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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 1 of 2 CPE-037 05/14 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. 2 of 2 CPE-037 05/14