SCHEDULE OF BENEFITS DIRECT REFERRAL DENTAL PLAN*
SOC-STANDARD
This Schedule of Benefits lists the services available to you under your SafeGuard plan, as well as the co-payments associated with each procedure. There are other factors that impact how your plan works and those are included here in the Exclusions & Limitations. Specialty Care Information: During the course of treatment, your SafeGuard selected general dentist may recommend the services of a dental specialist. *Your SafeGuard selected general dentist is responsible for coordinating your dental care, and if necessary, referring you to a SafeGuard contracted specialist, and will submit all required documentation to SafeGuard for any necessary referral. Benefits provided by SafeGuard Health Plans, Inc. Code
Service
Co-payment
Diagnostic Treatment D0120 Periodic oral evaluation – established patient D0140 Limited oral evaluation – problem focused D0150 Comprehensive oral evaluation – new or established patient D0160 Detailed and extensive oral evaluation – problem focused, by report D0170 Re-evaluation – limited, problem focused (established patient; not post-operative visit) D0180 Comprehensive periodontal evaluation – new or established patient D9491 Office visit - per visit (including all fees for sterilization and/ or infection control)
$0 $0 $0 $0 $0 $0 $0
Radiographs/Diagnostic Imaging (X-rays) D0210 Intraoral – complete series (including bitewings) (once every 2 years) D0220 Intraoral – periapical first film D0230 Intraoral – periapical each additional film D0240 Intraoral – occlusal film D0250 Extraoral – first film D0260 Extraoral – each additional film D0270 Bitewing – single film D0272 Bitewings – two films D0274 Bitewings – four films D0277 Vertical bitewings – 7 to 8 films D0330 Panoramic film D0350 Oral/facial photographic images
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
Tests and Examinations D0460 Pulp vitality tests
$0
Preventive Services Procedures identified with a symbol (†) are limited to two (2) treatments in any 12 consecutive months. D1110 Prophylaxis – adult† $0 D1120 Prophylaxis – child† $0 D1203 Topical application of fluoride (prophylaxis not included) – child† $0 D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients† $0 D1310 Nutritional counseling for control of dental disease $0 SOC-S-SOB
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Code
Service
Co-payment
D1320 D1330 D1351 D1510 D1515 D1520 D1525
Tobacco counseling for the control and prevention of oral disease Oral hygiene instructions Sealant – per tooth Space maintainer – fixed – unilateral Space maintainer – fixed – bilateral Space maintainer – removable – unilateral Space maintainer – removable – bilateral
$0 $0 $0 $0 $0 $0 $0
Restorative Treatment • An additional charge will be applied for any procedure using noble, high noble metal or titanium, and will be the member’s responsibility. • If porcelain, resin or resin-based composite is used on molar crowns, the member is responsible for an additional $75 above the set crown co-payment. D2140 Amalgam – one surface, primary or permanent $0 D2150 Amalgam – two surfaces, primary or permanent $0 D2160 Amalgam – three surfaces, primary or permanent $0 D2161 Amalgam – four or more surfaces, primary or permanent $0 D2330 Resin-based composite – one surface, anterior $0 D2331 Resin-based composite – two surfaces, anterior $0 D2332 Resin-based composite – three surfaces, anterior $0 D2335 Resin-based composite – four or more surfaces or involving incisal angle (anterior) $0 D2390 Resin-based composite crown, anterior $0 D2542 Onlay – metallic – two surfaces $50 D2543 Onlay – metallic – three surfaces $50 D2544 Onlay – metallic – four or more surfaces $50 D2710 Crown – resin-based composite (indirect) $50 D2712 Crown – ¾ resin-based composite (indirect) $50 D2720 Crown – resin with high noble metal $50 D2721 Crown – resin with predominantly base metal $50 D2722 Crown – resin with noble metal $50 D2740 Crown – porcelain/ceramic substrate $50 $50 D2750 Crown – porcelain fused to high noble metal D2751 Crown – porcelain fused to predominantly base metal $50 D2752 Crown – porcelain fused to noble metal $50 D2780 Crown – ¾ cast high noble metal $50 D2781 Crown – ¾ cast predominantly base metal $50 D2782 Crown – ¾ cast noble metal $50 D2790 Crown – full cast high noble metal $50 D2791 Crown – full cast predominantly base metal $50 D2792 Crown – full cast noble metal $50 D2794 Crown – titanium $50 D2910 Recement inlay, onlay, or partial coverage restoration $0 D2915 Recement cast or prefabricated post and core $0 D2920 Recement crown $0 D2930 Prefabricated stainless steel crown – primary tooth $0 D2931 Prefabricated stainless steel crown – permanent tooth $0 D2940 Sedative filling $0 D2950 Core buildup, including any pins $0 D2951 Pin retention – per tooth, in addition to restoration $0 D2952 Post and core in addition to crown, indirectly fabricated $0 D2953 Each additional indirectly fabricated post – same tooth $40 D2954 Prefabricated post and core in addition to crown $0 D2957 Each additional prefabricated post – same tooth $0 SOC-S-SOB
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Code
Service
Co-payment
Endodontics D3110 Pulp cap – direct $0 D3120 Pulp cap – indirect $0 D3220 Therapeutic pulpotomy – removal of pulp coronal to the dentinocemental junction and application of medicament $0 D3310 Anterior $20 D3320 Bicuspid $40 D3330 Molar $60 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $20 D3346 Retreatment of previous root canal therapy – anterior $20 D3347 Retreatment of previous root canal therapy – bicuspid $40 D3348 Retreatment of previous root canal therapy – molar $60 D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.) $0 D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) $0 D3353 Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.) $ 0 D3410 Apicoectomy/periradicular surgery – anterior $50 D3421 Apicoectomy/periradicular surgery – bicuspid (first root) $50 D3425 Apicoectomy/periradicular surgery – molar (first root) $50 D3426 Apicoectomy/periradicular surgery (each additional root) $50 D3430 Retrograde filling – per root $0 D3450 Root amputation – per root $0 Periodontics D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces per quadrant $0 D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or bounded teeth spaces per quadrant $0 D4260 Osseous surgery (including flap entry and closure) – four or more contiguous teeth or bounded teeth spaces per quadrant $150 D4261 Osseous surgery (including flap entry and closure) – one to three contiguous teeth or bounded teeth spaces per quadrant $150 D4341 Periodontal scaling and root planing – four or more teeth per quadrant $0 D4342 Periodontal scaling and root planing – one to three teeth per quadrant $0 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $ 0 Removable Prosthodontics Denture relines are limited to one (1) during any 12 consecutive months. D5110 Complete denture – maxillary D5120 Complete denture – mandibular D5130 Immediate denture – maxillary D5140 Immediate denture – mandibular D5211 Maxillary partial denture – resin base (including any conventional clasps, rests and teeth) D5212 Mandibular partial denture – resin base (including any conventional clasps, rests and teeth) D5213 Maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5214 Mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5281 Removable unilateral partial denture – one piece cast metal (including clasps and teeth) SOC-S-SOB
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$65 $65 $65 $65 $65 $65 $65 $65 $50 8/07
Code
Service
Co-payment
D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5820 D5821 D5850 D5851
Adjust complete denture – maxillary Adjust complete denture – mandibular Adjust partial denture – maxillary Adjust partial denture – mandibular Repair broken complete denture base Replace missing or broken teeth – complete denture Repair resin denture base Repair cast framework Repair or replace broken clasp Replace broken teeth – per tooth Add tooth to existing partial denture Add clasp to existing partial denture Rebase complete maxillary denture Rebase complete mandibular denture Rebase maxillary partial denture Rebase mandibular partial denture Reline complete maxillary denture (chairside) Reline complete mandibular denture (chairside) Reline maxillary partial denture (chairside) Reline mandibular partial denture (chairside) Reline complete maxillary denture (laboratory) Reline complete mandibular denture (laboratory) Reline maxillary partial denture (laboratory) Reline mandibular partial denture (laboratory) Interim partial denture (maxillary) Interim partial denture (mandibular) Tissue conditioning, maxillary Tissue conditioning, mandibular
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $20 $20 $20 $20 $0 $0 $0 $0 $15 $15 $15 $15 $60 $60 $0 $0
Prosthodontics (Fixed) • An additional charge will be applied for any procedure using noble, high noble metal or titanium, and will be the member’s responsibility. • If porcelain, resin or resin-based composite is used on molar crowns, the member is responsible for an additional $75 above the set crown co-payment. D6205 Pontic – indirect resin based composite $50 D6210 Pontic – cast high noble metal $50 D6211 Pontic – cast predominantly base metal $50 D6212 Pontic – cast noble metal $50 D6214 Pontic – titanium $50 D6240 Pontic – porcelain fused to high noble metal $50 D6241 Pontic – porcelain fused to predominantly base metal $50 D6242 Pontic – porcelain fused to noble metal $50 D6250 Pontic – resin with high noble metal $0 D6251 Pontic – resin with predominantly base metal $0 D6252 Pontic – resin with noble metal $0 D6545 Retainer – cast metal for resin bonded fixed prosthesis $50 D6710 Crown – indirect resin based composite $50 D6720 Crown – resin with high noble metal $0 D6721 Crown – resin with predominantly base metal $0 D6722 Crown – resin with noble metal $0 D6750 Crown – porcelain fused to high noble metal $50 D6751 Crown – porcelain fused to predominantly base metal $50 D6752 Crown – porcelain fused to noble metal $50 D6780 Crown – ¾ cast high noble metal $50 SOC-S-SOB
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Code
Service
D6781 D6782 D6790 D6791 D6792 D6794 D6930 D6940 D6970
Crown – ¾ cast predominantly base metal Crown – ¾ cast noble metal Crown – full cast high noble metal Crown – full cast predominantly base metal Crown – full cast noble metal Crown – titanium Recement fixed partial denture Stress breaker Post and core in addition to fixed partial denture retainer, indirectly fabricated Prefabricated post and core in addition to fixed partial denture retainer Core build up for retainer, including any pins Each additional indirectly fabricated post – same tooth Each additional prefabricated post – same tooth Fixed partial denture repair, by report
D6972 D6973 D6976 D6977 D6980
Co-payment $50 $50 $50 $50 $50 $50 $0 $0 $0 $0 $0 $40 $0 $0
Oral and Maxillofacial Surgery D7111 Extraction, coronal remnants – deciduous tooth $0 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $0 D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth $0 D7220 Removal of impacted tooth – soft tissue $0 D7230 Removal of impacted tooth – partially bony $15 D7240 Removal of impacted tooth – completely bony $0 D7241 Removal of impacted tooth – completely bony, with unusual surgical complications $15 D7250 Surgical removal of residual tooth roots (cutting procedure) $15 D7285 Biopsy of oral tissue – hard (bone, tooth) $0 D7286 Biopsy of oral tissue – soft $0 D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $0 D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant $0 D7320 Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $0 D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant $0 D7340 Vestibuloplasty – ridge extension (secondary epithelialization) $0 D7350 Vestibuloplasty – ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) $0 D7471 Removal of lateral exostosis (maxilla or mandible) $0 D7472 Removal of torus palatinus $0 D7473 Removal of torus mandibularis $0 D7960 Frenulectomy (frenectomy or frenotomy) – separate procedure $0 D7963 Frenuloplasty $0
Code
Service
Co-payment
D8090 Comprehensive orthodontic treatment of the adult dentition $1,000 D8660 Pre-orthodontic treatment visit $25 D8680 Retention phase (including Fee for fixed/removable retainers and monthly visits for 24 months) $0 D8999 Start-up fee $250 D8999 Orthodontic visits beyond 24 months of treatment $25 per visit Adjunctive General Services D9110 Palliative (emergency) treatment of dental pain – minor procedure D9210 Local anesthesia not in conjunction with operative or surgical procedures D9211 Regional block anesthesia D9215 Local anesthesia D9310 Consultation – diagnostic service provided by dentist or physician other than requesting dentist or physician D9430 Office visit for observation (during regularly scheduled hours) – no other services performed D9440 Office visit – after regularly scheduled hours D9999 Broken appointment (less than 24 hour notice)
$0 $0 $0 $0 $0 $0 $0 $5
Children under six years of age, who are unable to be treated by their Plan dentist, may be referred to a pedodontist. The member will be responsible for a co-payment equal to 50% of the specialist’s fee. SafeGuard will pay the balance. Current Dental Terminology © American Dental Association
Orthodontics • Refer to Orthodontic Exclusions & Limitations for details. • Start-up fees shall consist of the initial examination, diagnosis and consultation, and the retention phase of treatment of up to two years maximum. This includes initial construction, placement and adjustments to retainers for a maximum period of two years. D8070 Comprehensive orthodontic treatment of the transitional dentition $1,000 D8080 Comprehensive orthodontic treatment of the adolescent dentition $1,000 SOC-S-SOB
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Dental Terminology Definitions
Exclusions and Limitations of Benefits
These definitions are designed to give you a “layman’s understanding” of some dental terminology in order for you to better understand your plan; they are not full descriptions.
Limitations of Benefits 1. Prophylaxis is limited to two (2) treatments in any 12 consecutive months. 2.
An additional charge will be applied for any procedure using noble or high noble metal, and will be the member’s responsibility.
Amalgam:
A silver filling.
3.
Anterior:
Teeth that are in the front of the mouth.
If porcelain, resin or resin-based composite is used on molar crowns, the member is responsible for an additional $75 above the set crown co-payment.
Bicuspid:
Most people have eight bicuspid teeth; they are located immediately preceding the molar teeth with two in each quadrant of the mouth.
4.
Bridge:
A replacement for one or more missing teeth that is permanently attached to the teeth adjacent to the empty space(s).
Full upper and lower dentures are not to exceed one (1) each in any three-year period. Replacement will be provided for an existing denture or bridge only if it is unsatisfactory and cannot be made satisfactory.
5.
Crown:
A covering created to place over a tooth to strengthen and/or replace tooth structure. A crown can be made of different materials (noble, high noble), base metal, porcelain or porcelain and metal.
Partial dentures are not to be replaced within any three-year period unless necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible.
Endodontics:
Procedures that treat the nerve or the pulp of the tooth due to injury or infection.
Oral Surgery:
Surgery to remove teeth, reshape portions of the bone in the mouth, or biopsy suspect areas of the mouth.
Orthodontics:
Braces and other procedures to straighten the teeth.
Periodontics:
Procedures related to treatment of the supporting structures of the teeth (gums, underlying bone).
Porcelain or Composite Restorations:
These are tooth colored restorations. If porcelain or composite is used on molar crowns, the member is responsible for an additional $75 above the set co-payment.
6.
Denture relines limited to one (1) during any 12 consecutive months.
7.
Periodontal treatments limited to five (5) during any 12 consecutive months.
8.
Bite-wing X-rays limited to not more than one series of four films in any six-month period.
9.
Full mouth X-rays limited to one (1) set every 24 consecutive months.
Exclusions of Benefits 1. Cosmetic dental care. 2.
General anesthesia and the services of a special anesthesiologist.
3.
Dental conditions arising out of and due to enrollee’s employment or for which Workers' Compensation is payable. Services which are provided to the enrollee by State government or agency thereof, are provided without cost to the enrollee by any municipality, county or other subdivisions.
4.
Treatment required by reason of war. Hospital charges of any kind.
Posterior:
Teeth that set towards the back of the mouth, including molars and bicuspids (premolars).
5. 6.
Major surgery of fractures and dislocations.
Primary Teeth:
The first set of teeth (“baby” teeth).
7.
Loss or theft of dentures or bridgework.
Prophylaxis:
Scaling and polishing of teeth by removal of the plaque above the gum line.
8.
Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage.
Prosthodontics:
The restoration of natural and/or the replacement of missing teeth with artificial substitutes.
9.
Any procedure not specifically listed as a covered benefit is not a covered benefit and may be available on a fee-for-services basis.
Quadrant:
One of the four equal sections into which your mouth can be divided (some procedures like periodontics are done in quadrants).
Resin-based Composite:
10. Congenital malformations. 11. Malignancies. 12. Dispensing of drugs not normally supplied in dental office.
Tooth-colored (white) fillings.
Specialty Referral Services: During the course of treatment, your SafeGuard selected general dentist may recommend the services of a dental specialist. Your SafeGuard selected general dentist is responsible for coordinating your dental care, and if necessary, referring you to a SafeGuard contracted specialist, and will submit all required documentation to SafeGuard for any necessary referral.
13. Additional treatment costs incurred because a dental procedure is unable to be performed in the dentist's office due to the general health and physical limits of the enrollee. Orthodontic Exclusion & Limitations The Plan provides coverage for orthodontic treatment plans provided through SafeGuard panel orthodontists. The maximum cost to the enrollee for each treatment plan is $1,000 plus start-up costs and subject to the following: A. Orthodontic treatment is available to all enrollees. B.
Orthodontic treatment must be provided by a member of the SafeGuard orthodontic panel. EL’s - SOC-S
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Exclusions and Limitations of Benefits C.
Plan benefits cover 24 months of usual and customary orthodontic treatment.
D.
Should an enrollee be terminated for whatever reason and at the time of termination be receiving or thodontic treatment, the enrollee and not SafeGuard will be responsible for payment of balance due for treatment performed after termination. The enrollee's payment shall be based on the maximum fee of $1,000 and be pro-rated over the number of months to completion of the treatment and be payable on such terms and conditions as are arranged between the enrollee and the orthodontist. In no event shall the enrollee be liable for more than the sum of $1,000 for the treatment plan (does not include start-up fees).
E.
Start-up fees shall consist of the initial examination, diagnosis and consultation, and the retention phase of treatment of up to two years maximum. This includes initial construction, placement and adjustments to retainers for a maximum period of two years. This amount is $250 and is subject to review and change on an annual basis.
F.
If treatment is not required or the enrollee chooses not to start treatment after the diagnosis and consultation has been completed by the provider, the enrollee will be charged consultation fee of $25 in addition to diagnostic record fees.
G.
The European method of orthodontia - activator appliances used in conjunction with eventual banding - is to be considered as full treatment.
H.
Should this contract be terminated by either party due to the breach or nonrenewal at the end of any applicable term, the provision of Paragraph D above, shall apply with respect to an enrollee being treated for orthodontic work which is not completed at the date of termination.
I.
SafeGuard guarantees that a covered State employee will not lose benefits as a result of a change in prepaid carriers. In the event that a covered employee should change prepaid plans and the orthodontist with the previous carrier is unwilling to complete the orthodontic treatment that has been started for the co-payment that was agreed upon between the orthodontist and the enrollee, SafeGuard will first contact the orthodontist and attempt to make arrangements for no loss of coverage. Should the orthodontist not meet SafeGuard standards, SafeGuard will guarantee that the covered employee may transfer to a SafeGuard orthodontist and that the orthodontic treatment plan will be completed for an amount not to exceed the total copayment that the patient is obligated to pay under the SafeGuard Plan, including credit for any payments that have already been paid as a part of that treatment plan.
The 1. 2. 3. 4. 5. 6. 7.
following are not included as orthodontic benefits: Cephalometric X-rays; Tracings and photographs; Study models; Lost, stolen or broken orthodontic appliances; Retreatment of orthodontic cases; Changes in treatment necessitated by accident of any kind; Surgical procedures (including extraction of teeth solely for the purpose of orthodontics) incidental to orthodontic treatment; Myofunctional therapy; Surgical procedures related to cleft palate, micrognathia or macrognathia; Treatment related to temporomandibular joint disturbances and/or hormonal imbalance; Any dental procedure considered within the field of general dentistry such as fillings or extractions; Malocclusions which are so severe or mutilated so as not to be amenable to ideal orthodontic therapy; Treatment that extends 24 months beyond the point of full permanent dentition will be subject to an office visit charge of $25 per office visit. Additional charges due to gross non-cooperation are not covered.
8. 9. 10. 11. 12. 13. 14.
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