will be
notified you not less than thirty (30) days before the effective date.
Reinstatement
Receipt by SafeGuard of the proper prepaid or periodic payment after
cancellation of the contract for non-payment shall reinstate the contract as
SG-INDIV-EOC 12
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though it had never been cancelled if such payment is received on or before
the due date of the succeeding payment.
An enrollee or subscriber who alleges that his or her enrollment has been
canceled or not renewed because of his or her health status or requirements
for health care services may request a review by the Director of the California
Department of Managed Health Care. If the Director determines that a proper
complaint exists, the Director shall notify SafeGuard. Within 15 days after
receipt of such notice, SafeGuard shall either request a hearing or reinstate
the enrollee or subscriber. If, after a hearing, the Director determines that the
cancellation or failure to renew is improper, the Director shall order SafeGuard
to reinstate the enrollee or subscriber. A reinstatement pursuant to this provision
shall be retroactive to the time of cancellation or failure to renew and SafeGuard
shall be liable for the expenses incurred by the subscriber or enrollee for
covered health care services from the date of cancellation or non-renewal to
and including the date of reinstatement.
Continuity of Care:
Current Members
Current members may have the right to the benefit of completion of care with
their Terminated Provider for certain specificed dental conditions. Please call
SafeGuard at (800) 880-1800 to see if you may be eligible for this benefit.
You may request a copy of SafeGuard's Continuity of Care Policy. You must
make a specific request to continue under the care of your Terminated Provider.
We are not required to continue your care with that provider if you are not
eligible under our policy or if we cannot reach agreement with your Terminated
Provider on the terms regarding your care in accordance with California law.
New Members
New members may have the right to the benefit of completion of care with
their Non-Participating Provider for certain specified dental conditions. Please
call SafeGuard at (800) 880-1800 to see if you may be eligible for this
benefit. You may request a copy of SafeGuard's Continuity of Care Policy. You
must make a specific request to continue under the care of your Non-
Participating Provider. We are not required to continue your care with that
provider if you are not eligible under our policy or if we cannot reach agreement
with your Non-Participating Provider on the terms regarding your care in
accordance with California law. This policy does not apply to new members of
an individual subscriber contract.
You may obtain a copy of SafeGuard’s policy on continuation of care, which
contains the specific information relating to the required qualifying events for
receiving continuation of care, or you may receive information regarding your
rights to continuation of care from our Customer Service Department by calling
(800) 880-1800. If you have further questions, you are encouraged to contact
the California Department of Managed Health Care, which protects HMO
consumers, by telephone at its toll-free number, 1-888-HMO-2219, or at a
SG-INDIV-EOC 13
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TDD number for the hearing impaired at 1-877-688-9891, or online at
www.hmohelp.ca.gov.
Member Rights
During the term of the contract between you and SafeGuard, SafeGuard
guarantees that it will not decrease any benefits, increase any co-payment, or
change any exclusion or limitation. SafeGuard will not cancel or fail to renew
your enrollment in this Plan because of your health condition or your requirements
for dental care. Your Selected General Dental Office is responsible to you for
all treatment and services, without interference from SafeGuard.
However, your Selected General Dentist must follow the rules and limitations
set up by SafeGuard and conduct his or her professional relationship with you
within the guidelines established by SafeGuard. If SafeGuard’s relationship
with your Selected General Dental Office ends, your dentist is obligated to
complete any and all treatment in progress. SafeGuard will arrange a transfer
for you to another dentist to provide for continued coverage under the Plan. As
indicated on your enrollment form, your signature authorizes SafeGuard to
obtain copies of your dental records, if necessary.
As a member, you have the right to...
• Be treated with respect, dignity and recognition of your need for privacy
and confidentiality.
• Express complaints and be informed of the complaint process.
• Have access and availability to care and access to and copies of your
dental records.
• Participate in decision-making regarding your course of treatment.
• Be provided information regarding Selected General Dental Offices.
• Be provided information regarding the services, benefits and specialty
referral process provided by SafeGuard.
Member Responsibilities
As a member, you have the responsibility to...
• Identify yourself to your Selected General Dental Office as a SafeGuard
member. If you fail to do so, you may be charged the dentist’s usual and
customary fees instead of the applicable co-payment, if any.
• Treat the dentist and his or her office staff with respect and courtesy and
cooperate with the prescribed course of treatment. If you continually refuse
a prescribed course of treatment, your Selected General Dentist or Specialist
has the right to refuse to treat you. SafeGuard will facilitate second opinions
SG-INDIV-EOC 14
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and will permit you to change your Selected General Dental Office; however,
SafeGuard will not interfere with the dentist-patient relationship and cannot
require a particular dentist to perform particular services.
• Keep scheduled appointments or contact the dental office twenty-four
(24) hours in advance to cancel an appointment. If you do not, you may be
charged a missed appointment fee.
• Make co-payments at the time of service. If you do not, the dentist may
collect those co-payments from you at subsequent appointments and in
accordance with their policies and procedures.
• Notify SafeGuard of changes in family status. If you do not, SafeGuard
will be unable to authorize dental care for you and/or your family members.
Language Assistance
As a SafeGuard member you have a right to free language assistance services,
including interpretation and translation services. SafeGuard collects and
maintains your language preferences, race, and ethnicity so that we can
communicate more effectively with our members. If you require spoken or
written language assistance or would like to inform SafeGuard of your preferred
language, please contact us at (800) 880-1800.
Como miembro de SafeGuard usted tiene derecho a recibir servicios gratuitos
de asistencia en idiomas. Esto incluye servicios de interpretación y traducción.
SafeGuard recaba la información sobre sus preferencias de idioma, raza, y
etnia de manera que nos podamos comunicar eficazmente con nuestros
afiliados. Si necesita asistencia verbal o escrita en su idioma o quiere
informarle a SafeGuard sobre su idioma de preferencia, comuníquese con
nosotros al (800) 880-1800.
SG-INDIV-EOC 15
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The following definitions are used in this Evidence of
Coverage.
Arbitration
A non-court proceeding which is used to solve legal disputes. It is usually
held before an attorney or judge who weighs the evidence and renders a
binding decision, which has the force of law. Arbitration is an efficient
alternative to a trial court proceeding for resolving legal disputes.
Co-payment
The amount listed on the Schedule of Benefits for covered services that the
member is required to pay at the time of treatment.
Dental Records
A single complete record kept at the site of your dental care. Dental records
refers to diagnostic aids, such as intraoral and extra-oral radiographs, written
treatment records including, but not limited to, progress notes, dental or
periodontal chartings, treatment plans, specialty referrals, consultation reports
or other written material relating to an individual’s medical and dental history,
diagnosis, condition, treatment and/or evaluation.
Dependent
Eligible family members of a subscriber who is enrolled in SafeGuard. (See
Dependent Coverage).
Emergency Dental Services
Dental services rendered for the relief of acute pain, bleeding, infection,
fever, or for conditions that may result in disability or death, and where delay
of treatment would be medically unadvisable.
Medically Necessary
Covered services that are necessary and meet with professionally recognized
standards of practice. The fact that a dentist may prescribe, order, recommend
or approve a service or material does not, in itself, make it medically necessary,
or make it a covered service and material even though it is not listed in this
Policy or the Schedule of Benefits as an exclusion.
Member
An individual enrolled in the SafeGuard dental plan.
Plan
Coverage for specified dental care services purchased by an Organization for
its members for a fixed, periodic payment made in advance of treatment.
Such plans often include the use of fixed co-payments to clarify the financial
obligation of covered dental care, and are subject to Exclusions and Limitations.
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Prepayment Fee
The monthly fee paid to SafeGuard by your Organization. The prepayment fee
is not the same as a co-payment.
Selected General Dentist
A SafeGuard contracting dentist who agrees in writing to provide dental
services under special terms, conditions and financial reimbursement
arrangements with SafeGuard.
Service Area
The Service Area is the geographical area in which SafeGuard has a panel of
Selected General Dentists and specialists who have agreed to provide care
to SafeGuard members.
Subscriber
The person, usually the employee, who represents the family unit in relation
to the dental benefit program. Also known as: certificate holder, enrollee.
Termination of Benefits
A member’s loss of program eligibility and disenrollment from the plan. Reason
for termination of benefits are detailed within this document.
SG-INDIV-EOC 17
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SAFEGUARD DENTAL & VISION HIPAA NOTICE OF PRIVACY PRACTICES
FOR PERSONAL HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION.
Dear SafeGuard Customer:
PLEASE REVIEW IT CAREFULLY.
This is your Health Information Privacy Notice from SafeGuard Health Plans,
Inc. and/or SafeHealth Life Insurance Company doing business as SafeGuard
Dental & Vision (“SafeGuard”), part of the MetLife, Inc. family of companies.
Please read it carefully. You have received this notice because of your dental
and/or vision coverage with us (the “Plan”). SafeGuard and each member of
the SafeGuard family of companies (an “Affiliate”) strongly believe in protecting
the confidentiality and security of information we collect about you. This notice
refers to SafeGuard by using the terms “us,” “we,” or “our.”
This notice describes how we protect the personal health information we have
about you which relates to your SafeGuard Plan coverage (“Personal Health
Information”), and how we may use and disclose this information. Personal
Health Information includes individually identifiable information which relates
to your past, present or future health, treatment or payment for health care
services. This notice also describes your rights with respect to the Personal
Health Information and how you can exercise those rights.
We are required to provide this Notice to you by the Health Insurance Portability
and Accountability Act (“HIPAA”). For additional information regarding our HIPAA
Medical Information Privacy Policy or our general privacy policies, please see the
privacy notices contained at our website, www.safeguard.net. You may submit
questions to us there or you may write to us directly at MetLife/SafeGuard,
Institutional Business HIPAA Privacy Office, P.O. Box 6896, Bridgewater, NJ
08807-6896.
We are required by law to:
• maintain the privacy of your Personal Health Information;
• provide you this notice of our legal duties and privacy practices with
respect to your Personal Health Information; and
•follow the terms of this notice.
We protect your Personal Health Information from inappropriate use or
disclosure. Our employees, and those of companies that help us service your
SafeGuard Plan, are required to comply with our requirements that protect the
confidentiality of Personal Health Information. They may look at your Personal
2/09

Health Information only when there is an appropriate reason to do so, such as
to administer our products or services.
We will not disclose your Personal Health Information to any other company
for their use in marketing their products to you. However, as described below,
we will use and disclose Personal Health Information about you for business
purposes relating to your SafeGuard Plan coverage.
The main reasons for which we may use and may disclose your Personal Health
Information are to evaluate and process any requests for coverage and claims
for benefits you may make, or in connection with other health-related benefits
or services that may be of interest to you. The following describe these and
other uses and disclosures, together with some examples.
• For Payment: We may use and disclose Personal Health Information to
pay for benefits under your SafeGuard Plan coverage. For example, we
may review Personal Health Information contained on claims to reimburse
providers for services rendered. We may also disclose Personal Health
Information to other insurance carriers to coordinate benefits with respect
to a particular claim. Additionally, we may disclose Personal Health
Information to a health plan or an administrator of an employee welfare
benefit plan for various payment-related functions, such as eligibility
determination, audit and review, or to assist you with your inquiries or
disputes.
• For Health Care Operations: We may also use and disclose Personal
Health Information for our insurance operations. These purposes include
evaluating a request for SafeGuard Plan products or services, administering
those products or services, and processing transactions requested by
you.
We may also disclose Personal Health Information to Affiliates, and to
business associates outside of the SafeGuard family of companies, if
they need to receive Personal Health Information to provide a service to
us and will agree to abide by specific HIPAA rules relating to the protection
of Personal Health Information. Examples of business associates are:
billing companies, data processing companies, or companies that provide
general administrative services. Personal Health Information may be
disclosed to reinsurers for underwriting, audit or claim review reasons.
Personal Health Information may also be disclosed as part of a potential
merger or acquisition involving our business in order to make an informed
business decision regarding any such prospective transaction.
• Where Required by Law or for Public Health Activities: We disclose
Personal Health Information when required by federal, state or local law.
Examples of such mandatory disclosures include notifying state or local
health authorities regarding particular communicable diseases, or providing
Personal Health Information to a governmental agency or regulator with
health care oversight responsibilities. We may also release Personal Health
2/09

Information to a coroner or medical examiner to assist in identifying a
deceased individual or to determine the cause of death.
• To Avert a Serious Threat to Health or Safety: We may disclose Personal
Health Information to avert a serious threat to someone’s health or safety.
We may also disclose Personal Health Information to federal, state or
local agencies engaged in disaster relief, as well as to private disaster relief
or disaster assistance agencies to allow such entities to carry out their
responsibilities in specific disaster situations.
• For Health-Related Benefits or Services: We may use Personal Health
Information to provide you with information about benefits available to
you under your current SafeGuard Plan coverage or policy and, in limited
situations, about health-related products or services that may be of interest
to you.
• For Law Enforcement or Specific Government Functions: We may disclose
Personal Health Information in response to a request by a law enforcement
official made through a court order, subpoena, warrant, summons or
similar process. We may disclose Personal Health Information about you
to federal officials for intelligence, counterintelligence, and other national
security activities authorized by law.
• When Requested as Part of a Regulatory or Legal Proceeding: If you or
your estate are involved in a lawsuit or a dispute, we may disclose Personal
Health Information about you in response to a court or administrative order.
We may also disclose Personal Health Information about you in response
to a subpoena, discovery request, or other lawful process by someone
else involved in the dispute, but only if efforts have been made to tell you
about the request or to obtain an order protecting the Personal Health
Information requested. We may disclose Personal Health Information to any
governmental agency or regulator with whom you have filed a complaint
or as part of a regulatory agency examination.
• Other Uses of Personal Health Information: Other uses and disclosures
of Personal Health Information not covered by this notice and permitted by
the laws that apply to us will be made only with your written authorization
or that of your legal representative. If we are authorized to use or disclose
Personal Health Information about you, you or your legally authorized
representative may revoke that authorization, in writing, at any time, except
to the extent that we have taken action relying on the authorization. You
should understand that we will not be able to take back any disclosures
we have already made with authorization.
YOUR RIGHTS REGARDING PERSONAL HEALTH INFORMATION
WE MAINTAIN ABOUT YOU
The following are your various rights as a consumer under HIPAA concerning
your Personal Health Information. Should you have questions about a specific
right, please write to us at the location listed in our discussion of that right.
2/09

• Right to Inspect and Copy Your Personal Health Information: In most
cases, you have the right to inspect and obtain a copy of the Personal
Health Information that we maintain about you. To inspect and copy
Personal Health Information, you must submit your request in writing
to SafeGuard Dental & Vision, 95 Enterprise, Suite 200, Aliso Viejo,
CA 92656. To receive a copy of your Personal Health Information, you
may be charged a fee for the costs of copying, mailing or other supplies
associated with your request. However, certain types of Personal Health
Information will not be made available for inspection and copying. This
includes Personal Health Information collected by us in connection with,
or in reasonable anticipation of, any claim or legal proceeding. In very
limited circumstances, we may deny your request to inspect and obtain
a copy of your Personal Health Information. If we do, you may request
that the denial be reviewed. The review will be conducted by an individual
chosen by us who was not involved in the original decision to deny your
request. We will comply with the outcome of that review.
• Right to Amend Your Personal Health Information: If you believe that
your Personal Health Information is incorrect or that an important part of
it is missing, you have the right to ask us to amend your Personal Health
Information while it is kept by or for us. You must provide your request
and your reason for the request in writing, and submit it to SafeGuard
Dental & Vision, 95 Enterprise, Suite 200, Aliso Viejo, CA 92656. We may
deny your request if it is not in writing or does not include a reason that
supports the request. In addition, we may deny your request if you ask
us to amend Personal Health Information that:
• is accurate and complete;
• was not created by us, unless the person or entity that created
the Personal Health Information is no longer available to make the
amendment;
• is not part of the Personal Health Information kept by or for us; or
• is not part of the Personal Health Information which you would be
permitted to inspect and copy.
• Right to a List of Disclosures: You have the right to request a list of the
disclosures we have made of Personal Health Information about you.
This list will not include disclosures made for treatment, payment, health
care operations, for purposes of national security, made to law enforcement
or to corrections personnel, or made pursuant to your authorization or
made directly to you. To request this list, you must submit your request in
writing to SafeGuard Dental & Vision, 95 Enterprise, Suite 200, Aliso Viejo,
CA 92656. Your request must state the time period from which you want
to receive a list of disclosures. The time period may not be longer than
six years and may not include dates before April 14, 2003. Your request
should indicate in what form you want the list (for example, on paper or
2/09

electronically). The first list you request within a 12-month period will be
free. We may charge you for responding to any additional requests. We
will notify you of the cost involved and you may choose to withdraw
or modify your request at that time before any costs are incurred.
• Right to Request Restrictions: You have the right to request a restriction
or limitation on Personal Health Information we use or disclose about
you for treatment, payment or health care operations, or that we disclose
to someone who may be involved in your care or payment for your care,
like a family member or friend. While we will consider your request, we
are not required to agree to it. If we do agree to it, we will comply with
your request. To request a restriction, you must make your request
in writing to SafeGuard Dental & Vision, 95 Enterprise, Suite 200, Aliso
Viejo, CA 92656. In your request, you must tell us: (1) what information
you want to limit; (2) whether you want to limit our use, disclosure or both;
and (3) to whom you want the limits to apply (for example, disclosures
to your spouse or parent). We will not agree to restrictions on Personal
Health Information uses or disclosures that are legally required, or
which are necessary to administer our business.
• Right to Request Confidential Communications: You have the right
to request that we communicate with you about Personal Health
Information in a certain way or at a certain location if you tell us that
communication in another manner may endanger you. For example, you
can ask that we only contact you at work or by mail. To request confidential
communications, you must make your request in writing to SafeGuard
Dental & Vision, 95 Enterprise, Suite 200, Aliso Viejo, CA 92656 and
specify how or where you wish to be contacted. We will accommodate
all reasonable requests.
• Right to File a Complaint: If you believe your privacy rights have been
violated, you may file a complaint with us or with the Secretary of the
Department of Health and Human Services. To file a complaint with us,
please contact MetLife/SafeGuard, Institutional Business HIPAA Privacy
Office, P.O. Box 6896, Bridgewater, NJ 08807-6896. All complaints must
be submitted in writing. You will not be penalized for filing a complaint.
If you have questions as to how to file a complaint, please contact us
at (908) 253-2706.
ADDITIONAL INFORMATION
Changes to This Notice: We reserve the right to change the terms of this notice
at any time. We reserve the right to make the revised or changed notice effective
for Personal Health Information we already have about you, as well as any
Personal Health Information we receive in the future. The effective date of this
notice and any revised or changed notice may be found on the last page, at the
bottom right-hand corner of the notice. You will receive a copy of any revised
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notice from SafeGuard by mail or by e-mail, but only if e-mail delivery is offered
by SafeGuard and you agree to such delivery.
Further Information: You may have additional rights under other applicable laws.
For additional information regarding our HIPAA Medical Information Privacy
Policy or our general privacy policies, please contact us at (908) 253-2706 or
write to us at MetLife/SafeGuard, Institutional Business HIPAA Privacy Office,
P.O. Box 6896, Bridgewater, NJ 08807-6896
© Metropolitan Life Insurance Company, New York, NY Effective - (02012008)

000685723/3297-CA-DAIS-CDT9KIT-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.
SmileSaversm is a registered servicemark of SafeGuard Health Enterprises, Inc.

SM-DHMO-C