Direct Referral Dental Plan* SOC-STANDARD
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- Elwin Reeves
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1 SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* SOC-STANDARD This Schedule of Benefits lists the services available to you under your SafeGuard plan, as well as the co-payments associated with each procedure. There are other factors that impact how your plan works and those are included here in the Exclusions and Limitations. 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 to SafeGuard for any necessary referral. Children under six years of age, who are unable to be treated by their Plan dentist, may be referred to a pedodontist. The member will be responsible for a co-payment equal to 50% of the specialist s fee. SafeGuard will pay the balance. Diagnostic Treatment D0120 Periodic oral evaluation - established patient D0140 Limited oral evaluation problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation - new or established patient D0160 Detailed and extensive oral evaluation - problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not postoperative visit) D0171 Re-evaluation post-operative office visit D0180 Comprehensive periodontal evaluation - new or established patient Office visit - per visit (including all fees for sterilization and/or infection control) Radiographs/Diagnostic Imaging (X-rays) D0210 Intraoral complete series of radiographic images D0220 Intraoral periapical first radiographic image D0230 Intraoral periapical each additional radiographic image D0240 Intraoral occlusal radiographic image D0250 Extra-oral 2D projection radiographic image created using a stationary radiation source, and detector D0251 Extra-oral posterior dental radiographic image D0270 Bitewing single radiographic image D0272 Bitewings two radiographic images D0274 Bitewings four radiographic images D0277 Vertical bitewings 7 to 8 radiographic images D0330 Panoramic radiographic image D0350 2D oral/facial photographic image obtained intra-orally or extra-orally Tests and Examinations D0460 Pulp vitality tests 01/17
2 Preventive Services Procedures identified with a symbol ( ) are limited to two (2) treatments in any 12 (twelve) consecutive months D1110 Prophylaxis adult D1120 Prophylaxis child D1206 Topical application of fluoride varnish D1208 Topical application of fluoride excluding varnish D1310 Nutritional counseling for control of dental disease D1320 Tobacco counseling for the control and prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant per tooth D1510 Space maintainer fixed unilateral D1515 Space maintainer fixed bilateral D1520 Space maintainer removable unilateral D1525 Space maintainer removable bilateral Restorative Treatment An additional charge, will be applied for any procedure using noble, high noble metal or titanium, and will be the member s responsibility. If porcelain, resin or resin-based composite is used on molar crowns, the member is responsible for an additional $75 co-payment above the set crown co-payment. D2140 Amalgam one surface, primary or permanent D2150 Amalgam two surfaces, primary or permanent D2160 Amalgam three surfaces, primary or permanent D2161 Amalgam four or more surfaces, primary or permanent D2330 Resin-based composite one surface, anterior D2331 Resin-based composite two surfaces, anterior D2332 Resin-based composite three surfaces, anterior D2335 Resin-based composite four or more surfaces or involving incisal angle (anterior) D2390 Resin-based composite crown, anterior D2542 Onlay metallic two surfaces $50 D2543 Onlay metallic three surfaces $50 D2544 Onlay metallic four or more surfaces $50 D2710 Crown resin-based composite (indirect) $50 D2712 Crown ¾ resin-based composite (indirect) $50 D2720 Crown resin with high noble metal $50 D2721 Crown resin with predominantly base metal $50 D2722 Crown resin with noble metal $50 D2740 Crown porcelain/ceramic substrate $50 D2750 Crown porcelain fused to high noble metal $50 D2751 Crown porcelain fused to predominantly base metal $50 D2752 Crown porcelain fused to noble metal $50 D2780 Crown ¾ cast high noble metal $50 D2781 Crown ¾ cast predominantly base metal $50 D2782 Crown ¾ cast noble metal $50 D2790 Crown full cast high noble metal $50 D2791 Crown full cast predominantly base metal $50
3 D2792 Crown full cast noble metal $50 D2794 Crown titanium $50 D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core D2920 Re-cement or re-bond crown D2930 Prefabricated stainless steel crown primary tooth D2931 Prefabricated stainless steel crown permanent tooth D2940 Protective restoration D2950 Core buildup, including any pins when required D2951 Pin retention per tooth, in addition to restoration D2952 Post and core in addition to crown, indirectly fabricated D2953 Each additional indirectly fabricated post same tooth $40 D2954 Prefabricated post and core in addition to crown D2957 Each additional prefabricated post same tooth Endodontics All procedures exclude final restoration. D3110 Pulp cap direct (excluding final restoration) D3120 Pulp cap indirect (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament D3310 Endodontic therapy, anterior tooth (excluding final restoration) $20 D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) $40 D3330 Endodontic therapy, molar (excluding final restoration) $60 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $20 D3346 Retreatment of previous root canal therapy anterior $20 D3347 Retreatment of previous root canal therapy bicuspid $40 D3348 Retreatment of previous root canal therapy molar $60 D3351 Apexification/recalcification initial visit (apical closure / calcific repair of perforations, root resorption, etc.) D3352 Apexification/recalcification interim medication replacement D3353 Apexification/recalcification final visit (includes completed root canal therapy apical closure/calcific repair of perforations, root resorption, etc.) D3410 Apicoectomy anterior $50 D3421 Apicoectomy bicuspid (first root) $50 D3425 Apicoectomy molar (first root) $50 D3426 Apicoectomy (each additional root) $50 D3430 Retrograde filling per root D3450 Root amputation per root Periodontics D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant D4260 Osseous surgery (including elevation of a full thickness flap and closure) four $150 or more contiguous teeth or tooth bounded spaces per quadrant D4261 Osseous surgery (including elevation of a full thickness flap and closure) one $150 to three contiguous teeth or tooth bounded 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
4 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis Removable Prosthodontics Denture relines are limited to one (1) during any twelve (12) consecutive months. D5110 Complete denture maxillary D5120 Complete denture mandibular D5130 Immediate denture maxillary D5140 Immediate denture mandibular D5211 Maxillary partial denture resin base (including any conventional clasps, rests and teeth) D5212 Mandibular partial denture resin base (including any conventional clasps, rests and teeth) D5213 Maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5214 Mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5221 Immediate maxillary partial denture resin base (including any conventional clasps, rests and teeth) D5222 Immediate mandibular partial denture resin base (including any conventional clasps, rests and teeth) D5223 Immediate maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5224 Immediate mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5281 Removable unilateral partial denture - one piece cast metal (including clasps $50 and teeth) D5410 Adjust complete denture maxillary D5411 Adjust complete denture mandibular D5421 Adjust partial denture maxillary D5422 Adjust partial denture mandibular D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5620 Repair cast framework D5630 Repair or replace broken clasp - per tooth D5640 Replace broken teeth per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture - per tooth D5710 Rebase complete maxillary denture $20 D5711 Rebase complete mandibular denture $20 D5720 Rebase maxillary partial denture $20 D5721 Rebase mandibular partial denture $20 D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5740 Reline maxillary partial denture (chairside) D5741 Reline mandibular partial denture (chairside) D5750 Reline complete maxillary denture (laboratory) $15 D5751 Reline complete mandibular denture (laboratory) $15 D5760 Reline maxillary partial denture (laboratory) $15
5 D5761 Reline mandibular partial denture (laboratory) $15 D5820 Interim partial denture (maxillary) $60 D5821 Interim partial denture (mandibular) $60 D5850 Tissue conditioning, maxillary D5851 Tissue conditioning, mandibular Crowns/Fixed Bridges - Per Unit An additional charge, will be applied for any procedure using noble, high noble metal or titanium, and will be the member s responsibility. If porcelain, resin or resin-based composite is used on molar crowns, the member is responsible for an additional $75 co-payment above the set crown co-payment. D6205 Pontic - indirect resin based composite $50 D6210 Pontic cast high noble metal $50 D6211 Pontic cast predominantly base metal $50 D6212 Pontic cast noble metal $50 D6214 Pontic titanium $50 D6240 Pontic porcelain fused to high noble metal $50 D6241 Pontic porcelain fused to predominantly base metal $50 D6242 Pontic porcelain fused to noble metal $50 D6250 Pontic resin with high noble metal D6251 Pontic resin with predominantly base metal D6252 Pontic resin with noble metal D6545 Retainer cast metal for resin bonded fixed prosthesis $50 D6710 Crown indirect resin based composite $50 D6720 Crown resin with high noble metal D6721 Crown resin with predominantly base metal D6722 Crown resin with noble metal D6750 Crown porcelain fused to high noble metal $50 D6751 Crown porcelain fused to predominantly base metal $50 D6752 Crown porcelain fused to noble metal $50 D6780 Crown ¾ cast high noble metal $50 D6781 Crown ¾ cast predominantly base metal $50 D6782 Crown ¾ cast noble metal $50 D6790 Crown full cast high noble metal $50 D6791 Crown full cast predominantly base metal $50 D6792 Crown full cast noble metal $50 D6794 Crown titanium $50 D6930 Re-cement or re-bond fixed partial denture D6940 Stress breaker D6980 Fixed partial denture repair necessitated by restorative material failure Oral Surgery D7111 Extraction, coronal remnants deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth soft tissue D7230 Removal of impacted tooth partially bony $15 D7240 Removal of impacted tooth completely bony
6 D7241 Removal of impacted tooth completely bony, with unusual surgical $15 complications D7250 Removal of residual tooth roots (cutting procedure) $15 D7285 Incisional biopsy of oral tissue hard (bone, tooth) D7286 Incisional biopsy of oral tissue soft D7310 Alveoloplasty in conjunction with extractions four or more teeth or tooth spaces, per quadrant D7311 Alveoloplasty in conjunction with extractions one to three teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions four or more teeth or tooth spaces, per quadrant D7321 Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant D7340 Vestibuloplasty - ridge extension (secondary epithelialization) D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) D7471 Removal of lateral exostosis (maxilla or mandible) D7472 Removal of torus palatinus D7473 Removal of torus mandibularis D7960 renulectomy aka frenectomy or frenotomy separate procedure not incidental to another procedure D7963 Frenuloplasty Orthodontics Start-up fees shall consist of the initial examinations, diagnosis and consultation, and the retention phase of treatment up to two (2)years maximum. This includes initial construction, placement and adjustments to retainers for a maximum period of two (2) years. Refer to Orthodontic Exclusions & Limitations for details. D8070 Comprehensive orthodontic treatment of the transitional dentition $1,000 D8080 Comprehensive orthodontic treatment of the adolescent dentition $1,000 D8090 Comprehensive orthodontic treatment of the adult dentition $1,000 D8660 Pre-orthodontic treatment examination to monitor growth and development $25 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) Start-up fee $250 Ortho visits beyond twenty-four (24) months of active treatment or retention $25 per visit Adjunctive General Services D9110 Palliative (emergency) treatment of dental pain minor procedure D9210 Local anesthesia not in conjunction with operative or surgical procedures D9211 Regional block anesthesia D9215 Local anesthesia in conjunction with operative or surgical procedures D9219 Evaluation for deep sedation or general anesthesia D9310 Consultation diagnostic service provided by dentist or physician other than requesting dentist or physician D9430 Office visit for observation (during regularly scheduled hours) no other services performed D9440 Office visit after regularly scheduled hours D9986 Missed appointment Not to exceed (less than 24-hr notice) $25
7 D9987 Cancelled appointment (if less than 24-hr notice, see D9986) Children under six years of age, who are unable to be treated by their Plan dentist, may be referred to a pedodontist. The member will be responsible for a co-payment equal to 50% of the specialist s fee. SafeGuard will pay the balance. Current Dental Terminology American Dental Association
8 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: Porcelain or Composite Restorations: Posterior: Primary Teeth: Prophylaxis: Prosthodontics: Quadrant: Resin-based Composite: Specialty Referral Services: 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). These are tooth colored restorations. If porcelain or composite is used on molar crowns, the member is responsible for an additional $75 above the set co-payment. 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 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 to SafeGuard for any necessary referral. SGM-SOB-SOC-S-CA-DEF Customer Service (800) /11
9 Exclusions and Limitations Limitations of Benefits 1. Prophylaxis is limited to two (2) treatments in any 12 consecutive months. 2. An additional charge will be applied for any procedure using noble or high noble metal, and will be the member s responsibility. 3. If porcelain, resin or resin-based composite is used on molar crowns, the member is responsible for an additional $75 above the set crown co-payment. 4. Full upper and lower dentures are not to exceed one (1) each in any three-year period. Replacement will be provided for an existing denture or bridge only if it is unsatisfactory and cannot be made satisfactory. 5. Partial dentures are not to be replaced within any three-year period unless necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible. 6. Denture relines limited to one (1) during any 12 consecutive months. 7. Periodontal treatments limited to five (5) during any 12 consecutive months. 8. Bite-wing X-rays limited to not more than one series of four films in any six-month period. 9. Full mouth X-rays limited to one (1) set every 24 consecutive months. Exclusions of Benefits 1. Cosmetic dental care. 2. General anesthesia and the services of a special anesthesiologist. 3. Dental conditions arising out of and due to enrollee s employment or for which Workers' Compensation is payable. Services which are provided to the enrollee by State government or agency thereof, are provided without cost to the enrollee by any municipality, county or other subdivisions. 4. Treatment required by reason of war. 5. Hospital charges of any kind. 6. Major surgery of fractures and dislocations. 7. Loss or theft of dentures or bridgework. 8. Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage. 9. Any procedure not specifically listed as a covered benefit is not a covered benefit and may be available on a fee-for-services basis. 10. Congenital malformations. 11. Malignancies. 12. Dispensing of drugs not normally supplied in dental office. 13. Additional treatment costs incurred because a dental procedure is unable to be performed in the dentist's office due to the general health and physical limits of the enrollee. Orthodontic Exclusion & Limitations The Plan provides coverage for orthodontic treatment plans provided through SafeGuard panel orthodontists. The maximum cost to the enrollee for each treatment plan is $1,000 plus start-up costs and subject to the following: A. Orthodontic treatment is available to all enrollees. B. Orthodontic treatment must be provided by a member of the SafeGuard orthodontic panel. C. Plan benefits cover 24 months of usual and customary orthodontic treatment. D. Should an enrollee be terminated for whatever reason and at the time of termination be receiving orthodontic treatment, the enrollee and not SafeGuard will be responsible for payment of balance due for treatment performed after termination. The enrollee's payment shall be based on the maximum fee of $1,000 and be pro-rated over the number of months to completion of the treatment and be payable on such terms and conditions as are arranged between the enrollee and the orthodontist. In no event shall the enrollee be liable for more than the sum of $1,000 for the treatment E. Start-up fees shall consist of the initial examination, diagnosis and consultation, and the retention phase of treatment of up to two years maximum. This includes initial construction, placement and adjustments to retainers for a maximum period of two years. This amount is $250 and is subject to review and change on an annual basis. SGM-SOB-SOC-S-CA-V2 Customer Service (800)
10 Exclusions and Limitations (continued) F. If treatment is not required or the enrollee chooses not to start treatment after the diagnosis and consultation has been completed by the provider, the enrollee will be charged consultation fee of $25 in addition to diagnostic record fees. G. The European method of orthodontia - activator appliances used in conjunction with eventual banding - is to be considered as full treatment. H. Should this contract be terminated by either party due to the breach or nonrenewal at the end of any applicable term, the provision of Paragraph D above, shall apply with respect to an enrollee being treated for orthodontic work which is not completed at the date of termination. I. SafeGuard guarantees that a covered State employee will not lose benefits as a result of a change in prepaid carriers. In the event that a covered employee should change prepaid plans and the orthodontist with the previous carrier is unwilling to complete the orthodontic treatment that has been started for the co-payment that was agreed upon between the orthodontist and the enrollee, SafeGuard will first contact the orthodontist and attempt to make arrangements for no loss of coverage. Should the orthodontist not meet SafeGuard standards, SafeGuard will guarantee that the covered employee may transfer to a SafeGuard orthodontist and that the orthodontic treatment plan will be completed for an amount not to exceed the total copayment that the patient is obligated to pay under the SafeGuard Plan, including credit for any payments that have already been paid as part of that treatment plan. The following are not included as orthodontic benefits: 1. Cephalometric X-rays; 2. Tracings and photographs; 3. Study models; 4. Lost, stolen or broken orthodontic appliances; 5. Retreatment of orthodontic cases; 6. Changes in treatment necessitated by accident of any kind; 7. Surgical procedures (including extraction of teeth solely for the purpose of orthodontics) incidental to orthodontic treatment; 8. Myofunctional therapy; 9. Surgical procedures related to cleft palate, micrognathia or macrognathia; 10. Treatment related to temporomandibular joint disturbances and/or hormonal imbalance; 11. Any dental procedure considered within the field of general dentistry such as fillings or extractions; 12. Malocclusions which are so severe or mutilated so as not to be amenable to ideal orthodontic therapy; 13. Treatment that extends 24 months beyond the point of full permanent dentition will be subject to an office visit charge of $25 per office visit. 14. Additional charges due to gross non-cooperation are not covered. SGM-SOB-SOC-S-CA-V2 Customer Service (800)
11 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) 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) LAP
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