Cigna Dental Care (*DHMO) Patient Charge Schedule - K1 08
|
|
|
- Edith Simmons
- 5 years ago
- Views:
Transcription
1 Cigna Dental Care (*DHMO) Patient Charge Schedule - K1 08 Important Highlights: Employee: $14.32 Employee + Spouse: $27.77 Employee + Child(ren): $36.44 Employee + Family: $45.71 This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services. This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist, Orthodontist or Oral Surgeon. You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child s 7th birthday. Procedures NOT listed on this Patient Charge Schedule are NOT covered and are the patient s responsibility at the dentist s usual fees. The administration of IV sedation, general anesthesia, and/or Nitrous Oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment. Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable. This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement. Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract. All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated. The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures.
2 K1-08 Cigna Dental Care (*DHMO) Patient Charge Schedule This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services. This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist, Orthodontist or Oral Surgeon. You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child s 7th birthday. Procedures NOT listed on this Patient Charge Schedule are NOT covered and are the patient s responsibility at the dentist s usual fees. The administration of IV sedation, general anesthesia, and/or Nitrous Oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment. Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable. This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement. Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract /11 K1-08
3 Cigna Dental Care Patient Charge Schedule (K1-08) Important Highlights (continued) All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated. The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures. Code Procedure Description Patient Charge Diagnostic/Preventive Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic Oral Evaluations (D0120), Comprehensive Oral Evaluations (D0150), Comprehensive Periodontal Evaluations (D0180), and Oral Evaluations for Patients Under 3 Years of Age (D0145). D9310 Consultation (Diagnostic Service Provided by Dentist or Physician Other than Requesting Dentist or Physician) D9430 Office Visit for Observation No Other Services Performed D9450 Case Presentation Detailed and Extensive Treatment Planning D0120 Periodic Oral Evaluation Established Patient D0140 Limited Oral Evaluation Problem Focused D0145 Oral Evaluation for a Patient Under 3 Years of Age and Counseling with Primary Caregiver D0150 Comprehensive Oral Evaluation New or Established Patient D0170 D0210 Re-evaluation Limited, Problem Focused (Not Postoperative Visit) X-Rays Intraoral Complete Series (Including Bitewings) (Limit 1 Every 3 Years) D0220 X-Rays Intraoral Periapical First Film D0230 X-Rays Intraoral Periapical Each Additional Film D0240 X-Rays Intraoral Occlusal Film D0270 X-Rays (Bitewing) Single Film D0272 X-Rays (Bitewings) 2 Films -2-
4 Cigna Dental Care Patient Charge Schedule (K1-08) Code Procedure Description Patient Charge D0273 X-Rays (Bitewings) 3 Films D0274 X-Rays (Bitewings) 4 Films D0277 X-Rays (Bitewings, Vertical) 7 to 8 Films D0330 X-Rays (Panoramic Film) (Limit 1 Every 3 Years) D0431 Oral Cancer Screening Using a Special Light Source $50.00 D0460 Pulp Vitality Tests $13.00 D0470 Diagnostic Casts D0472 D0473 D0474 Pathology Report Gross Examination of Lesion (Only When Tooth Related) Pathology Report Microscopic Examination of Lesion (Only When Tooth Related) Pathology Report Microscopic Examination of Lesion and Area (Only When Tooth Related) D1110 Prophylaxis (Cleaning) Adult (Limit 2 per Calendar Year) Additional Prophylaxis (Cleaning) In Addition to the 2 Prophylaxes (Cleanings) Allowed per Calendar Year $45.00 D1120 Prophylaxis (Cleaning) Child (Limit 2 per Calendar Year) D1203 D1206 Additional Prophylaxis (Cleaning) In Addition to the 2 Prophylaxes (Cleanings) Allowed per Calendar Year Topical Application of Fluoride Child (Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year. Topical Fluoride Varnish Therapeutic Application for Moderate to High Caries Risk Patients Child (Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year. $30.00 D1330 Oral Hygiene Instructions D1351 Sealant Per Tooth $11.00 D1352 Preventive Resin Restoration in a Moderate to High Caries Risk Patient Permanent Tooth $11.00 D1510 Space Maintainer Fixed Unilateral $ D1515 Space Maintainer Fixed Bilateral $ D1555 Removal of Fixed Space Maintainer
5 Cigna Dental Care Patient Charge Schedule (K1-08) Code Procedure Description Patient Charge Restorative (Fillings) D2140 Amalgam 1 Surface, Primary or Permanent D2150 Amalgam 2 Surfaces, Primary or Permanent D2160 Amalgam 3 Surfaces, Primary or Permanent D2161 Amalgam 4 or More Surfaces, Primary or Permanent D2330 Resin-Based Composite 1 Surface, Anterior D2331 Resin-Based Composite 2 Surfaces, Anterior D2332 Resin-Based Composite 3 Surfaces, Anterior D2335 Resin-Based Composite 4 or More Surfaces or Involving Incisal Angle, Anterior $85.00 D2390 Resin-Based Composite Crown, Anterior $85.00 D2391 Resin-Based Composite 1 Surface, Posterior $45.00 D2392 Resin-Based Composite 2 Surfaces, Posterior $57.00 D2393 Resin-Based Composite 3 Surfaces, Posterior $79.00 D2394 Resin-Based Composite 4 or More Surfaces, Posterior $ Crown and Bridge All charges for crown and bridge (fixed partial denture) are per unit (each replacement or supporting tooth equals 1 unit) Replacement limit 1 every 5 years. D2510 Inlay Metallic 1 Surface $ D2520 Inlay Metallic 2 Surfaces $ D2530 Inlay Metallic 3 or More Surfaces $ D2542 Onlay Metallic 2 Surfaces $ D2543 Onlay Metallic 3 Surfaces $ D2544 Onlay Metallic 4 or More Surfaces $ D2740 Crown Porcelain/Ceramic Substrate $ D2750 Crown Porcelain Fused to High Noble Metal $ D2751 Crown Porcelain Fused to Predominantly Base Metal $ D2752 Crown Porcelain Fused to Noble Metal $ D2780 Crown 3/4 Cast High Noble Metal $
6 After your enrollment is effective: Call the dental office identified in your Welcome Kit. If you wish to change dental offices, a transfer can be arranged at no charge by calling Cigna Dental at the toll-free number listed on your ID card or plan materials. Multiple ways to locate a *DHMO Network General Dentist: Online provider directory at Online provider directory on mycigna.com Call the number located on your ID card to: Use the Dental Office Locator via Speech Recognition Speak to a Customer Service Representative EMERGENCY: If you have a dental emergency as defined in your group s plan documents, contact your Network General Dentist as soon as possible. If you are out of your service area or unable to contact your Network Office, emergency care can be rendered by any licensed dentist. Definitive treatment (e.g., root canal) is not considered emergency care and should be performed or referred by your Network General Dentist. Consult your group s plan documents for a complete definition of dental emergency, your emergency benefit and a listing of Exclusions and Limitations. * The term DHMO is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features. Cigna and Cigna Dental are registered service marks and the Tree of Life logo is a service mark of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries, including Connecticut General Life Insurance Company ( CGLIC ), Cigna Health and Life Insurance Company ( CHLIC ), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. ( CDHI ) and its subsidiaries, and not by Cigna Corporation. The Cigna Dental Care plan is provided by Cigna Dental Health Plan of Arizona, Inc.; Cigna Dental Health of California, Inc.; Cigna Dental Health of Colorado, Inc.; Cigna Dental Health of Delaware, Inc.; Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes; Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska); Cigna Dental Health of Kentucky, Inc.; Cigna Dental Health of Maryland, Inc.; Cigna Dental Health of Missouri, Inc.; Cigna Dental Health of New Jersey, Inc.; Cigna Dental Health of North Carolina, Inc.; Cigna Dental Health of Ohio, Inc.; Cigna Dental Health of Pennsylvania, Inc.; Cigna Dental Health of Texas, Inc.; and Cigna Dental Health of Virginia, Inc. In other states, the Cigna Dental Care plan is underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc., and administered by CDHI / Cigna
NJAY2 State of New Jersey Retiree Plan Cigna Dental Care (*DHMO) Patient Charge Schedule
State of New Jersey Retiree Plan Cigna Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. IMPORTANT HIGHLIGHTS s pay the
NJAY1 State of New Jersey Retiree Plan Cigna Dental Care (*DHMO) Patient Charge Schedule
State of New Jersey Retiree Plan Cigna Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. IMPORTANT HIGHLIGHTS s pay the
CIGNA Dental Care (*DHMO) Patient Charge Schedule
A2O07 CIGNA Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
RSXV9 ALDINE INDEPENDENT SCHOOL DISTRICT BASIC CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient
cigna dental care (*DHMO) patient charge schedule
C15V9 Subject to regulatory approval cigna dental care (*DHMO) patient charge schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
A3O09 cigna dental care (*DHMO) patient charge schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
Cigna Dental Care (*DHMO) Patient Charge Schedule
W1-08 Cigna Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered
State of TN Cigna Dental Care (*DHMO) Patient Charge Schedule Plan effective 1/1/2016
State of TN Cigna Dental Care (*DHMO) Schedule Plan effective 1/1/2016 This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule
CIGNA Dental Care (*DHMO) Patient Charge Schedule
G1-07 CIGNA Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered
CIGNA DENTAL CARE (*DHMO)
B1-05 CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
Cigna Dental Care (*DHMO) Patient Charge Schedule
W1-09 Cigna Dental Care (*DHMO) Patient Charge Schedule This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Patient
cigna dental care (*DHMO) patient charge schedule
(*DHMO) patient charge schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered dental
cigna dental care (*DHMO) patient charge schedule
A2I09 Subject to regulatory approval (*DHMO) patient charge schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
WAO09 cigna dental care (*DHMO) patient charge schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
WAOV9 cigna dental care (*DHMO) patient charge schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
CIGNA Dental Care (*DHMO) Patient Charge Schedule
P6XV0 CIGNA Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered
Cigna Dental Care (*DHMO) Patient Charge Schedule
P5XV0 Cigna Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
W1-09 CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
K1-V9 TX CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
L1-09 TX CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
G1-V9 TX (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered
cigna dental care (*DHMO) patient charge schedule
K1I09 Subject to regulatory approval cigna dental care (*DHMO) patient charge schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
PSX09 PINELLAS COUNTY CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
P6XV0 CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
P3X00 NB209 BAXALTA CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule
cigna dental care (*DHMO) patient charge schedule
Q2-00 Subject to regulatory approval cigna dental care (*DHMO) patient charge schedule This Charge Schedule describes the benefits of your dental plan and includes a list of covered procedures, and coinsurance
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
P6XV0 TX CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
Exclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #
Exclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #6694 7.2011 MAXIMUM BENEFIT Calendar Year Orthodontic Lifetime CALENDAR YEAR DEDUCTIBLE WHO CAN BE COVERED
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
P4X00 CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
P6XV0 CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
State of Tennessee. Prepaid Plan. Dental Benefit Option. Sponsored by the. State of Tennessee
State of Tennessee Prepaid Plan Dental Benefit Option Sponsored by the State of Tennessee 2011 Products and services marketed by Assurant Employee Benefits are underwritten and/or provided by Union Security
WASHINGTON STATE COUNCIL OF COUNTY AND CITY EMPLOYEES AFSCME AFL-CIO DENTAL PLAN VIII
WASHINGTON STATE COUNCIL OF COUNTY AND CITY EMPLOYEES AFSCME AFL-CIO DENTAL PLAN VIII HOW TO OBTAIN PLAN BENEFITS To obtain benefits see the Payment of Claims provision. Forward Your completed claim form
SECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE
DentiCare of Alabama, Inc. 3595 Grandview Parkway, Suite 650 Birmingham, AL 35243 SECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE SECTION I: PLAN DENTIST SERVICES (Subject to Exclusions and Limitations Listed
State of tennessee Dental BenefIt option I Sponsored by the State of tennessee. a Guide to your cigna Dental prepaid plan
State of tennessee Dental BenefIt option a Guide to your cigna Dental prepaid plan Sponsored by the State of tennessee I 2017 Offered by: Cigna Health and Life Insurance Company, Connecticut General Life
CIGNA DENTAL PPO (DPPO)
County of San Mateo CIGNA DENTAL PPO (DPPO) Plan year: 2017 Offered by Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 862420 b You go the extra
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
Delta Dental EPO City & County of Denver Group #6791 EPO
MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule
Delta Dental EPO City & County of Denver Group #6791 EPO
MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule
HELP IS HERE. Caring that you make the right choice. A helpful, friendly resource
HELP IS HERE Caring that you make the right choice Need help deciding if Cigna coverage is right for you? The information you re looking for is just a phone call away! A helpful, friendly resource Learn
Managed DentalGuard Texas
Page 1 of 5 0120 0120 0140 0140 0150 0150 0460 0470 0999 9310 9310 9430 9440 0210 0220 0230 0240 0270 0272 0274 0330 1110 1120 1999 1201 1203 1204 1310 1330 1351 9999 1510 1515 1550 2110 2120 2130 2131
State of Tennessee Prepaid Plan
State of Tennessee Prepaid Plan Dental Benefit Option Sponsored by the State of Tennessee 2009 Products and services marketed by Assurant Employee Benefits are underwritten and/or provided by Union Security
Delta Dental of Colorado EXCLUSIVE PANEL OPTION (EPO) Schedule EPO 1B List of Patient Co-Payments. * See Special Provisions on Last Page
List of Co-Payments Code edure Code Definition Co-Pay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation
Active. Comparison of Dental Benefits
Carpenters Southwest Administrative Corporation ADMINISTRATIVE OFFICE: 533 S. Fremont Ave. Los Angeles, CA 90071-1706 Tel: (213) 386-8590 Toll Free: (800) 293-1370 www.carpenterssw.org Active Comparison
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
Delta Dental of Colorado DENVER HEALTH AND HOSPITAL AUTHORITY GROUP #587. EXCLUSIVE PANEL OPTION (EPO) List of Patient Copayments
List of Copayments Code edure Code Definition Copay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation
Summary Plan Description and Plan Document. Cigna Dental Plan Appendices
Summary Plan Description and Plan Document Cigna Dental Plan Appendices EFFECTIVE DATE: JANUARY 1, 2016 Table of Contents Contents Appendix I Chart At a Glance... 1 2016 Cigna Dental Plan Highlights &
Access Dental Family DHMO
866-569-9900 HTTPS://MYDENTAL.GUARDIANLIFE.COM SCHEDULE OF BENEFITS Access Dental Family DHMO This Schedule of Benefits lists the services available to you under your Access Dental Individual & Family
It s easy to find a network dentist or specialist.
Smile! It s easy to find a network dentist or specialist. Finding a Cigna Dental PPO (DPPO) network dentist or specialist is quick and easy whether you prefer searching online or speaking to a customer
Ameriprise Financial Dental Plan 2017 Summary Plan Description
Ameriprise Financial Dental Plan 2017 Summary Plan Description 2017 Ameriprise Financial, Inc. All rights reserved. 248258 D (3/17) Table of Contents Overview... 1 Participation and Cost... 1 Summary of
SCHEDULE A Description of Benefits and Copayments DHMO-901
866.650.3660 WWW.PREMIERLIFE.COM SCHEDULE A Description of Benefits and Copayments DHMO-901 The benefits shown below are performed as deemed appropriate by the attending Primary Care Dentist subject to
DELTA DENTAL PPO sm AGREEMENT SUPPLEMENT TO DELTA DENTAL PREMIER PARTICIPATING DENTIST S AGREEMENT
DELTA DENTAL PPO sm AGREEMENT SUPPLEMENT TO DELTA DENTAL PREMIER PARTICIPATING DENTIST S AGREEMENT This agreement (the "Supplement") supplements the Delta Dental Premier Participating Dentist s Agreement
School District of Collier County Dental Plan Review
School District of Collier County Dental Plan Review Dental Plan Effective: January 1, 2013 Making your plan election Things to Consider: Cost of premium compared to cost of dental services consider the
Dental Benefits Options For State, Education & Local Government Employees
2016 2017 Dental Benefits Options For State, Education & Local Government Employees Option 1: Delta Dental PPO* Benefit Plan Delta Dental PPO Network Delta Dental Premier Network OR Non-Participating Dentist
Dominion Dental Services
Dominion Dental Services Plan 603X Presented by Professional Benefit Administrators 1 (800) 578-2082 SUMMARY OF BENEFITS AND COPAYMENTS Enrollee pays DIAGNOSTIC Office Visit/Infectious Disease Control.....$
23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company
www.bcbsla.com 23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company 1 Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are
The. Dental Plan. Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation
The Dental Plan Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation Now you can have comprehensive DENTAL coverage at a cost you can afford! Since 1981, Denta-Chek has been providing
Newport News Public Schools Summary Schedule of Services Delta Dental PPO EPO Plan
Newport News Public Schools Summary of Services Delta Dental PPO EPO Plan Services In-Network Out-of-Network PPO Premier All Other Diagnostic & Preventive Oral Exams & Teeth Cleanings Fluoride Applications
ADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE PATIENT PAYS APPOINTMENTS
PRESTIGE 25 Schedule of Benefits and Subscriber Copayments ADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE PATIENT PAYS APPOINTMENTS 5130 Immediate maxillary (upper)...$300.00 9430 Office visit (normal
Managed DentalGuard - Plan Schedule
D0999 Office visit during regular hours, general dentist only * $5 Evaluations D0120 Periodic oral examination established patient 0 D0140 Limited oral evaluation problem focused 0 D0145 Oral evaluation
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
DIAGNOSTIC/PREVENTIVE SERVICES
DIAGNOSTIC/PREVENTIVE SERVICES Diagnostic Services D0120 Periodic oral evaluation 100% 100% D0140 Limited oral evaluation problem focused 100% 100% D0150 Comprehensive oral evaluation 100% 100% D0160 Detailed
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
2017 Dental Options BALTIMORE CITY PUBLIC SCHOOLS. Baltimore City Public Schools 2017 Dental Options C1
2017 Dental Options BALTIMORE CITY PUBLIC SCHOOLS Baltimore City Public Schools 2017 Dental Options C1 Table of Contents Important Information for 2017... 1 Dental HMO (DHMO)... 2 Preferred Dental PPO
Aetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE
Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: BNSF Railway Company GROUP AGREEMENT: 727796 PLAN EFFECTIVE: January 1, 2016 The benefits
Plan Details and Rates. Monthly Premium Rate Schedule
Basis of Reimbursement Plan Details and Rates MetLife Option 1 (Low) MetLife Option 2 (High) In-Network Out-of-Network In-Network Out-of-Network 70th percentile 70th percentile of Negotiated Negotiated
Baltimore City Public Schools 2013 Dental Options
Baltimore City Public Schools 2013 Dental Options Baltimore City Public Schools Important Phone Numbers for 2013 DHMO Customer Service (410) 847-9060 or (888) 833-8464 DHMO Mailing Address The Dental Network
HumanaDental PPO 09 (High Option)
HumanaDental PPO 09 (High Option) FLORIDA ICUBA If you use IN-NETWORK provider If you use OUT-OF-NETWORK provider Plan-year deductible Annual maximum Preventive services Oral examinations X-rays Cleanings
Employee Plan Information
Dental and Vision Premier Advantage FLEXIBLE DENTAL PLANS to meet your changing needs Employee Plan Information An option that allows you to move between the dental hmo and ppo plans as your needs change.
ADA Code Restorative Procedures (Fillings) Member Fee Usual Fee You Save D2951 Pin retention per tooth $ 35.00
Northeast General Dentistry Fee Schedule I District of Columbia, Maryland, New Jersey, New York, Pennsylvania, Virginia Please note: This fee schedule applies to procedures performed by a General Dentists
Schedule of Benefits Access Dental Family DHMO
Schedule of Benefits Access Dental Family DHMO This Schedule of Benefits lists the services available to you under your Premier Access Individual & Family Plan, as well as the Copayments associated with
FEE SCHEDULE. Complete Dental Plan is a discount plan offered and administered by our organization at:
FEE SCHEDULE Complete Dental Plan is a discount plan offered and administered by our organization at: 7801 CORAL WAY SUITE # 106, MIAMI, FL 33144 (786) 326-6873 F (305) 6979785 COMPLETE DENTAL PLAN HIGHLIGHTS
Concordia Plus Schedule of Benefits
Concordia Plus Schedule of Benefits Plan MD/DC 6 IMPORTANT INFORMATION ABOUT YOUR PLAN This schedule of benefits provides a listing of procedures covered by your plan. For procedures that require a copayment,
Kaiser Permanente and Delta Dental
Kaiser Permanente and Delta Dental Dental Program for Kaiser Permanente FEHBP Enrollees You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan. Kaiser Permanente and Delta Dental
DELTA DENTAL OF OKLAHOMA
DELTA DENTAL OF OKLAHOMA STATE, EDUCATION & LOCAL GOVERNMENT EMPLOYEES DENTAL BENEFITS OPTIONS 2019 OUR STANDARD IS TO EXCEED YOUR EXPECTATIONS WE DELIVER A SUPERIOR CUSTOMER EXPERIENCE DDOK DOES NOT DENY
Aetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE
Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: Clear Creek ISD GROUP AGREEMENT: 620318 PLAN EFFECTIVE: September 1, 2014 The benefits shown
RETIREE DENTAL PLAN. RETIREE DENTAL PLAN FEE SCHEDULE Page 1 of 8
D0120 periodic oral evaluation $ 30.50 D0140 limited oral evaluation problem focused $ 30.50 D0150 comprehensive oral evaluation - new or established patient $ 30.50 D0160 detailed and extensive oral evaluation
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
Employee Benefit Fund July 2018 ADA Codes and Plan Fees
CSEA Employee Benefit Fund July 2018 ADA Codes and Plan Fees DIAGNOSTIC D0120 periodic oral examination 40 34 42 45 48 38 30 32 31 D0140 limited oral examination (Does not look at 9110) 40 34 42 45 48
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
Schedule of Benefits (GR-9N S )
Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: BNSF Railway Company GP-727796 Issue Date: January 1, 2016 Effective Date: January 1, 2016 Schedule: 1A Cert Base: 1 For: DMO - All
Schedule of Benefits (GR-9N S )
Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: Roman Catholic Diocese Of Dallas GP-870560-WI Issue Date: February 9, 2015 Effective Date: January 1, 2015 Schedule: 7A Cert Base:
For all eligible employees of Maricopa County Community College District, Policy # All Eligible Employees
DHMO Dental Benefit Highlights For all eligible employees of Maricopa County Community College District, Policy #907728 All Eligible Employees Effective date: July 1, 2018 This dental plan can help lower
Brevard Public Schools
Brevard Public Schools Your Delta Dental Benefits Plan Delta Dental PPO High & Low Option Plan Highlights Diagnostic & Preventive Maximum Waiver Benefit Missing Teeth Covered Composite Fillings Covered
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.
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
GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual
Effective: January 1, 2016 Eligibility: (866) 436-3093 GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual Diagnostic D0999 Office Visit Copay - Per Person, Per Visit $9.00
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
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%
DID YOU KNOW? Every in preventive oral care can save in restorative and emergency treatments. 1
DID YOU KNOW? Every in preventive oral care can save in restorative and emergency treatments. 1 Research shows that oral health and overall health are closely related. So when you keep your teeth healthy,
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
TX Prepaid DHMO Dental
TX Prepaid DHMO Dental Good news about dental benefits for employees of Pearland Independent School District A Dental Plan Means Healthy Smiles Because you are a valued employee, we are pleased to offer
Dental Benefit Summary MetLife Preferred Dentist Program (PDP)
Dental Benefit Summary MetLife Preferred Dentist Program (PDP) CORE and BUY-UP Dental Options Note: MetLife Dental Plans require that any dental election, including declining coverage, can only be changed
General Dentist Fee Schedule
General Dentist Fee Schedule ADA Diagnostic D0120 Periodic oral evaluation $0 $72 $72 D0140 Limited oral evaluation problem focused $77 $107 $30 D0150 Comprehensive oral evaluation new or established patient
General Dentist Fee Schedule
General Dentist Fee Schedule Diagnostic D0120 Periodic oral evaluation $0 $59 $59 D0140 Limited oral evaluation problem focused $71 $88 $17 D0150 Comprehensive oral evaluation new or established patient
Uniform Dental Benefits: State Participants 2015
Uniform Dental Benefits (Certificate of Coverage) Please read the following information carefully for Your procedure frequencies and provisions. All dental benefits are paid according to the terms of the
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