DHMO Certificate of Benefits - Lake County

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Dependent- means any of the following persons:1. Your spouse;2. Your child;a) from birth to age 26; orb) at least 26 years of age and:i. primarily dependent upon You for support because of mental or physical handicap;ii. was incapacitated and insured under Policy on his 26 th birthday; andiii. continues to be incapacitated beyond his 26 th birthday.A child also includes adopted children, as well as stepchildren or foster children living with You in a parent-childrelationship Amend DEP-AGE (04/02)(rev. 09/10 HCR)
CS 150Schedule of Benefits and Subscriber CopaymentsADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE PATIENT PAYSAPPOINTMENTS9310 Consultation (diagnostic serviceprovided by dentist other thanpractitioner providing treatment) ........$15.009430 Office Visit (normal hours) ..................$5.009440 Office Visit (after regularlyscheduled hours) ............................$35.009999 Emergency visit during regularlyscheduled hours, by report ...............$20.009999 Broken appointments (without 24 hrnotice, per 15 min) Maximum $40per broken appointment. No chargewill be made due to emergencies .....$10.00DIAGNOSTIC120 Periodic oral evaluation ...........NO CHARGE140/150/160Limited/Comprehensiveoral evaluation ......................NO CHARGE180 Comprehensive periodontalevaluation - new or establishedpatient .........................................$10.00210 X-Ray Intraoral - complete seriesincluding bitewings ................NO CHARGE220 X-Ray Intraoral - periapical -first film ................................NO CHARGE230 X-Ray Intraoral - periapical -each additional film ................NO CHARGE270 X-Ray Bitewing - single film ......NO CHARGE272 X-Ray Bitewings - two films .......NO CHARGE274 Bitewings - four films ...............NO CHARGE330 Panoramic film .......................NO CHARGE460 Pulp vitality tests .....................NO CHARGE470 Diagnostic casts .....................NO CHARGEPREVENTIVE CARE1110/1120Prophylaxis-adult/child-routine(once every 6 months) ............NO CHARGE1110/1120Prophylaxis-adult/child-(additional) .....$20.001201 Topical application of fluoride(including prophylaxis) child(up to 16 years of age) ...........NO CHARGE1203 Topical application of fluoride(not including prophylaxis) child(up to 16 years of age) ...........NO CHARGE1330 Oral hygiene instruction ..........NO CHARGE1351 Sealant - per tooth ..........................$10.001510 Space Maintainer - fixed -unilateral .............................$45.00 + LABPREVENTIVE CARE (cont.)1515 Space Maintainer - fixed -bilateral ...............................$45.00 + LAB1520 Space Maintainer - removable -unilateral .............................$85.00 + LAB1525 Space Maintainer - removable -bilateral ...............................$85.00 + LAB1550 Recementation of spacemaintainer .....................................$10.00RESTORATIVE2140 Amalgam - one surface,primary or permanent .............NO CHARGE2150 Amalgam - two surfaces,primary or permanent .............NO CHARGE2160 Amalgam - three surfaces,primary or permanent .............NO CHARGE2161 Amalgam - four or more surfaces,primary or permanent .............NO CHARGE2940 Sedative filling ...............................$15.002999 Sedative base (under fillings),by report ............................. NO CHARGERESIN RESTORATION2330 Resin - one surface, anterior .............$35.002331 Resin - two surfaces, anterior ............$40.002332 Resin - three surfaces, anterior ...........$50.002391 Resin - based composite -one surface, posterior .....................$60.002392 Resin - based composite -two surfaces, posterior ....................$80.002393 Resin - based composite -three surfaces, posterior .................$100.002394 Resin - based composite -four or more surfaces, posterior .......$120.002510 Inlay - metallic - one surface .............$95.002520 Inlay - metallic - two surfaces ..........$105.002530 Inlay - metallic - three ormore surfaces ..............................$130.00CROWN & BRIDGE2740 Crown - porcelain/ceramicsubstrate .................................$280 + LAB2750* Crown - porcelain fused tohigh noble metal ..........................$280.002751 Crown - porcelain fused topredominantly base metal ..............$280.002752* Crown - porcelain fused to noblemetal .........................................$280.002790* Crown - full cast high noble metal ...$280.00CS150 03/03005CS1504Current Dental Terminology © 2004 American Dental Association. All rights reserved.
Page 1 and 2: CS150 Dental PlanFlorida
Page 3 and 4: I. “Effective Date” is the firs
Page 5 and 6: the right to collect from the Membe
Page 7 and 8: paid. Transfers are limited to one
Page 9 and 10: Dental records concerning services
Page 11: formal written grievance with Compa
Page 15 and 16: ADA CODE PROCEDURE PATIENT PAYS ADA
Page 17 and 18: NoticesThe following pages contain
Page 19 and 20: • Procedure or nature of the trea
Page 21 and 22: The notice will describe the plan's
Page 23 and 24: state Medicaid law regarding medica
Page 25 and 26: COBRA continuation coverage general
Page 27 and 28: Of elected, continuation coverage u
Page 29 and 30: Notice of Privacy Practicesfor your
Page 31 and 32: Notice of Privacy Practices (contin
Page 33 and 34: Questions & AnswersDHMOThank you fo
Page 35: Is your dental plan adental insuran

DHMO Certificate of Benefits - Lake County

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