Download MetLife Voluntary Dental

MetLife Voluntary Dental
DHMO Plan Highlights
At CoPower, we make understanding and using your benefits easy. Below is helpful
information about your chosen plan:
Highlights
With more than 140 years of
experience in the insurance
business and 90 years in
the group benefits business,
MetLife is positioned to
meet its obligations to your
clients and their employees
both today and in the
future. MetLife has years of
experience serving 60,000
corporate customers, including
more the 90 of the Top 100
Fortune 500 companies.
FINDING A
PROVIDER
Need help finding a MetLife
HMO dentist in your
area? CoPower is here to
help. The DHMO dental
network includes over 8,400
participating network dentist
access points in California.
Simply visit copower.com and
click on the Quick Link for
“Find a Provider” to quickly and
easily find the HMO provider in
your network for you.
• The DHMO plan offers more than 400 covered services.
• Dependent Children/Students are covered up to age 26.
• Employee Contributions : 50-100%
• Benefits are payable immediately from the start date of an individual’s benefits
• Employees can view and manage their dental benefits online.
MANAGED DENTAL PLAN (MET185A - CALIFORNIA)
Code
Description
Copayment
Office Visit
Diagnostic Treatment
D0120
Periodic Oral Evaluation – Established Patient
$0
D0150
Comprehensive Oral Evaluation – New or Established Patient
$0
D0210
Intra-oral – Complete Series (Including Bite-wings)
$0
D0274
Bite-wings – Four Films
$0
D1110
Prophylaxis – Adult
$0
D1120
Prophylaxis – Child
$0
D1351
Sealant – per tooth
$0
D2140
Amalgam – One Surface, Primary or Permanent
$0
D2330
Resin-Based Composite – One Surface, Anterior
$0
D2391
Resin-Based Composite – One Surface, Posterior
$30
D2750
Crown – Porcelain Fused to High Noble Metal
$185
D2751
Crown – Porcelain Fused to Predominantly Base Metal
$185
D3220
Therapeutic Pulpotomy (excluding final restoration) –
Removal of pulp coronal to the dentinocemental junction
and application of medicament
$10
D3330
Endodontic therapy, Molar (excluding final restoration)
$200
Preventive Services
Restorative Services
Crowns
Endodontics
CPE-037 2/15
MetLife Voluntary Dental
DHMO Plan Highlights
Periodontics
TO FILE A CLAIM:
MetLife Dental Claims
Phone: (877) 638-3379
www.metlife.com/dental
DO I NEED
AN ID CARD?
Members who enroll under
MetLife Dental will receive ID
cards. ID cards are sent directly
to members and contain all the
necessary information to use
the MetLife Dental coverage.
D4260
Osseous Surgery (Including Flap Entry and closure) – Four or
more contiguous teeth or tooth bounded spaces per quadrant
$295
D4341
Periodontal scaling and root planing –
Four or more teeth per quadrant
$40
D4910
Periodontal Maintenance
$30
D5110
Complete Denture - Maxillary
$210
D5120
Complete Denture - Mandibular
$210
D5211
Maxillary partial denture – resin base
(including any conventional clasps, rests and teeth)
$240
D5212
Mandibular partial denture – resin based
(including any conventional clasps, rests and teeth)
$240
D6010
Surgical placement of implant body: endosteal implant
$1,005
D6059
Abutment supported porcelain fused to metal crown
(high noble metal)
$660
Prosthodontics
Implants
Crowns / Fixed Bridges
PLAN
ADMINISTRATION:
For more information on plan
coverage, contact a CoPower
Group Service Representative
Monday through Friday,
8:00 am to 5:00 pm PST.
T: 888.920.2322
E: [email protected]
www.copower.com
D6241
Pontic – Procelain fused to predominantly base metal
$185
D6750
Crown - Porcelain fused to predominantly base metal
$185
D7140
Extraction, erupted tooth or exposed root
(elevation and/or forceps removal)
$0
D7210
Extraction, erupted tooth or exposed root
(elevation and/or forceps removal)
$30
D7220
Removal of impacted tooth – soft tissue
$45
D7240
Removal of impacted tooth – completely bony
$80
D8020
Limited orthodontic treatment of the transitional dentition
$725
D8030
Limited orthodontic treatment of the adolescent dentition
$725
D8040
Limited orthodontic treatment of the adult dentition
$725
D8070
Comprehensive orthodontic treatment of the transitional
dentition
$1,695
D8080
Comprehensive orthodontic treatment of the adolescent
dentition
$1,695
D8090
Comprehensive orthodontic treatment of the adult dentition
$1,695
Oral Surgery
Orthodontics
* The above description is only a summary of the Managed Dental Plan being offered. A complete copy of all the terms and conditions of the
Managed Dental Plan being offered is set forth in the Managed Dental Plan. Schedule of Benefits provided per request.
CPE-037 2/15