Avera Health Plans Certificate of Coverage. Pediatric Dental Coverage Addendum
|
|
|
- Brian Norton
- 5 years ago
- Views:
Transcription
1 Avera Health Plans Certificate of Coverage Pediatric Dental Coverage Addendum
2 Pediatric Dental Coverage Addendum If you are enrolled in this plan, you are entitled to the benefits described below. Other requirements such as, but not limited to, in-network/out-of-network providers, workrelated injury, claim filing, complaint procedures, right of recovery, eligibility and enrollment, coordination of benefits, termination, continuation provisions and other general provisions noted in the Certificate (Evidence) of Coverage or Individual Health Insurance Policy are applicable to this addendum unless otherwise noted below. All benefits are subject to the definitions, limitations and exclusions listed and are payable only when deemed necessary for the prevention, diagnosis, care or treatment of a covered condition and meet generally accepted dental protocols. All exams, oral evaluations and treatments are combined under one limitation under the plan. Periodic oral exam, oral evaluations and comprehensive oral exam are combined and limited to one exam every 6 months (from the date services were last rendered). All services requiring more than one visit are payable once all visits are completed. Eligibility Coverage is provided for members up to age 19. If member turns 19 in the middle of a plan year, coverage is provided for the remainder of the plan year except for orthodontic services. Orthodontic services will be provided until the end of the month of their 19 th birthday. Waiting Period There is a waiting period for orthodontic services. To meet this requirement, the member receiving orthodontia services must be enrolled in the same plan for an entire and continuous 24 month waiting period to receive orthodontic coverage in the same plan option. Any change in the plan option will result in the member having to satisfy a new 24 month waiting period, for that plan option, in order to be eligible for orthodontic services. Re-enrollment, after returning from another dental carrier plan, will require the member to satisfy a new 24 month orthodontia waiting period for the elected plan option. Coverage Termination Coverage ends when a member is 19 years of age or older at time of open enrollment. Coverage will automatically term at end of a plan year when a member becomes 19 years of age during a plan year. Page 1
3 Continuation of Coverage Upon the termination of this plan, certain benefits will be continued to be paid for a 31 day period after the plan termination date if before coverage ends the provider: Page 2 Prepared the abutment teeth for the completion of installation of prosthetic devices Made an impression Prepared tooth for cast restoration Provider opened pulp chamber and the device is installed or treatment is completed within 31 days of plan termination date Identification Cards You can use your member ID card; you do not need a separate card for dental services. Where Can I Get Covered Care You can obtain care from any licensed dentist in the United States. Precertification is required for care outside of the United States. Plan Providers You may choose any dental provider in the state when using benefits provided in this plan. Do I Need an Authorization? Predetermination is necessary for any treatment or services with an anticipated cost of $300 or more. Precertification is required to such services (but not limited to) orthodontia and periodontal services, crowns, bridges, inlays/ onlays veneers, implants and overdentures. Alternate Benefit Alternate benefits applicable to your treatment plan will be determined during predetermination. Should treatment service charges differ from the precertification, the plan reserves the right to determine if alternate benefit is applicable to the actual services rendered. If the plan pays benefits based on a lower reimbursed service, in accordance with this section, you may be responsible for the excess treatment service charges between what the plan pays and what is billed. Dental Review Precertification will be conducted by licensed dentists who review the clinical documentation submitting by your treating dentist. These dentists review this material checking for dental necessity for certain procedures such as crowns, bridges, onlays, implants, periodontal treatments, as well as other services. This dentist may recommend an alternate benefit be applied to a service in accordance with the terms of this plan; therefore, it is important that these dental services are pre-determined so you and your dentist are aware of the coverage terms and benefits before services are performed.
4 What is Covered (all time limitations are based on the last service date) For a detailed list of all services covered, please go to or call our Service Center. Basic Coverage Member Coinsurance: 0% Diagnostic and Treatment Dental examinations, visits and consultation, 1 examination every 6 months Preventive Services Cleanings, 1 cleaning every 6 months Fluoride treatment (topical), 2 applications every 12 months Bitewing X-rays, 1 set every 6 months Intermediate Coverage Member Coinsurance: 30% Minor Restorative Services Resin based anterior composites (alternate benefit of amalgam for molar teeth) Prefabricated stainless steel crowns (1 per tooth in 60 months) Endodontic Services Therapeutic pulpotomy (exclusions apply) Periodontic Services Periodontal scaling and root planning 4 or more teeth, per quadrant, 1 every 24 months Prosthodontic Services Rebase of complete maxillary dentures 1 in 36 month period; 6 months after initial installation. Oral Surgery Removal of an impacted tooth Surgical access of an unerupted tooth Major Coverage Member Coinsurance: 50% Major Restorative Services Metallic Onlays 1 per tooth every 60 months Porcelain or ceramic crown substrate 1 per tooth every 60 months Endodontic Services Anterior, bicuspid and molar root canal (exclusions apply) Retreatment of anterior, bicuspid and molar root canal therapy (exclusions apply) Periodontic Services Gingivectomy or Gingivoplasty 1 to 3 teeth, per quadrant, 1 every 36 months Prosthodontic Services Page 3
5 Porcelain, ceramic and cast metal retainers for resin bonded fixed prosthesis 1 every 60 months Implant Services Services are subject to plan guidelines Orthodontic Services Member Coinsurance: 50% Orthodontia procedures which help restore oral structures to health and function and to treat serious medical conditions such as cleft palate and cleft lip; maxillary/mandibular micrognathia (underdeveloped upper or lower jaw); extreme mandibular prognathism or severe asymmetry (craniofacial anomalies) Anesthesia Services Member Coinsurance: 30% Sedation (not including anesthesia or oral) Page 4
6 What is Not Covered Services and treatment not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist Services and treatment resulting from failure to comply with professionally prescribed treatment Services related to the diagnosis and treatment of temporomandibular joint dysfunction Duplicate, provisional and temporary devices, appliances and services Fabrication of athletic mouth guard Oral sedation or anesthesia Repair or replacement of damaged, lost, stolen or missing devices or appliances Adjustment of a denture or bridgework which is made within 6 months after installation (if completed by the same provider) Removal of fixed space maintainer Plaque control programs, oral hygiene instruction, tobacco counseling and dietary instruction Use of materials or home health aids to prevent decay (such as toothpaste, fluoride gels/rinse and dental floss) Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedure include (but are not limited to) equilibration, periodontal splinting, full mouth rehabilitation and restoration of misalignment of teeth Hospital costs or additional fees as a result of treatment at the hospital (inpatient or outpatient) Gold foil restorations Decalcification procedures Sealants for teeth other than unrestored permanent molars Bone grafts when done in connection with extractions, apicoetomies or noncovered/non-eligible implants Select radiographic imaging: TMJ arthrogram, other TMJ imaging and tomographic survey Select dental testing: saliva analysis, viral culture, caries testing, adjunctive pre-diagnostic testing, special staining, immunohistochemical stains, tissue in-situ hybridization, direct/in-direct immunofluorescence, electron microscopy and accession transepithelial sampling Select orthodontia procedures: rapid palatal expansion, component part placement, interceptive orthodontic treatment, comprehensive orthodontic treatment (during which orthodontic appliances have been placed for active treatment and periodically adjusted), removable appliance therapy and orthodontic retention (removal of appliances, construction and placement of retainers) Any services that are considered strictly cosmetic in nature (including teeth whiteners, whitening or bleaching procedures) Specialized procedures and techniques (such as precision attachments, personalization or precious metal bases) Page 5
7 Services and treatment which are for any illness or bodily injury which occurs in the course of employment if a benefit or compensation is available Services and treatment for injuries resulting from the maintenance or use of a motor vehicle Services and treatment for injuries resulting from war or act of war, self-inflicted injury or illness or committing/attempting to commit a felony and/or engaging in illegal occupation or activities Services and treatment which are not dentally necessary or which do not meet generally accepted standards of dental practice Services and treatment which are experimental or investigational Any charges incurred for failure to keep a schedule appointment Any charges incurred for copies and distribution of your records, charts or X-rays Any charges for the completion of forms or telephone consultations Office infection control charges State or territorial taxes on dental services Services provided free-of-charge by any governmental entity or provided with no obligation to pay, except where this exclusion is prohibited by law Page 6
Pediatric Dental Rider
Pediatric Dental Rider Words that are capitalized in this Rider can be found in the Glossary section of Your Evidence of Coverage (EOC) as defined terms. Health Choice Insurance Co. is a Health Maintenance
A Reason to Smile. Dental Care with No Surprises. Dental insurance underwritten by: Mutual of Omaha Insurance Company
A Reason to Smile Dental Care with No Surprises Dental insurance underwritten by: Mutual of Omaha Insurance Company 258665 Knowing what a visit to the dentist will cost is challenging. And dental coverage
Blue Edge Dental SCHEDULE OF BENEFITS, EXCLUSIONS AND LIMITATIONS - HIGH A. BENEFITS
Blue Edge Dental SCHEDULE OF BENEFITS, EXCLUSIONS AND LIMITATIONS - HIGH A. BENEFITS Annual Deductible Per Insured Person Annual Deductible Per Insured Family $100 Per Calendar Year $300 Per Calendar Year
Massachusetts Family High Dental Plan with Enhanced Child Orthodontia
SCHEDULE OF BENEFITS Massachusetts Family High Dental Plan with Enhanced Child Orthodontia This Schedule of Benefits lists the services available under the MetLife plan, as well as the co-insurance payments
Blue Edge Dental SCHEDULE OF BENEFITS, EXCLUSIONS AND LIMITATIONS - HIGH
Blue Edge Dental A. BENEFITS SCHEDULE OF BENEFITS, EXCLUSIONS AND LIMITATIONS - HIGH Annual Deductible Per Insured Person $50 Per Calendar Year Annual Maximum Per Insured Person $1,000 Covered Services:
Regence Enliven Dental Plan Highlights for Groups /1/2018
Plan Features This plan is based and includes preventive and diagnostic services, as well as restorative and major services. Orthodontia is included for all ages. This plan features an Exclusive Provider
The following chart provides an illustration of the dental coverage provided under the Plan. Summary of Dental Care Benefits
DENTAL CARE You or your eligible dependents may incur reasonable and customary charges for services and supplies provided by or under the supervision of a licensed, certified or registered oral surgeon
PLAN OPTION 1 High Plan Out-of-Network Negotiated Fee - MAC
Pearl Companies Dental Metropolitan Life Insurance Company Network: PDP Coverage Type In-Network Schedule PLAN OPTION 1 High Plan Out-of-Network - MAC In-Network Schedule PLAN OPTION 2 Low Plan Out-of-Network
Wherever hard working people keep the country running, MetLife Federal Dental is with you Dental Plan Summary
Wherever hard working people keep the country running, MetLife Federal Dental is with you. 09 Dental Plan Summary Contents Plan Highlights Overview Covered Dental Services Benefits Options 6 Enroll in
PLAN OPTION 1 Low Plan Employees (30 hours) Out-of-Network % of Negotiated Fee*
Green Dot Public Schools MetLife Dental Insurance Plan Summary Network: PDP PLAN OPTION 1 Low Plan Employees (30 hours) PLAN OPTION 2 High Plan Employees (30 hours) Coverage Type In-Network Fee * Out-of-Network
MetLife Dental Insurance Plan Summary
Public School Retirement System of the City of St Louis For MS and TX residents MetLife Dental Insurance Plan Summary Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams) Type B: Basic
DENTAL PLAN QUICK FACTS AND QUICK LINKS
DENTAL PLAN QUICK FACTS AND QUICK LINKS A Quick Look at the Dental Plan Dental Service TakeCare Network Dentists Only Annual Maximum Benefit $1,500 per covered person per calendar year Diagnostic & Preventive
HIGH OPTION PLAN for Eligible Part and Full-Time Employees Excluding Employees Residing in Mississippi or Texas. Out-of-Network.
Dental Insurance Plan Summary Excluding Employees Residing in Mississippi or Texas Network: PDP Plus HIGH OPTION PLAN for Eligible Part and Full-Time Employees Excluding Employees Residing in Mississippi
PLAN OPTION 1. Network Select Plan. Out-of-Network % of R&C Fee **
Harvest Management Sub LLC. dba Holiday Retirement Dental Metropolitan Life Insurance Company Network: PDP Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic (fillings, extractions)
Dental. Ingredion Corporation. Network: PDP. In-Network. Out-of-Network. Coverage Type. Metropolitan Life Insurance Company
Ingredion Corporation Dental Metropolitan Life Insurance Company Network: PDP Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic Restorative (fillings, extractions) Type C: Major
PLAN OPTION 1 High Plan. Out-of-Network % of R&C Fee ** % of Negotiated
Clearway Energy Group LLC Dental Metropolitan Life Insurance Company Network: PDP Plus Coverage Type In-Network % of Negotiated Fee * PLAN OPTION 1 High Plan In-Network Out-of-Network % of R&C Fee ** %
Non-voluntarydental (2-9) Kansas
Non-voluntarydental (2-9) Option 3 PPO Max 1000 Option 5 PPO 1500 Option 6 PPO 2000 Option 7 Aetna Dental Preventive Care PPO Max 100/80/50 PPO 100/80/50 PPO 100/80/50 PPO Max Plan 100/0/0 Annual deductible
PLAN OPTION 1 High Plan. Out-of-Network % of R&C Fee ** % of Negotiated 100% 100% 100% 100% 80% 80% 50% 50%
Covenant Health All Full Time and Part Time Employees Excluding Maristhill Union Employees Dental Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic (fillings,
Georgia State University Dental Plan Benefits
Georgia State University Dental Plan Benefits For the savings you need, the flexibility you want and service you can trust. Benefit Summary Coverage Type PDP In-Network Out-of-Network Type A cleanings,
Annual Deductible, Payment Provisions and Annual Maximum
Dental Plan Dental Benefits are available only to those Participants and their eligible dependents where the Participant Group has opted for this coverage and completed an enrollment form requesting coverage
Choice, Service, Savings. To help you enroll, the following pages outline your company's dental plan and address any questions you may have.
Dental Plan Design for: San Jose Convention & Visitors Bureau Effective Date: March 1, 2000 Amendment Effective Date ± : November 1, 2017 Date Prepared: January 4, 2018 Choice, Service, Savings. To help
Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits
Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits Annual Benefit Limit: $1500 Annual Member Deductible: $50 PPO Dentist $50 Non-PPO Dentist Family Coverage Deductible Limit 3 times Annual
In-Network 100% 80% 50%
National Louis University PPO Dental Plan High Dental Network: PDP Plus Coverage Type In-Network Out-of-Network % of Negotiated Fee * % of R&C Fee ** Type A: Preventive (cleanings, exams, X-rays) Type
PLAN OPTION 1 High Plan. Out-of-Network % of R&C Fee ** % of Negotiated 100% 100% 100% 100% 80% 80% 80% 80% 50% 50% 50% 50%
Hays CISD Dental Plans Dental Metropolitan Life Insurance Company Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic (fillings, extractions) Type C: Major (bridges,
DENTAL FOR EVERYONE DIAMOND PLAN PPO & PREMIER SUMMARY OF BENEFITS, LIMITATIONS AND EXCLUSIONS
DENTAL FOR EVERYONE DIAMOND PLAN PPO & PREMIER SUMMARY OF BENEFITS, LIMITATIONS AND EXCLUSIONS DEDUCTIBLE Your dental plan features a deductible. This is an amount you must pay out of pocket before Benefits
For the savings you need, the flexibility you want and service you can trust.
Cobb County School District Dental Plan Benefits For the savings you need, the flexibility you want and service you can trust. Benefit Summary Plan Option 1- Base Plan (Copay Plan) Coverage Type In-Network
Surgical Care Affiliates Dental Plan Benefits
Surgical Care Affiliates Dental Plan Benefits For the savings you need, the flexibility you want and service you can trust. Benefit PDP Plus Summary Core Plan All Full-Time and Part Time Teammates Buy
Dental. EAG, Inc. - All locations except Easton & Columbia. Network: PDP Plus. In-Network. Out-of-Network. Coverage Type
EAG, Inc. - All locations except Easton & Columbia Dental Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) In-Network Out-of-Network % of Negotiated Fee * % of R&C Fee ** 100%
In-Network 70% Deductible Individual $25 $50 Annual Maximum Benefit Per Person $2,000 $2,000
UC Berkeley Student Health Insurance Plan (SHIP) Group Number: 151675 MetLife Dental Insurance Plan Summary Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic Restorative
HealthPartners Dental Distinctions Benefits Chart
HealthPartners Dental Distinctions Benefits Chart Effective Date: The later of the effective date, or most recent anniversary date, of the Master Group Contract and your effective date of coverage under
Independence Dental. PPO dental insurance for individuals and families. Brochure Independence Dental PPO
Independence Dental PPO dental insurance for individuals and families Underwritten by Independence American Insurance Company, (IAIC), a member of the IHC Group, an insurance organization composed of Independence
Dental. Lower Colorado River Authority. Network: PDP Plus. L i s t o f P r i m a r y C o v e r e d S e r v i c e s & L i m i t a t i o n s.
Lower Colorado River Authority Dental Metropolitan Life Insurance Company Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic Restorative (fillings, extractions)
Summary of Benefits Dental Coverage - New Dental Option
Summary of Benefits Dental Coverage - New Dental Option Managed Dental Plan MET225 - Texas Code Description Co-Payment Diagnostic Treatment D0120 Periodic Oral Evaluation established patient $0 D0150 Comprehensive
Dental. Michigan Conference of the United Methodist Church. Network: PDP Plus. In-Network. Out-of-Network. Coverage Type
Michigan Conference of the United Methodist Church Dental Metropolitan Life Insurance Company Network: PDP Plus Coverage Type In-Network Out-of-Network % of Negotiated Fee * % of R&C Fee ** Type A: Preventive
In-Network % of Negotiated Fee * % of Negotiated Fee * 100% 80% 50%
Dental Metropolitan Life Insurance Company Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic Restorative (fillings, extractions) Type C: Major Restorative (bridges,
Benefits are payable after a twelve (12) month waiting period. We will require the following information with the first claim:
Your WellAway Broker: J+C Budmiger GmbH Eta-Glob Help-System CH-3900 Brig / Switzerland Dental Benefits Rider Basic & Major Subject to a USD $ 50 deductible per policy year All benefits In Aggregate USD
Aetna Dental presents A Dental Benefit Summary for Michigan Voluntary Option 2; Freedom-of-Choice; No Ortho DMO
Aetna Dental presents A Dental Benefit Summary for Michigan Voluntary Option 2; Freedom-of-Choice; No Ortho DMO PPO Max Annual Deductible* Individual None $75 Family None $225 Preventive Service Covered
THIS PLAN DOES NOT MEET THE MINIMUM ESSENTIAL HEALTH BENEFIT REQUIREMENTS FOR
SCHEDULE OF EXCLUSIONS AND LIMITATIONS THIS PLAN DOES NOT MEET THE MINIMUM ESSENTIAL HEALTH BENEFIT REQUIREMENTS FOR PEDIATRIC ORAL HEALTH AS REQUIRED UNDER THE FEDERAL AFFORDABLE CARE ACT. Exclusions
Creighton University s Enhanced Dental Plan Benefits
Creighton University s Enhanced Dental Plan Benefits For the savings you need, the flexibility you want and service you can trust. Benefit Summary Coverage Type PDP In-Network: Out-of-Network: Type A cleanings,
In-Network 100% 80% 50% 40%
DriveTime Automotive Group, Inc. Dental Network: PDP Plus Standard Plan Coverage Type Type A: Preventive (cleanings, exams, X-rays, composite fillings ) Type B: Basic Restorative (extractions, endodontics,
MetLife Dental Insurance Plan Summary. In-Network % of Negotiated Fee * % of R&C Fee 100% 100% 80% 80% 50% 50%
TriNet IV, Inc. Classic Option LA, MS, MT& TX Employees Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic Restorative (fillings, extractions) Type C: Major Restorative
Non-voluntary dental (2-9) Nevada
Non-voluntary dental (2-9) Option 1 DMO Access Option 2 Preventive Care PPO Option 3 PPO 1000 Option 4 PPO Active Option 5 PPO 2000 Plan 42 PPO 100/0/0 PPO 100/50/50 Preferred 100/80/50 Non-Preferred 80/60/50
Non-voluntary dental (2-9) Texas
Non-voluntary dental (2-9) Option 1 DMO Access Option 2 DMO Option 3 Freedom-of-Choice Monthly selection between the DMO and the PDN Plan Option 4 PDN Max Option 5 PDN 1500 DMO Copay 42 DMO 100/90/60 DMO
Aetna Dental presents A Dental Benefit Summary for Florida Voluntary Option 2; Freedom-of-Choice; w/ortho DMO
Aetna Dental presents A Dental Benefit Summary for Florida Voluntary Option 2; Freedom-of-Choice; w/ortho DMO PPO Max Annual Deductible* Individual None $75 Family None $225 Preventive Service Copay/Covered
In-Network 100% 100% 80% 80% 50% 50%
Douglas County School System High Dental Plan Dental Metropolitan Life Insurance Company Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic Restorative (fillings,
MetLife Dental Insurance Plan Summary
Northshore School District MetLife Dental Insurance Plan Summary Network: PDP Plus Coverage Type Level 1 % of Negotiated 99% of R&C * % of Negotiated Level 2 99% of R&C * Type A: Preventive (cleanings,
Healthcare 212. BrightIdea Dental. Save more for yourself, spend less on your dentist. Powering Change in Healthcare.
Healthcare 212 BrightIdea Dental Save more for yourself, spend less on your dentist. Powering Change in Healthcare. With BrightIdea Dental visiting the dentist isn t expensive; however, neglecting your
PLAN OPTION 1 Plus Plan. Out-of-Network % of R&C Fee ** % of Negotiated
Metropolitan Life Insurance Company Network: PDP Plus Coverage Type In-Network % of Negotiated Fee * PLAN OPTION 1 Plus Plan In-Network Out-of-Network % of R&C Fee ** % of Negotiated Fee * PLAN OPTION
Dental Benefit Summary
DMO Passive PPO Annual Deductible* Individual None $75 Family None $225 Preventive Service Covered Percent 100% 80% Basic Service Covered Percent 100% 50% Major Service Covered Percent 60% 50% Annual Benefit
Plan Benefits and Features In-Network Out-of-Network
Dental Benefit Summary San Jose State University Research Foundation Effective Date: January 01, 2019 Policy Number: 004201 Class Definition: Class 1: All Active Full Time Employees working at least 20Plan:
Texas Essential Health Benefit PLUS Family Plan with EHB PLUS (for Children)
This summary of benefits, along with the exclusions and limitations describe the benefits of the Essential Health Benefit PLUS Family Plan with EHB PLUS (for Children). Please review closely to understand
Out-of- In-Network Essential Health Benefit. Network** N/A Class IV/Orthodontia N/A Deductible. $0 $50 Out of Pocket Maximum
Utah Essential Health Benefit PPO Family Plan with EHB (for Children) This summary of benefits, along with the exclusions and limitations describe the benefits of the Essential Health Benefit PPO Family
MetLife Dental Insurance Plan Summary
MetLife Dental Insurance Plan Summary Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic (fillings, extractions) Type C: Major (bridges, dentures) In-Network %
MetLife Dental Insurance Plan Summary
University of Louisiana at Lafayette MetLife Dental Insurance Plan Summary Network: PDP Plus Coverage Type In-Network Out-of-Network % of Negotiated Fee * 90% of R&C Fee ** Type A: Preventive (cleanings,
Non-voluntary dental (2-9) Colorado
Non-voluntary dental (2-9) Option 1 DMO Access Option 2 Freedom-of-Choice Monthly selection between the DMO and PPO Option 3 PPO Max 1000 Option 4 Active PPO Plan 42 DMO 100/90/60 PPO 100/70/40 PPO Max
Good news about dental benefits for employees of. LCMC Health
Dental PPO Good news about dental benefits for employees of LCMC Health Why is dental health so important? Regular dental care does more than just improve smiles. Along with good oral hygiene, it can help
PLAN OPTION 1 Basic Plan. Out-of-Network % of R&C Fee ** % of Negotiated. Deductible Individual $35 $35 $50 $50
Dental Metropolitan Life Insurance Company Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic (fillings, extractions) Type C: Major (bridges, dentures) Type D:
Aetna Dental presents A Dental Benefit Summary for Florida Option 3; Freedom-of-Choice; w/ortho DMO
Aetna Dental presents A Dental Benefit Summary for Florida Option 3; Freedom-of-Choice; w/ortho DMO PPO Annual Deductible* Individual None $50 Family None $150 Preventive Service Covered Percent 100% 100%
III. Dental Program Table of Contents
III. Dental Program Table of Contents About This Section...1 An Overview of Your Dental Program Options...2 MetLife and Delta Dental Options...2 Preventive/Diagnostic Care...3 Basic Restorative Care...3
Endodontics Root canal therapy Pulpotomy Apicoectomy Retrograde Filling. Oral Surgery Pallative Treatment
Washoe County School District Dental Benefit Matrix $2,000 Calendar Year Max; $50 Deductible, $100 Family Deductible Unlimited Maximum for Dependent Children to age 19; No Orthodontic Coverage Standard
Educational Service Center of Cuyahoga County Dental Plan Benefits
Educational Service Center of Cuyahoga County Dental Plan Benefits Network: PDP Plus Benefit Summary Coverage Type In-Network Out-of-Network Type A cleanings, oral examinations 100% of Negotiated Fee*
Dental Benefits Summary $1,000 Maximum
Annual Deductible* Individual Family Preventive Services Basic Services Major Services Dental Benefits Summary $1,000 Maximum Participating (Negotiated Charge) $50 $100 100% 80% 50% Active PPO With PPO
Colorado Essential Health Benefit PLUS Family Plan with EHB (for Children)
This summary of benefits, along with the exclusions and limitations describe the benefits of the Essential Health Benefit PLUS Family Plan with EHB (for Children). Please review closely to understand all
III. Dental Program Table of Contents
III. Dental Program Table of Contents About This Section...1 An Overview of Your Dental Program Options...2 Delta Dental...3 Preventive/Diagnostic Care...3 Basic Restorative Care...3 Major Restorative
prominencehealthplan.com Large Group PPO Dental Plans (51+)
Large Group PPO Dental Plans (51+) Sales and enrollment guide Here for you Introducing dental plans from Prominence Health Plan Dental care is an integral part of overall good health. The ability to offer
A DENTAL PLAN THAT BALANCES CHOICE & SAVINGS
A DENTAL PLAN THAT BALANCES CHOICE & SAVINGS GuideStone s Choice Dental Plan Cigna Total DPPO The Cigna Total Dental PPO (DPPO) network makes it easy to protect your health and your smile with the right
AIG Group Scheduled Reimbursement Dental SM Insurance
PRODUCT SPECIFICATIONS AIG Group Scheduled Reimbursement Dental SM Insurance Under the AIG Group Scheduled Reimbursement Dental SM plan, we combine choice and affordability to create long-term satisfaction.
PPO dental insurance for individuals and families
Independence Dental PPO dental insurance for individuals and families Underwritten by Independence American Insurance Company, (IAIC), a member of The IHC Group, an insurance organization composed of Independence
Evidence of Coverage Rider for Enrollees who are enrolled in the Freedom Comprehensive Dental Benefit
Evidence of Coverage Rider for Enrollees who are enrolled in the Freedom Comprehensive Dental Benefit Please keep this notice as it is part of your HealthPartners Freedom Balance with Rx (Cost)/HealthPartners
$50 (Type B & C) $50 (Type B & C) $1000 $1000 $1000 $1000
Overview of Benefits for: VAN BUREN PUBLIC SCHOOLS Date Prepared: 04-19-2018 The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefits
Dental Benefits. Savings, flexibility and service. For healthier smiles. Overview of Benefits for: CA GA Plan B $ th E/P/O Major Ortho
Dental Benefits Savings, flexibility and service. For healthier smiles. Overview of Benefits for: CA GA Plan B $1000 90th E/P/O Major Ortho With all of the emphasis on healthy living, it may be refreshing
We re proud to protect your smile.
Veterans Affairs Dental Insurance Program We re proud to protect your smile. Dental Plan Summary In collaboration with U.S. Department of Veterans Affairs Veterans Health Administration Contents Plan Highlights
Dental Benefits Summary
DMO Annual Deductible Individual Family Preventive Services 100% Basic Services 90% Major Services 60% Annual Benefit Maximum Office Visit Copay $5 Orthodontic Services Orthodontic Deductible Orthodontic
DENTAL FOR EVERYONE SUMMARY OF BENEFITS, LIMITATIONS AND EXCLUSIONS
DENTAL FOR EVERYONE SUMMARY OF BENEFITS, LIMITATIONS AND EXCLUSIONS DEDUCTIBLE The dental plan features a deductible. This is an amount the Enrollee must pay out-of-pocket before Benefits are paid. The
Page: 1. TRINET GROUP Effective Date: Dental Benefits Summary 80th OON R&C
TRINET GROUP Effective Date: 10-01-2018 Dental Benefits Summary 80th OON R&C Active PPO With PPOII Network Participating Non-participating Annual Deductible* Individual $50 $100 Family $150 $300 Preventive
PPO Dental. BENEFITS - Network Provider 1 Basic Premiere. Covered Services. Type I
Make sure you are protected with other popular SureBridge products: Accident Direct Critical Illness Direct Vision BENEFITS - Network Provider Basic Premiere Covered Services Type I Type II Type III Calendar
YSLETA ISD DENTAL PLAN. Employees are Eligible to elect Ysleta Dental if Selecting PLAN I, II, III, IV
YSLETA ISD DENTAL PLAN Employees are Eligible to elect Ysleta Dental if Selecting PLAN I, II, III, IV YSLETA ISD DENTAL PLAN SUMMARY OF BENEFITS $50 Individual Annual Deductible Preventive 80% Deductible
SPD Dental Plan 08/01/
Dental Plan 08/01/2017 5-1 Delta Dental Plan How the Dental Plan Works The Dental Plans pay benefits for you and your Eligible Dependents for a wide range of dental services and supplies. The Dental Plans:
In-Network 100% 80% 50%
Central Piedmont Community College Dental Metropolitan Life Insurance Company Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic Restorative (fillings, extractions)
It's Time to Enroll for Benefits
Dental Insurance It's Time to Enroll for Benefits MetLife Dental for State of Oklahoma employees Dental Insurance Group Benefits Dental options for State of Oklahoma employees MetLife Dental Plans always
Welcome to Arkansas Blue Cross and Blue Shield Dental Plan
Welcome to Arkansas Blue Cross and Blue Shield Dental Plan University of Arkansas System Dental Program Beginning January 1, 2018, the University of Arkansas System dental plan will be administered by
City Electric Supply Dental Plan Benefits
City Electric Supply Dental Plan Benefits Network: PDP Plus Benefit Summary Coverage Type In-Network Out-of-Network Type A cleanings, oral examinations 100% of Negotiated Fee* 100% of R&C Fee** Type B
Symantec Corporation Plan 1.0 Dental Plan Benefits
Symantec Corporation Plan 1.0 Dental Plan Benefits Network: PDP Benefit Summary Coverage Type In-Network Out-of-Network Type A cleanings, oral examinations 100% of Negotiated Fee* 100% of R&C Fee** Type
SCHEDULE OF BENEFITS POLICY BENEFITS
The Guardian Life Insurance Company of America A Mutual Company Incorporated 1860 by the State of New York 7 Hanover Square, New York, New York 10004 SCHEDULE OF BENEFITS The Schedule of Benefits provides
SCHEDULE OF BENEFITS. (Who pays what) POLICY BENEFITS BENEFIT YEAR INDIVIDUAL DEDUCTIBLE COINSURANCE PERCENTAGES
The Guardian Life Insurance Company of America A Mutual Company Incorporated 1860 by the State of New York 7 Hanover Square, New York, New York 10004 SCHEDULE OF BENEFITS (Who pays what) The Schedule of
Dental Benefits. When you use a MetLife PDP participating dentist:
Dental Benefits As a benefits eligible team member, you have a choice of four dental plans: First Commonwealth/Guardian Dental Health Maintenance Organization (Dental HMO) MetLife Value Plan MetLife Preferred
Delta Dental PPO Dentist
DENTAL COVERAGE HOW DENTAL COVERAGE WORKS The Trust provides dental coverage to you and your eligible Dependents. Delta Dental of Michigan, whose contact information is listed in your Schedule of Benefits,
A DENTAL PLAN THAT BALANCES CHOICE & SAVINGS
A DENTAL PLAN THAT BALANCES CHOICE & SAVINGS GuideStone s Choice Dental Plan with the Total Cigna DPPO Network The Total Cigna Dental PPO (DPPO) network makes it easy to help protect your health and your
Type A - Preventive 100% 100% Type B - Basic Restorative 80% 80% Type C - Major Restorative 60% 60% Type D - Orthodontia 50% 50%
Dental Plan Design for: Eastern PA Conference-UMC Original Plan Effective Date: January 1, 2017 Network: PDP Plus The Preferred Dentist Program was designed to help you get the dental care you need and
Regence Life and Health dental plans
is an Independent Licensee of the Blue Cross and Blue Shield Association Regence Life and Health Insurance Company Regence Life and Health dental plans Good health isn t complete without good dental care.
We re proud to protect your smile.
We re proud to protect your smile. Dental Plan Summary In collaboration with Veterans Affairs Dental Insurance Program U.S. Department of Veterans Affairs Veterans Health Administration Contents Plan Highlights
Arizona Essential Health Benefit for Children
Smile for Kids (EHB) This summary of benefits, along with the exclusions and limitations describe the benefits of the Essential Health Benefit (EHB) for Children. Please review closely to understand all
In-Network 100% 100% 50% 50% Deductible Individual $50 $50 Family $150 $150 Annual Maximum Benefit Per Person $1,250 $1,250
Douglas County School System Low Dental Plan Dental Metropolitan Life Insurance Company Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic Restorative (fillings,
We re proud to protect your smile.
Veterans Affairs Dental Insurance Program We re proud to protect your smile. Dental Plan Summary In collaboration with U.S. Department of Veterans Affairs Veterans Health Administration The Veterans Affairs
Paychex Dental Plan Benefits - Met Life Your Choice PPO
Paychex Dental Plan Benefits - Met Life Your Choice PPO Network: PDP Plus Benefit Summary Coverage Type In-Network Out-of-Network Type A cleanings, oral examinations 100% of Negotiated Fee* 100% of Negotiated
Dental Coverage. Click here to download and print this entire section.
Dental Coverage Click here to download and print this entire section. Good dental habits are an important part of safeguarding your general health. They also help you reduce dental bills. The dental coverage
Type A - Preventive 100% 100% Type B - Basic Restorative 90% 80% Type C - Major Restorative 60% 50% Deductible 3 Individual $50 $50 Family $150 $150
Dental Plan Design for: Educational Services Inc Original Plan Effective Date: July 1, 2016 Network: PDP Plus The Preferred Dentist Program was designed to help you get the dental care you need and help
Elite PPO Basic (DC) Coverage Schedule for Adult Services
Elite PPO Basic (DC) Coverage Schedule for Adult Services - age 19 and over (coverage begins the first day of the month following the month in which the Member turns 19) - Benefit Coverage In-Network Out-of
Dental Blue Program 2. Summary of Benefits. Amherst College
Dental Blue Program 2 Summary of Benefits Amherst College Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Dental Blue Program 2 Preventive