My Benefits



	Definitions Emergency Dental Services Specialized Services Benefits, Limitations and Exclusions Renewal, Cancellation and Termination of Benefits Grace Period Reinstatement Description of Benefits and Copayments (Schedule A) Limitations and Exclusions (Schedule B)

SCHEDULE OF BENEFITS AND COPAYMENTS

D1000-D1999 II. Preventive - When referable services are provided by a Contract Specialty Care Dentist, the Enrollee pays 75 percent of that Dentist's "filed fees." *

Code	Description	Enrollee Pays
D1110	Prophylaxis cleaning - adult - 1 per 6 month period ¹	$ 20
D1330	Oral hygiene instructions	No Cost
D1510	Space maintainer - fixed - unilateral	$ 100
D1515	Space maintainer - fixed - bilateral	$ 150
D1520	Space maintainer - removable - unilateral	$ 100
D1525	Space maintainer - removable - bilateral	$ 150
D1550	Re-cementation of space maintainer	$ 10
D1555	Removal of fixed space maintainer	$ 10

*Frequency limitations do not apply when services are needed more frequently due to medical necessity as determined by the Contract Dentist.

**If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed, referable procedures that are not available in the contract facility or that require a Dentist to provide Specialized Services may be provided by a contracted oral surgeon, endodontist, or periodontist at 75 percent of the Contract Specialty Care Dentist's "filed fees." Specialized Services are only available upon referral by the assigned Contract Dentist.