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MetLife Dental Planth12 District DHMO Dental ProgramHOW TO ENROLL-(MET185 Plan)1. Complete all sections of the MetLife Dental enrollment form then sign and date at the bottom of theform.2. Select a dentist by going to the MetLife link: www.metlife.com/mybenefits (Under account Sign in youtype AFGE as your employer, Click on Managed Dental plan, select the MET185 plan and enter your zipcode.) Find the Facility # for the dental provider you choose and enter that number on the enrollmentform in the 1st Choice Dental Office # box. (You may call Customer Service at 866.348.9501 to besure that the dentist you’re selecting is still open to enrollment and accepting new patients.)3. You may pay premiums via a biweekly allotment or semiannually by personal check or by credit card.If you will be paying for coverage by payroll deduction, complete the 1199A payroll deduction form(Section 1- Parts A, C, G and Signature; Section 2 Agency Name and Payroll Address). Many federalagencies now require employees to initiate the payroll deduction process electronically. If your agencyrequires this, please refer to the Direct Deposit Form for the Bank Routing Number (Section 3) and theAccount Number (Section 1, Part E). You can contact Benefit Architects for specific instructions on howto start the deductions thru Employee Express, MyPay, and the USDA National Finance Center.HOW MUCH DOES THE MET185 DENTAL heckSingle 11.00 143.00Single 1 18.00 234.00Family 25.00 325.00(These premiums are guaranteed for 3 years from 11/01/2012)Mail or fax the completed MetLife Dental enrollment form and 1199A form to the address below.If you are paying by semi-annual check, you will need to mail the check or money order alongwith your enrollment form. Payment by Credit card can be made over the telephone.Benefit Architects AdministratorsAttn: 12th District Dental Plan1256 Main Street, Suite 249Southlake, TX 76092Fax 800-238-2104(Please note the original 1199A must be turned in to your payroll center if you did not initiate thepayroll deduction electronically thru Employee Express, MyPay, USDA National Finance Center)WHEN AM I ELIGIBLE?*If paying by payroll deduction, Benefit Architects must have two (2) deductions by the15th of the month for eligibility to begin the first of the following month. (Semi Annualchecks and Credit Card payments are due by the 10th of the month.)If you need to find a dental provider in your area or need to order new ID cards, please contactCustomer Service at 866.348.9501. (This number can be used for both MetLife andMetLife dental)If at any time you have a change of address, or phone number, notify Benefit ArchitectsAdministrators and MetLife by phone. If you take a leave of absence due to injury, etc.please be advised that you will be responsible for making arrangements to pay for yourcoverage until your allotments begin again.QUESTIONS? Email: Dental@BenefitArchitects.com or call 800.733.7236, X-105
SCHEDULE OF BENEFITSBenefits provided by SafeGuard Health Plans, Inc., a MetLife companyDirect Referral Dental Plan*MET185This SCHEDULE OF BENEFITS lists the Covered Services available to You and Your Dependents under Yourdental plan, as well as Your and Your Dependent’s costs for each Covered Service. Your and YourDependent’s costs may include Co-Payments for a Covered Service.*Care under this plan is provided through a network of Selected General Dentists. Your Selected GeneralDentist is responsible for determining when the services of a Specialty Care Dentist are needed, andfacilitating any necessary referral. You and Your Dependents will be advised of the name, address andtelephone number of the Specialty Care Dentist in Your or Your Dependent’s Service Area.Missed Appointments: If You or Your Dependents need to cancel or reschedule an appointment, please notifythe Selected General Dental Office as far in advance as possible. This will allow the Selected General DentalOffice to accommodate another person in need of attention. If You or Your Dependents fail to do this in a timelyfashion, You or Your Dependents may be charged a missed appointment fee.Your and YourDependent’sServiceCo-Payment Broken Appointment (less than 24-hr notice)Not to exceed 25 Office visit - per visit (including all fees for sterilization and/or infection 5control)Your and YourDependent’sCodeServiceCo-PaymentDiagnostic TreatmentD0120 Periodic oral evaluation - established patient 0D0140Limited oral evaluation - problem focused 0D0145 0D0150Oral evaluation for a patient under three years of age and counseling withprimary caregiverComprehensive oral evaluation - new or established patient 0D0160Detailed and extensive oral evaluation - problem focused, by report 0D0170 0D0180Re-evaluation - limited, problem focused (established patient; not postoperative visit)Comprehensive periodontal evaluation - new or established patientD0190Screening of a patient 0D0191Assessment of a patient 0D0210Radiographs / Diagnostic Imaging (X-rays)Intraoral – complete series of radiographic images 0D0220Intraoral – periapical first radiographic image 0D0230Intraoral – periapical each additional radiographic image 0D0240Intraoral – occlusal radiographic image 0D0250Extraoral – first radiographic image 0D0260Extraoral – each additional radiographic image 0D0270Bitewing – single radiographic image 0D0272Bitewings – two radiographic images 0GCERT2010-DHMO-SOBsob 0CA1
SCHEDULE OF BENEFITS (continued)Your and YourDependent’sCo-PaymentD0273ServiceBitewings – three radiographic imagesD0274Bitewings – four radiographic images 0D0277Vertical bitewings – 7 to 8 radiographic images 0D0330Panoramic radiographic image 0D0340Cephalometric radiographic image 0D0350Oral/facial photographic images 0D0363Cone beam – three dimensional image reconstruction using existing data,includes multiple imagesCone beam CT capture and interpretation with limited field of view – less thanone whole jawCone beam CT capture and interpretation with field of view of one full dentalarch – mandibleCone beam CT capture and interpretation with field of view of one full dentalarch – maxilla, with or without craniumCone beam CT capture and interpretation with field of view of both jaws, withor without craniumCone beam CT image capture with limited field of view – less than one wholejawCone beam CT image capture with field of view of one full dental arch –mandibleCone beam CT image capture with field of view of one full dental arch –maxilla, with or without craniumCone beam CT image capture with field of view of both jaws, with or withoutcraniumInterpretation of diagnostic image by a practitioner not associated withcapture of the image, including reportTests and ExaminationsCollection of microorganisms for culture and 3D0391D0415 0 160 180 180 180 180 180 180 180 180 0 0D0425Caries susceptibility tests 0D0431 50D0460Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalitiesincluding premalignant and malignant lesions, not to include cytology orbiopsy proceduresPulp vitality testsD0470Diagnostic casts 0D0472Accession of tissue, gross examination, preparation and transmission ofwritten reportAccession of tissue, gross and microscopic examination, preparation andtransmission of written reportAccession of tissue, gross and microscopic examination, includingassessment of surgical margins for presence of disease, preparation andtransmission of written reportAccession of exfoliative cytologic smears, microscopic examination,preparation and transmission of written reportLaboratory accession of transepithelial cytologic sample, microscopicexamination preparation and transmission of written reportOther oral pathology procedures, by ob 0 0 0 0 0 0 02
SCHEDULE OF BENEFITS (continued)Your and YourDependent’sCo-PaymentServicePreventive ServicesD1110Prophylaxis – adult 0Additional-adult prophylaxis (maximum of 2 additional per year) 35Prophylaxis – child 0Additional-child prophylaxis (maximum of 2 additional per year) 25D1206Topical application of fluoride varnish 0D1208Topical application of fluoride 0D1310Nutritional counseling for control of dental disease 0D1320Tobacco counseling for the control and prevention of oral disease 0D1330Oral hygiene instructions 0 D1120 Includes periodontal hygiene instructionD1351Sealant – per tooth 0D1352 0D1510Preventive resin restoration in a moderate to high caries risk patient permanent toothSpace maintainer – fixed – unilateral 25D1515Space maintainer – fixed – bilateral 25D1520Space maintainer – removable – unilateral 35D1525Space maintainer – removable – bilateral 35D1550Re-cementation of space maintainer 5D1555Removal of fixed space maintainer 5D2140Restorative TreatmentAmalgam – one surface, primary or permanent 10D2150Amalgam – two surfaces, primary or permanent 15D2160Amalgam – three surfaces, primary or permanent 18D2161Amalgam – four or more surfaces, primary or permanent 20D2330Resin-based composite – one surface, anterior 10D2331Resin-based composite – two surfaces, anterior 15D2332Resin-based composite – three surfaces, anterior 18D2335 20D2390Resin-based composite – four or more surfaces or involving incisal angle(anterior)Resin-based composite crown, anteriorD2391Resin-based composite – one surface, posterior 30D2392Resin-based composite – two surfaces, posterior 45D2393Resin-based composite – three surfaces, posterior 65D2394Resin-based composite – four or more surfaces, posterior 65CrownsAn additional charge, not to exceed 150 per unit, will be applied for anyprocedure using noble, high noble or titanium metal. There is a 75 CoPayment per molar, for the use of porcelain.Cases involving seven (7) or more Crowns, implants and/or fixed Bridge unitsin the same treatment plan require an additional 125 Co-Payment per unit inaddition to the specified Co-Payment for each Crown, implant or Bridge unit.Inlay – metallic – one surface 165 D2510GCERT2010-DHMO-SOBsob 303
SCHEDULE OF BENEFITS (continued)Your and YourDependent’sCo-PaymentD2520ServiceInlay – metallic – two surfacesD2530Inlay – metallic – three or more surfaces 165D2542Onlay – metallic – two surfaces 185 165D2543Onlay – metallic – three surfaces 185D2544Onlay – metallic – four or more surfaces 185D2610Inlay – porcelain/ceramic – one surface 185D2620Inlay – porcelain/ceramic – two surfaces 185D2630Inlay – porcelain/ceramic – three or more surfaces 185D2642Onlay – porcelain/ceramic – two surfaces 185D2643Onlay – porcelain/ceramic – three surfaces 185D2644Onlay – porcelain/ceramic – four or more surfaces 185D2650Inlay – resin-based composite – one surface 185D2651Inlay – resin-based composite – two surfaces 185D2652Inlay – resin-based composite – three or more surfaces 185D2662Onlay – resin-based composite – two surfaces 185D2663Onlay – resin-based composite – three surfaces 185D2664Onlay – resin-based composite – four or more surfaces 185D2710Crown – resin-based composite (indirect) 185D2712Crown – ¾ resin-based composite (indirect) 185D2720Crown – resin with high noble metal 185D2721Crown – resin with predominantly base metal 185D2722Crown – resin with noble metal 185D2740Crown – porcelain/ceramic substrate 225D2750Crown – porcelain fused to high noble metal 185D2751Crown – porcelain fused to predominantly base metal 185D2752Crown – porcelain fused to noble metal 185D2780Crown – ¾ cast high noble metal 185D2781Crown – ¾ cast predominantly base metal 185D2782Crown – ¾ cast noble metal 185D2783Crown – ¾ porcelain/ceramic 185D2790Crown – full cast high noble metal 185D2791Crown – full cast predominantly base metal 185D2792Crown – full cast noble metal 185D2794Crown – titanium 185D2799 55D2910Provisional crown – further treatment or completion of diagnosis necessaryprior to final impressionRecement inlay, onlay, or partial coverage restorationD2915Recement cast or prefabricated post and core 0D2920Recement crown 0D2930Prefabricated stainless steel crown – primary tooth 25D2931Prefabricated stainless steel crown – permanent tooth 25GCERT2010-DHMO-SOBsob 04
SCHEDULE OF BENEFITS (continued)Your and ed resin crownD2933Prefabricated stainless steel crown with resin window 35D2940Protective restoration 0D2950Core buildup, including any pins 50D2951Pin retention – per tooth, in addition to restoration 10D2952Post and core in addition to crown, indirectly fabricated 50D2953Each additional indirectly fabricated post – same tooth 50D2954Prefabricated post and core in addition to crown 30D2955Post removal 10D2957Each additional prefabricated post – same tooth 30D2960Labial veneer (resin laminate) – chairside 250D2961Labial veneer (resin laminate) – laboratory 300D2962Labial veneer (porcelain laminate) – laboratory 350D2970Temporary crown (fractured tooth) 0D2971D2980Additional procedures to construct new crown under existing partial dentureframeworkCrown repair necessitated by restorative material failure 50 0D2981Inlay repair necessitated by restorative material failure 0D2982Onlay repair necessitated by restorative material failure 0D2983Veneer repair necessitated by restorative material failure 0D2990Resin infiltration of incipient smooth surface lesions 0 35 EndodonticsAll procedures exclude final restoration.D3110Pulp cap – direct (excluding final restoration) 0D3120Pulp cap – indirect (excluding final restoration) 0D3220Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronalto the dentinocemental junction and application of medicamentPulpal debridement, primary and permanent teeth 10D3221D3222 45D3310Partial pulpotomy for apexogenesis - permanent tooth with incomplete rootdevelopmentPulpal therapy (resorbable filling) – anterior, primary tooth (excluding finalrestoration)Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding finalrestoration)Endodontic therapy, anterior tooth (excluding final restoration)D3320Endodontic therapy, bicuspid tooth (excluding final restoration) 115D3330Endodontic therapy, molar tooth (excluding final restoration) 200D3331Treatment of root canal obstruction; non-surgical access 85D3332Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth 70D3333Internal root repair of perforation defects 85D3346Retreatment of previous root canal therapy – anterior 135D3347Retreatment of previous root canal therapy – bicuspid 175D3348Retreatment of previous root canal therapy – molar 275D3230D3240GCERT2010-DHMO-SOBsob 10 30 35 805
SCHEDULE OF BENEFITS (continued)Your and on/recalcification/pulpal regeneration – initial visit (apicalclosure/calcific repair of perforations, root resorption, pulp space, lpal regeneration – interim medicationreplacement (apical closure/calcific repair of perforations, root resorption,pulp space, disinfection, etc.)Apexification/recalcification – final visit (includes completed root canal therapy– apical closure/calcific repair of perforations, root resorption, etc.)Pulpal regeneration - (completion of regenerative treatment in an immaturepermanent tooth with a necrotic pulp); does not include final restorationApicoectomy/periradicular surgery – anteriorD3421Apicoectomy/periradicular surgery – bicuspid (first root) 95D3425Apicoectomy/periradicular surgery – molar (first root) 95D3426Apicoectomy/periradicular surgery (each additional root) 60D3430Retrograde filling – per root 40D3450Root amputation – per root 95D3460Endodontic endosseous implant 555D3910Surgical procedure for isolation of tooth with rubber dam 0D3920Hemisection (including any root removal), not including root canal therapy 90D3950Canal preparation and fitting of preformed dowel or post 15D3351D3352D3353D3354 65 65 65 65 95D4245PeriodonticsPeriodontal charting for planning treatment of periodontal disease is includedas part of overall diagnosis and treatment. No additional charge will apply toYou or Your Dependent or Us.Gingivectomy or gingivoplasty – four or more contiguous teeth or toothbounded spaces per quadrantGingivectomy or gingivoplasty – one to three contiguous teeth or toothbounded spaces per quadrantGingivectomy or gingivoplasty to allow access for restorative procedure, pertoothGingival flap procedure, including root planing – four or more contiguousteeth or tooth bounded spaces per quadrantGingival flap procedure, including root planing – one to three contiguous teethor tooth bounded spaces per quadrantApically positioned flapD4249Clinical crown lengthening – hard tissueD4260D4263Osseous surgery (including flap entry and closure) – four or more contiguousteeth or tooth bounded spaces per quadrantOsseous surgery (including flap entry and closure) – one to three contiguousteeth or tooth bounded spaces per quadrantBone replacement graft – first site in quadrant 180D4264Bone replacement graft – each additional site in quadrant 95D4265Biologic materials to aid in soft and osseous tissue regeneration 95D4266Guided tissue regeneration – resorbable barrier, per site 215D4267Guided tissue regeneration – nonresorbable barrier, per site (includesmembrane removal) 255 b 90 68 68 150 113 165 120 295 2106
SCHEDULE OF BENEFITS (continued)Your and YourDependent’sCo-PaymentD4268ServiceSurgical revision procedure, per toothD4270Pedicle soft tissue graft procedure 245D4273Subepithelial connective tissue graft procedures, per tooth 75D4274D4275Distal or proximal wedge procedure (when not performed in conjunction withsurgical procedures in the same anatomical area)Soft tissue allograft 380D4276Combined connective tissue and double pedicle graft, per tooth 75D4277D4320Free soft tissue graft procedure (including donor site surgery), first tooth oredentulous tooth position in a graftFree soft tissue graft procedure (including donor site surgery), each additionalcontiguous tooth or edentulous tooth position in same graft siteProvisional splinting – intracoronalD4321Provisional splinting – extracoronal 85D4278 0 70 245 245 95D4341Periodontal scaling and root planing – four or more teeth per quadrant 40D4342Periodontal scaling and root planing – one to three teeth per quadrant 30D4355Full mouth debridement to enable comprehensive evaluation and diagnosis 40D4381 60D4910Localized delivery of antimicrobial agents via controlled release vehicle intodiseased crevicular tissue, per toothPeriodontal maintenanceD4920Unscheduled dressing change (by someone other than treating dentist) 30Additional periodontal maintenance procedures (beyond 2 per 12 months) 0 55Removable ProsthodonticsDelivery of removable and fixed Prosthodontics includes up to 3 adjustmentswithin 6 months of delivery date of service.Complete denture – maxillary 210D5120Complete denture – mandibular 210D5130Immediate denture – maxillary 225D5140Immediate denture – mandibular 225D5211Maxillary partial denture – resin base (including any conventional clasps,rests and teeth)Mandibular partial denture – resin base (including any conventional clasps,rests and teeth)Maxillary partial denture – cast metal framework with resin denture bases(including any conventional clasps, rests and teeth)Mandibular partial denture – cast metal framework with resin denture bases(including any conventional clasps, rests and teethMaxillary partial denture – flexible base (including any clasps, rests and teeth) D5110D5212D5213D5214D5225D5226 240 240 260 260 365D5410Mandibular partial denture – flexible base (including any clasps, rests andteeth)Removable unilateral partial denture – one piece cast metal (including claspsand teeth)Adjust complete denture – maxillaryD5411Adjust complete denture – mandibular 0D5421Adjust partial denture – maxillary 0D5422Adjust partial denture – mandibular 0D5281GCERT2010-DHMO-SOBsob 365 250 07
SCHEDULE OF BENEFITS (c
Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* MET185 GCERT2010-DHMO-SOB CA sob 1 This SCHEDULE OF BENEFITS lists the Covered Services available to You and Your Dependents under Your dental plan, as well as Your and Your
