Download CoPower SELECT MetLife Vol Dental DHMO Plan Highlight

MetLife Voluntary Dental
5-50 DHMO Plan Highlights
At CoPower, we make understanding and using your benefits easy. Below is helpful
information about your chosen plan:
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/contact-us/findinga-provider/ to quickly and
easily find the HMO provider
in your network for you.
Highlights
• 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
Co-Payment
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
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MetLife Voluntary Dental
5-50 DHMO Plan Highlights
Periodontics
To file a claim:
MetLife Dental Claims
Phone: (877) 638-3379
www.metlife.com/dental
To adjust your record
information:
Please reach out to your
benefits administrator.
They can contact a CoPower
Group Service Representative
Monday through Friday, 8:00
am to 5:00 pm PST.
T: 888.920.2322
www.copower.com
Do I need an ID card?
Members who enroll under
MetLife Dental will receive
ID cards. ID cards are sent
directly to DHMO 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
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
Prosthodontics
Implants
Crowns / Fixed Bridges
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 Dnetal Plan. Schedule of Benefits provided per request.
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