Plan 3000 - Dental Alternatives Insurance Services Inc

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SCHEDULE OF BENEFITS (continued) Code Service teeth (molars or bicuspids). Co-payment When Services Performed by Contracted General Dentist Co-payment When Services Performed by Contracted Specialist D6210 Pontic – cast high noble metal $115 D6211 Pontic – cast predominantly base metal $115 D6212 Pontic – cast noble metal $115 D6240 Pontic – porcelain fused to high noble metal $120 D6241 Pontic – porcelain fused to predominantly base metal $120 D6242 Pontic – porcelain fused to noble metal $120 D6750 Crown – porcelain fused to high noble metal $120 D6751 Crown – porcelain fused to predominantly base metal $120 D6752 Crown – porcelain fused to noble metal $120 D6780 Crown – ¾ cast high noble metal $115 D6781 Crown – ¾ cast predominantly base metal $115 D6782 Crown – ¾ cast noble metal $115 D6790 Crown – full cast high noble metal $115 D6791 Crown – full cast predominantly base metal $115 D6792 Crown – full cast noble metal $115 D6930 Recement fixed partial denture $5 D6970 Post and core in addition to fixed partial denture retainer, $50 indirectly fabricated D6972 Prefabricated post and core in addition to fixed partial denture $40 retainer D6973 Core build up for retainer, including any pins $0 Oral Surgery D7111 Extraction, coronal remnants – deciduous tooth $9 $32 D7140 Extraction, erupted tooth or exposed root (elevation and/or $10 $35 forceps removal) D7210 Surgical removal of erupted tooth requiring removal of bone $25 $60 and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth – soft tissue $35 $100 D7230 Removal of impacted tooth – partially bony $50 $125 D7240 Removal of impacted tooth – completely bony $65 $150 D7250 Surgical removal of residual tooth roots (cutting procedure) $25 D7510 Incision and drainage of abscess – intraoral soft tissue U&C D7530 Removal of foreign body from mucosa, skin, or subcutaneous U&C alveolar tissue D7550 Partial ostectomy/sequestrectomy for removal of non-vital U&C bone D7910 Suture of recent small wounds up to 5 cm U&C D7960 Frenulectomy – also known as frenectomy or frenotomy – $35 $50 separate procedure not incidental to another procedure D7963 Frenuloplasty $35 $50 D7970 Excision of hyperplastic tissue – per arch U&C Orthodontics GCERT2010-DHMO-SOB Customer Service (800) 880-1800 sob 6
SCHEDULE OF BENEFITS (continued) Code Service Co-payment When Services Performed by Contracted General Dentist Co-payment When Services Performed by Contracted Specialist D8030 Limited orthodontic treatment of the adolescent dentition U&C $1,000 D8040 Limited orthodontic treatment of the adult dentition U&C $1,400 D8080 Comprehensive orthodontic treatment of the adolescent U&C $1,600 dentition D8090 Comprehensive orthodontic treatment of the adult dentition U&C $1,950 D8210 Removable appliance therapy $40 D8220 Fixed appliance therapy $60 D8660 Pre-orthodontic treatment visit U&C $40 D8670 Periodic orthodontic treatment visit (as part of contract) $10 $0 D8680 Orthodontic retention (removal of appliances, construction and U&C $450 placement of retainer(s)) D8693 Rebonding or recementing; and/or repair, as required, of fixed U&C $0 retainers Adjunctive General Services D9110 Palliative (emergency) treatment of dental pain – minor $15 $45 procedure D9120 Fixed partial denture sectioning $0 D9215 Local anesthesia in conjunction with operative or surgical $0 procedures D9310 Consultation – diagnostic service provided by dentist or $40 $40 physician other than requesting dentist or physician D9430 Office visit for observation (during regularly scheduled hours) $5 – no other services performed D9440 Office visit – after regularly scheduled hours $30 D9450 Case presentation, detailed and extensive treatment planning $5 $5 D9930 Treatment of complications (post-surgical) - unusual $0 $0 circumstances, by report D9941 Fabrication of athletic mouthguard $75 D9942 Repair and/or reline of occlusal guard $30 D9951 Occlusal adjustment – limited $12 D9972 External bleaching – per arch $175 Missed Appointments – without twenty-four (24) hour prior $20 $22 notice Record transfer - transfer of all materials with less than a full $10 mouth x-ray Record transfer - transfer of all materials with a full mouth x- ray $20 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. GCERT2010-DHMO-SOB Customer Service (800) 880-1800 sob 7
Page 1 and 2: Dental HMO SmileSaver 3000 Enrollme
Page 3 and 4: SmileSaver dental and vision plans
Page 5 and 6: SCHEDULE OF BENEFITS Benefits provi
Page 7 and 8: SCHEDULE OF BENEFITS (continued) Co
Page 9: SCHEDULE OF BENEFITS (continued) Co
Page 13 and 14: DENTAL BENEFITS: EXCLUSIONS The fol
Page 15 and 16: DENTAL BENEFITS: EXCLUSIONS (contin
Page 17 and 18: Benefits Provided by SafeGuard Heal
Page 19 and 20: Section TABLE OF CONTENTS Page At Y
Page 21 and 22: language assistance or would like t
Page 23 and 24: competence and skill of dental prac
Page 25 and 26: SmileSaver Individual & Family Enro
Page 27 and 28: Please refer to the Co-Payment sect
Page 29 and 30: conveyed to You within twenty-four
Page 31 and 32: Renewal Provisions Your Organizatio
Page 33 and 34: may be available to You. If You nee
Page 35 and 36: 1. Your employment ends for any rea
Page 37 and 38: 1. to a person who is not a residen
Page 39 and 40: Covered Service means a dental serv
Page 41 and 42: Prophylaxis means a standard cleani
Page 43 and 44: Health Information only when there
Page 45 and 46: • Right to Inspect and Copy Your
Page 47 and 48: notice from SafeGuard by mail or by
Page 49 and 50: The Schedule of Benefits and the Ex

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