Dominion Dental Services FederalDentalPlans com
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- Bu səhifədəki naviqasiya:
- Section 4 Your Cost for Covered Services
- Co-payment
- Section 5 Dental Services and Supplies Class A Basic Important things you should keep in mind about these benefits
- See Section 7 of this brochure for plan limitations. You Pay
- Out-of-Network: In full for all charges.
- High Option Copay Amount
Ordinarily, you must get your care from providers within the service area who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. An emergency is treatment due to injury, accident or severe pain requiring the services of a dentist which occurs under circumstances where it is neither medically or physically possible for you to be treated by a plan provider. We will not pay for any other services out of our service area unless the services have prior plan approval. If you move outside of our service area, you may enroll in another plan at that time. You do not have to wait until Open Season to change plans. Contact BENEFEDS at www. benefeds.com or call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 to change plans. Your rates are determined based on where you live. This is called a rating area. If you move, you must update your address through BENEFEDS. Your rates might change because of the move.
If you live in a limited access area and you receive covered services from an out-of- network provider, we will pay in accordance with our plan allowance. You are responsible for any difference between the amount billed and our payment. You can find a list of our limited access areas at FederalDentalPlans.com or by contacting us at 855-836-6337. Limited Access Areas There are no alternate benefits associated with this plan. The copayment for each listed procedure you receive is the total amount you will owe the dentist.
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2018 Enroll at www.BENEFEDS.com Section 4 Your Cost for Covered Services This is what you will pay out-of-pocket for covered care: A co-payment is a fixed amount of money you pay directly to the dentist when you receive covered services. Your benefit schedule lists the co-payments for each covered procedure. There is also a $10 office visit copay in addition to the listed charge per office visit, not per procedure. Example: In our Standard Plan, you pay $48 for an amalgam – one surface, primary or permanent (ADA Code D2140). Co-payment There is no annual benefit maximum limit under this plan. Annual Benefit Maximum There is no lifetime benefit maximum limit under this plan Lifetime Benefit Maximum The co-payment amounts listed in the benefit schedule along with the $10 office visit copay represent your total cost for in-network services (please note that the office visit copay is charged per visit, not per procedure). In-Network Services Benefits under your plan must be received through in-network dentists. There is no coverage for services rendered by an out-of-network provider except for out-of-network emergency services. Out-of-Network Services An emergency is treatment due to injury, accident or severe pain requiring the services of a dentist which occurs under circumstances where it is neither medically or physically possible for you to be treated by a plan provider. We will not pay for any other services out of our service area unless the services have prior plan approval. We will reimburse you up to $100 per member per year. When traveling overseas, we will authorize emergency services only.
The co-payments listed in Section 5 and the $10 office visit copay are the only payments you make to the dentist for covered services. There are no calculations based on plan allowances that will result in any additional costs to you. Plan Allowance 12
2018 Enroll at www.BENEFEDS.com Section 5 Dental Services and Supplies Class A Basic Important things you should keep in mind about these benefits: • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are necessary for the prevention, diagnosis, care, or treatment of a covered condition and meet generally accepted dental protocols. • All oral evaluations will be considered integral when provided on the same date of service by the same dentist. • There is no calendar year deductible. • There is no waiting period for basic services. • There is no annual benefit maximum. • See Section 7 of this brochure for plan limitations. You Pay: •
(please note that the office visit copay is charged per office visit, not per procedure). •
emergency services when the services of an assigned in-network provider are not available.
D0120 Periodic oral evaluation $0 $0
D0140 Limited oral evaluation – problem focused $0
$0 D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver $0
$0 D0150 Comprehensive oral evaluation – new or established patient $0 $0
D0160 Detailed and extensive oral evaluation – problem focused $30
$0 D0180 Comprehensive periodontal evaluation – new or established patient $0 $0
D0210 Intraoral – complete series (including bitewings) $0
$0 D0220 Intraoral – periapical first film $0 $0
D0230 Intraoral – periapical – each additional film $0
$0 D0240 Intraoral – occlusal film $0 $0
D0250 Extraoral – first film $0
$0 D0270 Bitewing – single film $0 $0
D0272 Bitewings – two films $0
$0 D0273 Bitewings – three films $0 $0
D0274 Bitewings – four films $0
$0 D0277 Vertical bitewings – 7 to 8 films $0 $0
D0330 Panoramic film $0
$0 D0425 Caries susceptibility tests $0 $0
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