Lighting the way to better health SM. Dental DIRECTORY. Directorio Dental. Broward, Miami-Dade, Palm Beach, Martin & St. Lucie

Transcripción

1 Lighting the way to better health SM Dental DIRECTORY Directorio Dental Broward, Miami-Dade, Palm Beach, Martin & St. Lucie Y0022_CCP_2013_1080_1671_FINAL approved 8/2012

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3 TABLE OF CONTENTS INTRODUCTION... 3 CHOICE OF DENTIST... 3 EMERGENCY CARE... 3 HOW DO YOU FIND SOLSTICE PROVIDERS IN YOUR AREA?... 3 SCHEDULE OF BENEFITS... 4 DENTAL EXCLUSIONS AND LIMITATIONS SPECIALTY SERVICES OUT-OF-NETWORK PROVIDERS MEMBER SUPPORT WHAT IS THE SERVICE AREA FOR COVENTRY HEALTH CARE OF FLORIDA? HOW DO YOU FIND DENTAL PROVIDERS IN YOUR AREA? DENTAL PLAN NETWORK

4 COVENTRY HEALTH CARE OF FLORIDA DENTAL CARE SERVICES DIRECTORY This directory provides a list of participating dental plan providers. This directory is current as of October Some dentists may have been added or removed from our network after this directory was printed. We do not guarantee that each dentist is still accepting new members. To get the most up-to-date information about dentists in your area, you can visit solsticebenefits.com or call Solstice s Customer Service Department at , Monday - Friday, 8:00 a.m. 6:00 p.m., EST. TTY users should call 711. Coventry Health Plan of Florida is a Coordinated Care Plan with a Medicare contract. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change on January 1 of each year. This information is available for free in other languages. Please contact Customer Service at for additional information. This document may be available in an alternate format such as Braille, larger print or audio. Esta información esta disponible en otros idiomas sin costo alguno. Para más información, por favor comuníquese con nuestro departamento de servicio al cliente llamando al Este documento esta disponible en diferentes formatos como Braile, letras grandes o audio. Y0022_CCP_2013_1080_1671 approved 8/2012 2

5 Introduction Coventry Health Plan of Florida has contracted with Solstice to provide dental services to you. You may select any dentist from this directory. All services must be obtained from Solstice s participating dentists. Whenever a copayment is required, it is to be paid directly to the dentist. For services not listed in this booklet, you will receive a discount off the dentist s usual, customary and reasonable rates. Choice of Dentist Solstice contracts with established dentists in the community to provide quality care to our members. When you need care, you must go to a dentist that is contracted with Solstice except in an emergency. Dentists undergo a thorough review process. Each privately owned office is operated by a licensed general dentist and a staff of professional auxiliaries. Emergency Care Emergency Care is available to treat severe pain, swelling, or bleeding, or to diagnose and treat unforeseen conditions which a reasonable person under the circumstances believes, if not given immediate attention, may lead to placing his/her health in serious jeopardy. Emergency treatment is available for palliative treatment for the abatement of pain for up to $100 per occurrence outside the service area. How do you find Solstice providers in your area? If you have questions about Solstice or require assistance in selecting a dentist, please call our Customer Service Department at , Monday - Friday, 8:00 a.m. 6:00 p.m., EST. TTY\TDD users should call 711. Or, visit solsticebenefits.com. 3

6 SCHEDULE OF BENEFITS Preventive Dental Plan* Diagnostic You Pay D0120 Periodic oral examination (1 every 6 months) $0 D0150 Comprehensive oral evaluation (1 every 24 months) $0 D0210 Full Mouth Series X-rays (1 every 36 months) $0 D0272 Bitewing X-rays (1 set every 12 months) $0 D0330 Panoramic film (1 every 36 months) $0 D1110 Adult Cleaning (1 every 6 months) $0 *These benefits are available to all members. 4

7 Basic Dental Plan** Diagnostic You Pay D0120 Periodic oral examination (1 every 6 months) $0 D0150 Comprehensive oral evaluation (1 every 24 months) $0 D0210 Full Mouth Series X-rays (1 every 36 months) $0 D0272 Bitewing X-rays (1 set every 12 months) $0 D0330 Panoramic film (1 every 36 months) $0 D1110 Adult Cleaning (1 every 6 months) $0 Restorative (Fillings) (1 restoration per 24 months) You Pay D 2140 Amalgam, one surface $49 D2150 Amalgam, two surfaces $63 D2160 Amalgam, three surfaces) $78 D2330 Resin restoration - one surface, anterior $63 D2331 Resin restoration - two surfaces, anterior $80 D2332 Resin restoration - three surfaces, anterior $98 D2391 Resin-based composite - one surface, post $67 D2392 Resin-based composite - two surfaces, post $98 D2393 Resin-based composite - three surfaces, post $117 Restorative (Crowns) (1 crown per 5 years) You Pay D2750 Porcelain high noble crown $471 D2751 Porcelain base metal crown $460 D2752 Porcelain noble metal crown $465 D2790 Full cast high noble crown $471 D2791 Full cast base metal crown $446 D2792 Full cast noble metal crown $463 D2950 Core build-up, including any pins (1 build-up per 5 years) $112 D2952 Cast post and core in addition to crown (1 post and core per 5 years) $170 Endodontics (Root Canal) You Pay D3310 Anterior root canal $287 D3320 Bicuspid root canal $338 D3330 Molar root canal $430 Periodontics (Gum Treatment) You Pay D4210 Gingivectomy, per quadrant (1 per 24 months) $276 D4260 Osseous surgery, per quadrant (1 per 24 months) $493 D4341 Periodontal scaling and root planing, per quadrant (1 per 24 months) $100 D4355 Full mouth debridement (1 per 24 months) $75 D4910 Periodontal maintenance (1 per 6 months) $56 5

8 Prosthodontics (Removable) You Pay D5110 Complete upper denture (1 upper denture per 5 years) $597 D5120 Complete lower denture (1 lower denture per 5 years) $597 D5130 Immediate upper denture (1 upper denture per 5 years) $663 D5140 Immediate lower denture (1 lower denture per 5 years) $663 D5211 Upper partial denture (1 partial denture per 5 years) $513 D5212 Lower partial denture (1 partial denture per 5 years) $513 Relines (limited to 1 per 24 months) D5730/31Reline upper/lower denture (chairside) (1 per 24 months) $150 D5740/41Reline upper/lower partial denture (chairside) (1 per 24 months) $145 D5750/51Reline upper/lower denture (laboratory) (1 per 24 months) $200 D5760/61Reline upper/lower partial denture (laboratory) (1 per 24 months) $200 Prosthodontics (Fixed) (1 pontic or crown per 5 years) You Pay D6210 Pontic, cast high noble metal $460 D6211 Pontic, cast base metal $408 D6212 Pontic, cast noble metal $422 D6240 Pontic, porcelain to high noble metal $463 D6241 Pontic, porcelain to base metal $425 D6242 Pontic, porcelain to noble metal $430 D6750 Crown, cast high noble metal) $482 D6751 Crown, cast base metal $453 D6752 Crown, cast noble metal $463 D6790 Crown, full cast to high noble metal $461 D6791 Crown, full cast to base metal $419 D6792 Crown, full cast to noble metal $455 Oral Surgery You Pay D7140 Extraction, erupted tooth or exposed root $59 D7210 Surgical removal of tooth $110 D7220 Removal, impacted soft tissue $130 D7230 Removal, impacted partial bony $169 D7240 Removal, impacted completely bony $207 D7310 Alveoloplasty in conjunction with extraction, per quadrant $132 Miscellaneous You Pay D9110 Palliative (emergency) treatment $41 D9230 Analgesia (nitrous oxide per 15 min) $23 **These benefits are available to members of H , H , H , H , H and H Service area includes Broward, Miami-Dade, Palm Beach and St. Lucie Counties. 6

9 Enhanced Dental Plan*** Diagnostic You Pay D0120 Periodic oral examination (1 every 6 months) $0 D0150 Comprehensive oral evaluation (1 every 24 months) $0 D0210 Full Mouth Series X-rays (1 every 36 months) $0 D0272 Bitewing X-rays (1 set every 12 months) $0 D0330 Panoramic film (1 every 36 months) $0 D1110 Adult Cleaning (1 every 6 months) $0 Restorative (Fillings) (1 restoration per 24 months) You Pay D 2140 Amalgam, one surface $25 D2150 Amalgam, two surfaces $30 D2160 Amalgam, three surfaces) $40 D2330 Resin restoration - one surface, anterior $30 D2331 Resin restoration - two surfaces, anterior $40 D2332 Resin restoration - three surfaces, anterior $50 D2391 Resin-based composite - one surface, post $30 D2392 Resin-based composite - two surfaces, post $40 D2393 Resin-based composite - three surfaces, post $50 Restorative (Crowns) (1 crown per 5 years) You Pay D2750 Porcelain high noble crown $250 D2751 Porcelain base metal crown $250 D2752 Porcelain noble metal crown $250 D2790 Full cast high noble crown $250 D2791 Full cast base metal crown $250 D2792 Full cast noble metal crown $250 D2950 Core build-up, including any pins (1 build-up per 5 years) $75 D2952 Cast post and core in addition to crown (1 post and core per 5 years) $125 Endodontics (Root Canal) You Pay D3310 Anterior root canal $200 D3320 Bicuspid root canal $200 D3330 Molar root canal $200 Periodontics (Gum Treatment) You Pay D4210 Gingivectomy, per quadrant (1 per 24 months) $200 D4260 Osseous surgery, per quadrant (1 per 24 months) $200 D4341 Periodontal scaling and root planing, per quadrant (1 per 24 months) $75 D4355 Full mouth debridement (1 per 24 months) $50 D4910 Periodontal maintenance (1 per 6 months) $25 7

10 Prosthodontics (Removable) You Pay D5110 Complete upper denture (1 upper denture per 5 years) $350 D5120 Complete lower denture (1 lower denture per 5 years) $350 D5130 Immediate upper denture (1 upper denture per 5 years) $325 D5140 Immediate lower denture (1 lower denture per 5 years) $325 D5211 Upper partial denture (1 partial denture per 5 years) $325 D5212 Lower partial denture (1 partial denture per 5 years) $325 Relines (limited to 1 per 24 months) D5730/31Reline upper/lower denture (chairside) (1 per 24 months) $100 D5740/41Reline upper/lower partial denture (chairside) (1 per 24 months) $100 D5750/51Reline upper/lower denture (laboratory) (1 per 24 months) $125 D5760/61Reline upper/lower partial denture (laboratory) (1 per 24 months) $125 Prosthodontics (Fixed) (1 pontic or crown per 5 years) You Pay D6210 Pontic, cast high noble metal $300 D6211 Pontic, cast base metal $300 D6212 Pontic, cast noble metal $300 D6240 Pontic, porcelain to high noble metal $300 D6241 Pontic, porcelain to base metal $300 D6242 Pontic, porcelain to noble metal $300 D6750 Crown, cast high noble metal) $300 D6751 Crown, cast base metal $300 D6752 Crown, cast noble metal $300 D6790 Crown, full cast to high noble metal $300 D6791 Crown, full cast to base metal $300 D6792 Crown, full cast to noble metal $300 Oral Surgery You Pay D7140 Extraction, erupted tooth or exposed root $25 D7210 Surgical removal of tooth $50 D7220 Removal, impacted soft tissue $100 D7230 Removal, impacted partial bony $125 D7240 Removal, impacted completely bony $150 D7310 Alveoloplasty in conjunction with extraction, per quadrant $75 Miscellaneous You Pay D9110 Palliative (emergency) treatment $15 D9230 Analgesia (nitrous oxide per 15 min) $15 ***These benefits are available to members of H and H Service area includes Broward, Miami- Dade, Palm Beach and St. Lucie Counties. 8

11 Complete Dental Plan**** Maximum Plan Benefit: $2,000 Diagnostic You Pay D0120 Periodic oral examination (1 every 6 months) $0 D0150 Comprehensive oral evaluation (1 every 24 months) $0 D0210 Full Mouth Series X-rays (1 every 36 months) $0 D0272 Bitewing X-rays (1 set every 12 months) $0 D0330 Panoramic film (1 every 36 months) $0 D1110 Adult Cleaning (1 every 6 months) $0 Restorative (Fillings) (1 restoration per 24 months) You Pay D 2140 Amalgam, one surface $0 D2150 Amalgam, two surfaces $0 D2160 Amalgam, three surfaces) $0 D2330 Resin restoration - one surface, anterior $0 D2331 Resin restoration - two surfaces, anterior $0 D2332 Resin restoration - three surfaces, anterior $0 D2391 Resin-based composite - one surface, post $0 D2392 Resin-based composite - two surfaces, post $0 D2393 Resin-based composite - three surfaces, post $0 Restorative (Crowns) (1 crown per 5 years) You Pay D2750 Porcelain high noble crown $0 D2751 Porcelain base metal crown $0 D2752 Porcelain noble metal crown $0 D2790 Full cast high noble crown $0 D2791 Full cast base metal crown $0 D2792 Full cast noble metal crown $0 D2950 Core build-up, including any pins (1 build-up per 5 years) $0 D2952 Cast post and core in addition to crown (1 post and core per 5 years) $0 Endodontics (Root Canal) You Pay D3310 Anterior root canal $0 D3320 Bicuspid root canal $0 D3330 Molar root canal $0 Periodontics (Gum Treatment) You Pay D4210 Gingivectomy, per quadrant (1 per 24 months) $0 D4260 Osseous surgery, per quadrant (1 per 24 months) $0 D4341 Periodontal scaling and root planing, per quadrant (1 per 24 months) $0 D4355 Full mouth debridement (1 per 24 months) $0 D4910 Periodontal maintenance (1 per 6 months) $0 9

12 Prosthodontics (Removable) You Pay D5110 Complete upper denture (1 upper denture per 5 years) $0 D5120 Complete lower denture (1 lower denture per 5 years) $0 D5130 Immediate upper denture (1 upper denture per 5 years) $0 D5140 Immediate lower denture (1 lower denture per 5 years) $0 D5211 Upper partial denture (1 partial denture per 5 years) $0 D5212 Lower partial denture (1 partial denture per 5 years) $0 Relines (limited to 1 per 24 months) D5730/31Reline upper/lower denture (chairside) (1 per 24 months) $0 D5740/41Reline upper/lower partial denture (chairside) (1 per 24 months) $0 D5750/51Reline upper/lower denture (laboratory) (1 per 24 months) $0 D5760/61Reline upper/lower partial denture (laboratory) (1 per 24 months) $0 Prosthodontics (Fixed) (1 pontic or crown per 5 years) You Pay D6210 Pontic, cast high noble metal $0 D6211 Pontic, cast base metal $0 D6212 Pontic, cast noble metal $0 D6240 Pontic, porcelain to high noble metal $0 D6241 Pontic, porcelain to base metal $0 D6242 Pontic, porcelain to noble metal $0 D6750 Crown, cast high noble metal) $0 D6751 Crown, cast base metal $0 D6752 Crown, cast noble metal $0 D6790 Crown, full cast to high noble metal $0 D6791 Crown, full cast to base metal $0 D6792 Crown, full cast to noble metal $0 Oral Surgery You Pay D7140 Extraction, erupted tooth or exposed root $0 D7210 Surgical removal of tooth $0 D7220 Removal, impacted soft tissue $0 D7230 Removal, impacted partial bony $0 D7240 Removal, impacted completely bony $0 D7310 Alveoloplasty in conjunction with extraction, per quadrant $0 Miscellaneous You Pay D9110 Palliative (emergency) treatment $0 D9230 Analgesia (nitrous oxide per 15 min) $0 ****These benefits are available to members of H , H and H Service area includes Broward and Miami-Dade Counties. 10

13 Complete Plus Dental Plan***** Maximum Plan Benefit: $6,000 Diagnostic You Pay D0120 Periodic oral examination (1 every 6 months) $0 D0150 Comprehensive oral evaluation (1 every 24 months) $0 D0210 Full Mouth Series X-rays (1 every 36 months) $0 D0272 Bitewing X-rays (1 set every 12 months) $0 D0330 Panoramic film (1 every 36 months) $0 D1110 Adult Cleaning (1 every 6 months) $0 Restorative (Fillings) (1 restoration per 24 months) You Pay D 2140 Amalgam, one surface $0 D2150 Amalgam, two surfaces $0 D2160 Amalgam, three surfaces) $0 D2330 Resin restoration - one surface, anterior $0 D2331 Resin restoration - two surfaces, anterior $0 D2332 Resin restoration - three surfaces, anterior $0 D2391 Resin-based composite - one surface, post $0 D2392 Resin-based composite - two surfaces, post $0 D2393 Resin-based composite - three surfaces, post $0 Restorative (Crowns) (1 crown per 5 years) You Pay D2750 Porcelain high noble crown $0 D2751 Porcelain base metal crown $0 D2752 Porcelain noble metal crown $0 D2790 Full cast high noble crown $0 D2791 Full cast base metal crown $0 D2792 Full cast noble metal crown $0 D2950 Core build-up, including any pins (1 build-up per 5 years) $0 D2952 Cast post and core in addition to crown (1 post and core per 5 years) $0 Endodontics (Root Canal) You Pay D3310 Anterior root canal $0 D3320 Bicuspid root canal $0 D3330 Molar root canal $0 Periodontics (Gum Treatment) You Pay D4210 Gingivectomy, per quadrant (1 per 24 months) $0 D4260 Osseous surgery, per quadrant (1 per 24 months) $0 D4341 Periodontal scaling and root planing, per quadrant (1 per 24 months) $0 D4355 Full mouth debridement (1 per 24 months) $0 D4910 Periodontal maintenance (1 per 6 months) $0 11

14 Prosthodontics (Removable) You Pay D5110 Complete upper denture (1 upper denture per 5 years) $0 D5120 Complete lower denture (1 lower denture per 5 years) $0 D5130 Immediate upper denture (1 upper denture per 5 years) $0 D5140 Immediate lower denture (1 lower denture per 5 years) $0 D5211 Upper partial denture (1 partial denture per 5 years) $0 D5212 Lower partial denture (1 partial denture per 5 years) $0 Relines (limited to 1 per 24 months) D5730/31Reline upper/lower denture (chairside) (1 per 24 months) $0 D5740/41Reline upper/lower partial denture (chairside) (1 per 24 months) $0 D5750/51Reline upper/lower denture (laboratory) (1 per 24 months) $0 D5760/61Reline upper/lower partial denture (laboratory) (1 per 24 months) $0 Prosthodontics (Fixed) (1 pontic or crown per 5 years) You Pay D6210 Pontic, cast high noble metal $0 D6211 Pontic, cast base metal $0 D6212 Pontic, cast noble metal $0 D6240 Pontic, porcelain to high noble metal $0 D6241 Pontic, porcelain to base metal $0 D6242 Pontic, porcelain to noble metal $0 D6750 Crown, cast high noble metal) $0 D6751 Crown, cast base metal $0 D6752 Crown, cast noble metal $0 D6790 Crown, full cast to high noble metal $0 D6791 Crown, full cast to base metal $0 D6792 Crown, full cast to noble metal $0 Oral Surgery You Pay D7140 Extraction, erupted tooth or exposed root $0 D7210 Surgical removal of tooth $0 D7220 Removal, impacted soft tissue $0 D7230 Removal, impacted partial bony $0 D7240 Removal, impacted completely bony $0 D7310 Alveoloplasty in conjunction with extraction, per quadrant $0 Miscellaneous You Pay D9110 Palliative (emergency) treatment $0 D9230 Analgesia (nitrous oxide per 15 min) $0 ***** These benefits are available to members of H and H Service area includes Miami-Dade County. 12

15 Dental Exclusions and Limitations It is your responsibility to understand your dental coverage, the Limitations and Exclusions and how to use your Dental Plan appropriately. Some covered medical expenses may be listed as exclusions in this document. When this occurs, this means the coverage may be provided through your Plan medical benefits. Your Dental Benefits are designed to cover your routine dental needs and not cosmetic or elective dental services. The following treatment, services or supplies are excluded from coverage: 1. Oral surgery requiring the setting of fractures or dislocations. 2. Orthographic surgery or procedures and appliances for the treatment of myofunctional, myoskeletal or temporomandibular joint disorders unless otherwise specified as an orthodontic benefit on the Schedule of Benefits. 3. Treatment of congenital malformations. 4. Treatment of cysts, neoplasms and malignancies. 5. Dispensing of drugs or medication (except oral anesthesia). 6. Any treatment requiring hospitalization (except for Emergency Care as described above). 7. Any work which is not able to be performed because of the general health and physical limits of the eligible enrollee, as dictated by said enrollee s Primary Care Physician or the Solstice Dentist(s). 8. Precision attachments or stress breakers. 9. Replacement of partial or full dentures within 2 years after installation unless resulting from the acts or omissions of Solstice. 10. Any treatment covered or provided by Worker s Compensation, employer s liability laws, Federal or State Government agency or provided without cost by any municipality, county or other political subdivision. 11. Any procedures such as implantation and/or dental procedure considered to be experimental by the providing dentist. 12. General anesthesia, IV sedation, or nitrous oxide unless medically necessary and pre-approved by Solstice. 13. Surgical treatment of Temporomandibular Joint Dysfunction (TMJ). 14. Replacement of lost or stolen prosthetic devices. 15. Any dental care provided by a Specialist, except when authorized by Solstice. 16. Services resulting from injury or trauma to sound and natural teeth (except for Emergency Care as described above). 17. Services resulting from any act of war, declared or not, or resulting from military service. 18. Services which, in the opinion of the contracted general dentist or specialist, are not necessary for the patient s dental health. 19. Any services which are not consistent with the usual and customary services provided by the contracted general dentist. 20. Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions, or medications. 21. Cost of dental care, which is covered under automobile, medical, no-fault or similar type of insurance. 22. Procedures performed before a person becomes a subscriber or member. 23. Services performed by a dentist or dental specialist, not contracted with Solstice. The following limitations apply to the Preventive, Basic, Enhanced and Complete Plans: 1. A periodic oral examination (D0120) is limited to one (1) time in any six (6) consecutive month period and a comprehensive oral examination (D0150) is limited to one (1) time in any twenty-four (24) consecutive month period at no charge. All subsequent oral evaluations will be at a 25% discount off the doctor s usual and customary fee without a frequency limitation. 13

16 2. All bitewing X-rays are limited to one set in any twelve (12) consecutive month period. 3. The dental prophylaxis or periodontal maintenance procedure is limited to one in any six (6) consecutive month period. 4. Periodontal scaling and root planing (per quadrant) and full mouth debridement is limited to one (1) per twenty-four (24) months. 5. New dentures include one (1) reline within the first six (6) months. 6. Reline of upper/lower denture is limited to one (1) per twenty-four (24) months. 7. Replacement of crowns, fixed bridges or dentures is limited to once every five (5) years. 8. When crown and/or bridgework exceed six (6) consecutive units, there will be an additional charge of $30 per unit. 9. Co-payments for endodontic procedures do not include the cost of the final restoration. 10. Either D0210 or D0330 reimbursable once every three years. 11. Copies of X-rays can be obtained for $2 per periapical film up to a maximum of $30. Panoramic X-ray can be obtained for a $15 fee. 12. D0210 are payable only when other inclusive films have not been taken (paid) within the last six months. 13. All denture adjustment fees are for dentures which were not fabricated at the present office. All denture adjustment for new dentures made within 12 months are at no fee to the member. 14. Surgical removal of wisdom tooth covered when pathology (disease) exists. Surgical removal of wisdom tooth/3rd molar when pathology does not exist will be covered at 25% off of the general dentist's or specialist's usual and customary fees. 15. Amalgam or Resin-based composite is limited to one (1) tooth per twenty-four (24) months. 16. A fee may be charged for a broken appointment without 24 hour notice per 15 minute unit maximum $15. The following limitations apply to the Complete Plus Plan: 1. Any oral evaluation is limited to D0120 one (1) time in any six (6) consecutive month period and D0150 one (1) time in any twenty-four (24) consecutive month period at no charge. All subsequent oral evaluations will be at a 25% discount off the doctor s usual and customary fee without a frequency limitation. 2. All bitewing X-rays are limited to two (2) sets in any twelve (12) consecutive month period. 3. The dental prophylaxis or periodontal maintenance procedure is limited to one in any six (6) consecutive month period. 4. Periodontal scaling and root planing (1 per quadrant) and full mouth debridement is limited to one (1) per quadrant per three (3) years. Periodontal maintenance is covered in addition to dental prophylaxis once every six (6) months for two (2) years following periodontal scaling and root planing. 5. New dentures include one (1) reline within the first six (6) months. 6. Reline of upper/lower denture is limited to one (1) per twelve (12) months. 7. Replacement of crowns, fixed bridges or dentures is limited to once every (5) years. 8. When crown and/or bridgework exceed six (6) consecutive units, there will be an additional charge of $30 per unit. 9. Co-payments for endodontic procedures do not include the cost of the final restoration. 10. Either D0210 or D0330 reimbursable once every three years. 11. Copies of X-rays can be obtained for $2 per periapical film up to a maximum of $30. Panoramic X-ray can be obtained for a $15 fee. 12. D0210 are payable only when other inclusive films have not been taken (paid) within the last six months. 13. All denture adjustment fees are for dentures which were not fabricated at the present office. All denture adjustment for new dentures made within 12 months are at no fee to the member. 14

17 14. Surgical removal of wisdom tooth covered when pathology (disease) exists. Surgical removal of wisdom tooth/3rd molar when pathology does not exist will be covered at 25% off of the general dentist's or specialist's usual and customary fees. 15. Amalgam or Resin-based composite is limited to six (6) times per mouth per twelve (12) months. 16. A fee may be charged for a broken appointment without 24 hour notice per 15 minute unit maximum $15. Specialty Services The Schedule of Benefits applies when listed dental services are performed by a participating general dentist, unless otherwise authorized by Solstice. Procedures not listed on the Schedule of Benefits that are performed by a participating general dentist will be charged at the participating general dentist s usual and customary fee less 25%. The participating general dentist you select may not perform all procedures listed. The co-payments shown apply to participating general dentists who do perform these services. Therefore, you are encouraged to secure availability of the scheduled services with your participating general dentist. Should the services of a specialist (Oral Surgeon, Endodontist, Periodontist, or Prosthodontist) be necessary, you may go directly to a participating specialist with no referral and receive a 25% reduction off the provider s usual and customary fee. You may obtain prior written authorization from Solstice and receive specialty treatment by an approved participating specialist at the listed copayments. Please refer to the Specialty Care Referral Policy in your Member Handbook. Out-of-Network Providers The co-payments listed in this document apply only when treatment is performed by a contracted general dentist. If the services of an Out-of-Network specialty care provider are recommended and available, then the above copayments do not apply and the member s charge will be the specialist s usual and customary fee. If you use Outof-Network providers, you will be responsible for the Out-of-Network provider s usual and customary fee. If you receive a bill from an Out-of-Network provider, submit it to Solstice s Customer Service Department for processing and determination of liability, if any. Solstice Benefits, Inc. PO Box Plantation, FL Member Support Solstice is responsible for all administrative functions of the program. Call Solstice s Customer Service Support Department, Monday - Friday, 8:00 a.m. 6:00 p.m., EST, TTY users should call 711. If you have a complaint or grievance regarding your dental coverage, submit it in writing to: Coventry Health Care of Florida, Inc. Grievance and Appeals Dept Concord Terrace Sunrise, FL

18 What is the service area for Coventry Health Care of Florida, Inc.? The counties in our service area are listed below. Broward, Miami-Dade, Palm Beach, Martin and St. Lucie Counties How do you find dental providers in your area? You can find participating dental providers nearest to your home and by reviewing the list of providers in this directory. Providers are listed in alphabetical order by County, Specialty and City. For an up-to-date listing of providers and to find a provider in your area, you may also visit our website at solsticebenefits.com. If you have questions about Coventry Health Care of Florida, Inc., or require assistance in selecting a dental provider, please call our Customer Service Department at , Monday - Sunday, 8:00 a.m. 8:00 p.m. EST. TTY/TDD users should call 711. Or visit solsticebenefits.com. 16

19 DENTAL PLAN NETWORK Dental Providers/Facilities by Type Total Number of each type of Provider/Facility General Dentist 2,056 Endodontist 251 Oral Surgeon 214 Periodontist 210 Dental providers listed in this portion of the directory are organized in the following manner: County (Listed alphabetically) Specialty (Listed alphabetically) City (Listed alphabetically) Provider (Listed alphabetically) 17

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21 TABLA DE CONTENIDO INTRODUCCIÓN ELECCIÓN DEL DENTISTA ATENCIÓN DE EMERGENCIA CÓMO ENCONTRAR PROVEEDORES DE SOLSTICE EN EL ÁREA EN QUE RESIDE RELACIÓN DE BENEFICIOS EXCLUSIONES Y LIMITACIONES DE CUIDADOS DENTALES SERVICIOS DE ESPECIALIDADES PROVEEDORES FUERA DE LA RED ASISTENCIA A LOS AFILIADOS CUÁL ES EL ÁREA DE SERVICIO DE COVENTRY HEALTH CARE OF FLORIDA? CÓMO ENCONTRAR PROVEEDORES DENTALES EN EL ÁREA EN QUE RESIDE RED DEL PLAN DENTAL

22 Coventry Health Care of Florida DIRECTORIO DE SERVICIOS DE CUIDADOS DENTALES Este directorio ofrece una lista de los proveedores que participan en el plan dental. El directorio fue actualizado el Octubre del Es posible que, después de la fecha de su impresión, se hayan incorporado o eliminado de nuestra red algunos dentistas. No garantizamos que cada dentista todavía esté aceptando nuevos afiliados. Para obtener la información más reciente sobre los dentistas en su área, puede visitar solsticebenefits.com o llamar al Departamento de Servicios al Afiliado de Solstice al , de lunes a viernes, de 8:00 a.m. a 6:00 p.m., hora del este. Los usuarios de TTY deben llamar al 711. Coventry Health Care of Florida es un Plan de Atención Coordinada con un contrato de Medicare. La información de beneficios brindada es un breve resumen, no la descripción completa de los beneficios. Para obtener más información comuníquese con el plan. Pueden aplicar limitaciones, copagos y restricciones. Los beneficios, las primas y/o los copagos/coaseguros podrían cambiar el 1 de enero de cada año. Disponemos de esta información gratis en otros idiomas. Para más información, comuníquese con Servicios al Afiliado al Es posible que este documento exista en otro formato como Braille, impresión en letras grandes o audio. Esta información está disponible en otros idiomas sin costo alguno. Para más información, por favor comuníquese con nuestro departamento de servicio al cliente llamando al Este documento está disponible en diferentes formatos como Braille, letras grandes o audio. Y0022_CCP_2013_1080_1671sp aprobado 8/

23 Introducción Coventry Health Care of Florida ha celebrado contrato con Solstice para ofrecerle servicios dentales. Usted puede escoger a cualquier dentista de este directorio. Todos los servicios se deben obtener de dentistas participantes de Solstice. Cada vez que se requiera realizar un copago, éste se debe pagar directamente al dentista. Para los servicios no detallados en este folleto, usted recibirá un descuento de los honorarios habituales y razonables cobrados por el dentista. Elección del dentista Solstice tiene contratos con dentistas bien establecidos en la comunidad para que brinden atención de calidad a nuestros afiliados. Cuando usted necesite atención, debe ir a un dentista contratado por Solstice excepto en caso de una emergencia. Los dentistas se someten a un proceso de evaluación riguroso. Cada consultorio de propiedad particular es operado por un dentista general debidamente licenciado y un equipo de profesionales auxiliares. Atención de emergencia La atención de emergencia está disponible para tratar casos de dolor severo, hinchazón o sangrado, o para diagnosticar y tratar afecciones no previstas que llevarían a una persona razonable, dadas las circunstancias, a creer que su salud correría un grave peligro si no se recibiera atención inmediata. El tratamiento de emergencia está disponible como tratamiento paliativo destinado a disminuir el dolor, a un costo de hasta $100 por evento/ocurrencia fuera del área de servicio. Cómo encontrar proveedores de Solstice en el área en que reside Si tiene preguntas sobre Solstice o necesita ayuda para seleccionar un dentista, llame a nuestro Departamento de Servicios al Afiliado al , de lunes a viernes, de 8:00 a.m. a 6:00 p.m., hora del este. Los usuarios de TTY\TDD deben llamar al 711. O visitar solsticebenefits.com. 21

24 RELACIÓN DE BENEFICIOS Plan Dental Preventivo* Diagnóstico Usted paga D0120 Examen bucal periódico (1 cada 6 meses) $0 D0150 Evaluación bucal completa (1 cada 24 meses) $0 D0210 Radiografías bucales completas en serie (1 cada 36 meses) $0 D0272 Radiografías interproximales (1 juego cada 12 meses) $0 D0330 Radiografía panorámica (1 cada 36 meses) $0 D1110 Limpieza en adultos (1 cada 6 meses) $0 *Estos beneficios están disponibles para todos los afiliados. 22

25 Plan Dental Básico** Diagnóstico Usted paga D0120 Examen bucal periódico (1 cada 6 meses) $0 D0150 Evaluación bucal completa (1 cada 24 meses) $0 D0210 Radiografías bucales completas en serie (1 cada 36 meses) $0 D0272 Radiografías interproximales (1 juego cada 12 meses) $0 D0330 Radiografía panorámica (1 cada 36 meses) $0 D1110 Limpieza en adultos (1 cada 6 meses) $0 Restauración (Empastes) Usted paga D2140 Amalgama, una superficie (1 empaste cada 24 meses) $49 D2150 Amalgama, dos superficies (1 empaste cada 24 meses) $63 D2160 Amalgama, tres superficies (1 empaste cada 24 meses) $78 D2330 Restauración con resinas - una superficie, anterior (1 empaste cada 24 meses) $63 D2331 Restauración con resinas - dos superficies, anterior (1 empaste cada 24 meses) $80 D2332 Restauración con resinas - tres superficies, anterior (1 empaste cada 24 meses) $98 D2391 Compuesto de resina - una superficie, posterior (1 empaste cada 24 meses) $67 D2392 Compuesto de resinas - dos superficies, posterior (1 empaste cada 24 meses) $98 D2393 Compuesto de resinas - tres superficies, posterior (1 empaste cada 24 meses) $117 Restauración (Coronas) Usted paga D2750 Corona de porcelana, fundida a metal altamente noble (1 corona cada 5 años) $471 D2751 Corona de porcelana, fundida a metal base (1 corona cada 5 años) $460 D2752 Corona de porcelana, fundida a metal noble (1 corona cada 5 años) $465 D2790 Corona con colado completo, de metal altamente noble (1 corona cada 5 años) $471 D2791 Corona con colado completo, de metal base (1 corona cada 5 años) $446 D2792 Corona con colado completo, de metal noble (1 corona cada 5 años) $463 D2950 Construcción del núcleo, pernos incluidos (1 construcción cada 5 años) $112 D2952 Poste y núcleo fundidos, además de la corona (1 poste y núcleo cada 5 años) $170 Endodoncia (Conducto radicular) Usted paga D3310 Conducto radicular anterior $287 D3320 Conducto radicular bicúspide $338 D3330 Conducto radicular molar $430 Periodoncia (Tratamiento de encías) Usted paga D4210 Gingivectomía, por cuadrante (1 cada 24 meses) $276 D4260 Cirugía ósea, por cuadrante (1 cada 24 meses) $493 D4341 Raspado periodontal y pulido radicular, por cuadrante (1 cada 24 meses) $100 D4355 Desbridamiento de toda la cavidad bucal (1 cada 24 meses) $75 D4910 Mantenimiento periodontal (1 cada 6 meses) $56 23

26 Prostodoncia (Removible) Usted paga D5110 Prótesis completa superior (1 prótesis superior cada 5 años) $597 D5120 Prótesis completa inferior (1 prótesis inferior cada 5 años) $597 D5130 Prótesis inmediata superior (1 prótesis superior cada 5 años) $663 D5140 Prótesis inmediata inferior (1 prótesis inferior cada 5 años) $663 D5211 Prótesis parcial superior (1 prótesis parcial cada 5 años) $513 D5212 Prótesis parcial inferior (1 prótesis parcial cada 5 años) $513 Rebasado Usted paga D5730/31 Rebasado de prótesis superior/inferior (consultorio) (1 c/24 meses) $150 D5740/41 Rebasado de prótesis parcial superior/inferior (consultorio) (1 c/24 meses) $145 D5750/51 Rebasado de prótesis superior/inferior (laboratorio) (1 cada 24 meses) $200 D5760/61 Rebasado de prótesis parcial superior/inferior (laboratorio) (1 cada 24 meses) $200 Prostodoncia (Fija) Usted paga D6210 Puente fundido a metal altamente noble (1 puente cada 5 años) $460 D6211 Puente fundido a metal base (1 puente cada 5 años) $408 D6212 Puente fundido a metal noble (1 puente cada 5 años) $422 D6240 Puente de porcelana, fundido a metal altamente noble (1 puente cada 5 años) $463 D6241 Puente de porcelana, fundido a metal base (1 puente cada 5 años) $425 D6242 Puente de porcelana, fundido a metal noble (1 puente cada 5 años) $430 D6750 Corona fundida a metal altamente noble (1 corona cada 5 años) $482 D6751 Corona fundida a metal base (1 corona cada 5 años) $453 D6752 Corona fundida a metal noble (1 corona cada 5 años) $463 D6790 Corona con colado completo, fundida a metal altamente noble (1 corona cada 5 años) $461 D6791 Corona con colado completo, fundida a metal base ( 1 corona cada 5 años) $419 D6792 Corona con colado completo, fundida a metal noble (1 corona cada 5 años) $455 Cirugía bucal Usted paga D7140 Extracción, pieza dental erupcionada o raíz expuesta $59 D7210 Extracción quirúrgica de pieza dental $110 D7220 Extracción de pieza dental impactada, tejido blando $130 D7230 Extracción de pieza dental impactada, parcialmente en tejido óseo $169 D7240 Extracción de pieza dental impactada, completamente en tejido óseo $207 D7310 Alveoloplastia junto con extracción, por cuadrante $132 Servicios varios Usted paga D9110 Tratamiento paliativo (de emergencia) $41 D9230 Analgesia (óxido nitroso durante 15 min.) $23 **Estos beneficios están a disposición de los afiliados a H , H , H , H , H y H El área de servicio incluye los condados de Broward, Miami-Dade, Palm Beach y St. Lucie. 24

27 Plan Dental Mejorado*** Diagnóstico Usted paga D0120 Examen bucal periódico (1 cada 6 meses) $0 D0150 Evaluación bucal completa (1 cada 24 meses) $0 D0210 Radiografías bucales completas en serie (1 cada 36 meses) $0 D0272 Radiografías interproximales (1 juego cada 12 meses) $0 D0330 Radiografía panorámica (1 cada 36 meses) $0 D1110 Limpieza en adultos (1 cada 6 meses) $0 Restauración (Empastes) Usted paga D2140 Amalgama, una superficie (1 empaste cada 24 meses) $25 D2150 Amalgama, dos superficies (1 empaste cada 24 meses) $30 D2160 Amalgama, tres superficies (1 empaste cada 24 meses) $40 D2330 Restauración con resinas - una superficie, anterior (1 empaste cada 24 meses) $30 D2331 Restauración con resinas - dos superficies, anterior (1 empaste cada 24 meses) $40 D2332 Restauración con resinas - tres superficies, anterior (1 empaste cada 24 meses) $50 D2391 Compuesto de resina - una superficie, posterior (1 empaste cada 24 meses) $30 D2392 Compuesto de resinas - dos superficies, posterior (1 empaste cada 24 meses) $40 D2393 Compuesto de resinas - tres superficies, posterior (1 empaste cada 24 meses) $50 Restauración (Coronas) Usted paga D2750 Corona de porcelana, fundida a metal altamente noble (1 corona cada 5 años) $250 D2751 Corona de porcelana, fundida a metal base (1 corona cada 5 años) $250 D2752 Corona de porcelana, fundida a metal noble (1 corona cada 5 años) $250 D2790 Corona con colado completo, de metal altamente noble (1 corona cada 5 años) $250 D2791 Corona con colado completo, de metal base (1 corona cada 5 años) $250 D2792 Corona con colado completo, de metal noble (1 corona cada 5 años) $250 D2950 Construcción del núcleo, pernos incluidos (1 construcción cada 5 años) $75 D2952 Poste y núcleo fundidos, además de la corona (1 poste y núcleo cada 5 años) $125 Endodoncia (Conducto radicular) Usted paga D3310 Conducto radicular anterior $200 D3320 Conducto radicular bicúspide $200 D3330 Conducto radicular molar $200 Periodoncia (Tratamiento de encías) Usted paga D4210 Gingivectomía, por cuadrante (1 cada 24 meses) $200 D4260 Cirugía ósea, por cuadrante (1 cada 24 meses) $200 D4341 Raspado periodontal y pulido radicular, por cuadrante (1 cada 24 meses) $75 D4355 Desbridamiento de toda la cavidad bucal (1 cada 24 meses) $50 D4910 Mantenimiento periodontal (1 cada 6 meses) $25 Prostodoncia (Removible) Usted paga D5110 Prótesis completa superior (1 prótesis superior cada 5 años) $350 D5120 Prótesis completa inferior (1 prótesis inferior cada 5 años) $350 D5130 Prótesis inmediata superior (1 prótesis superior cada 5 años) $325 25

28 Prostodoncia (Removible) (continuación) Usted paga D5140 Prótesis inmediata inferior (1 prótesis inferior cada 5 años) $325 D5211 Prótesis parcial superior (1 prótesis parcial cada 5 años) $325 D5212 Prótesis parcial inferior (1 prótesis parcial cada 5 años) $325 Rebasado Usted paga D5730/31 Rebasado de prótesis superior/inferior (consultorio) (1 cada 24 meses) $100 D5740/41 Rebasado de prótesis parcial superior/inferior (consultorio) (1 cada 24 meses) $100 D5750/51 Rebasado de prótesis superior/inferior (laboratorio) (1 cada 24 meses) $125 D5760/61 Rebasado de prótesis parcial superior/inferior (laboratorio) (1 cada 24 meses) $125 Prostodoncia (Fija) Usted paga D6210 Puente fundido a metal altamente noble (1 puente cada 5 años) $300 D6211 Puente fundido a metal base (1 puente cada 5 años) $300 D6212 Puente fundido a metal noble (1 puente cada 5 años) $300 D6240 Puente de porcelana, fundido a metal altamente noble (1 puente cada 5 años) $300 D6241 Puente de porcelana, fundido a metal base (1 puente cada 5 años) $300 D6242 Puente de porcelana, fundido a metal noble (1 puente cada 5 años) $300 D6750 Corona fundida a metal altamente noble (1 corona cada 5 años) $300 D6751 Corona fundida a metal base (1 corona cada 5 años) $300 D6752 Corona fundida a metal noble (1 corona cada 5 años) $300 D6790 Corona con colado completo, fundida a metal altamente noble (1 corona cada 5 años) $300 D6791 Corona con colado completo, fundida a metal base (1 corona cada 5 años) $300 D6792 Corona con colado completo, fundida a metal noble (1 corona cada 5 años) $300 Cirugía bucal Usted paga D7140 Extracción, pieza dental erupcionada o raíz expuesta $25 D7210 Extracción quirúrgica de pieza dental $50 D7220 Extracción de pieza dental impactada - tejido blando $100 D7230 Extracción de pieza dental impactada parcialmente en tejido óseo $125 D7240 Extracción de pieza dental impactada completamente en tejido óseo $150 D7310 Alveoloplastia junto con extracción, por cuadrante $75 Servicios varios Usted paga D9110 Tratamiento paliativo (de emergencia) $15 D9230 Analgesia (óxido nitroso durante 15 min.) $15 ***Estos beneficios están a disposición de los afiliados a H y H El área de servicio incluye los condados de Broward, Miami-Dade, Palm Beach y St. Lucie. 26

29 Plan Dental Completo**** Beneficio máximo del plan: $2,000 Diagnóstico Usted paga D0120 Examen bucal periódico (1 cada 6 meses) $0 D0150 Evaluación bucal completa (1 cada 24 meses) $0 D0210 Radiografías bucales completas en serie (1 cada 36 meses) $0 D0272 Radiografías interproximales (1 juego cada 12 meses) $0 D0330 Radiografía panorámica (1 cada 36 meses) $0 D1110 Limpieza en adultos (1 cada 6 meses) $0 Restauración (Empastes) Usted paga D2140 Amalgama, una superficie (1 empaste cada 24 meses) $0 D2150 Amalgama, dos superficies (1 empaste cada 24 meses) $0 D2160 Amalgama, tres superficies (1 empaste cada 24 meses) $0 D2330 Restauración con resinas - una superficie, anterior (1 empaste cada 24 meses) $0 D2331 Restauración con resinas - dos superficies, anterior (1 empaste cada 24 meses) $0 D2332 Restauración con resinas - tres superficies, anterior (1 empaste cada 24 meses) $0 D2391 Compuesto de resina - una superficie, posterior (1 empaste cada 24 meses) $0 D2392 Compuesto de resinas - dos superficies, posterior (1 empaste cada 24 meses) $0 D2393 Compuesto de resinas - tres superficies, posterior (1 empaste cada 24 meses) $0 Restauración (Coronas) Usted paga D2750 Corona de porcelana, fundida a metal altamente noble (1 corona cada 5 años) $0 D2751 Corona de porcelana, fundida a metal base (1 corona cada 5 años) $0 D2752 Corona de porcelana, fundida a metal noble (1 corona cada 5 años) $0 D2790 Corona con colado completo, de metal altamente noble (1 corona cada 5 años) $0 D2791 Corona con colado completo, de metal base (1 corona cada 5 años) $0 D2792 Corona con colado completo, de metal noble (1 corona cada 5 años) $0 D2950 Construcción del núcleo, pernos incluidos (1 construcción cada 5 años) $0 D2952 Poste y núcleo fundidos, además de la corona (1 poste y núcleo cada 5 años) $0 Endodoncia (Conducto radicular) Usted paga D3310 Conducto radicular anterior $0 D3320 Conducto radicular bicúspide $0 D3330 Conducto radicular molar $0 Periodoncia (Tratamiento de encías) Usted paga D4210 Gingivectomía, por cuadrante (1 cada 24 meses) $0 D4260 Cirugía ósea, por cuadrante (1 cada 24 meses) $0 D4341 Raspado periodontal y pulido radicular, por cuadrante (1 cada 24 meses) $0 D4355 Desbridamiento de toda la cavidad bucal (1 cada 24 meses) $0 D4910 Mantenimiento periodontal (1 cada 6 meses) $0 Prostodoncia (Removible) Usted paga D5110 Prótesis completa superior (1 prótesis superior cada 5 años) $0 27

30 Prostodoncia (Removible) (continuación) Usted paga D5120 Prótesis completa inferior (1 prótesis inferior cada 5 años) $0 D5130 Prótesis inmediata superior (1 prótesis superior cada 5 años) $0 D5140 Prótesis inmediata inferior (1 prótesis inferior cada 5 años) $0 D5211 Prótesis parcial superior (1 prótesis parcial cada 5 años) $0 D5212 Prótesis parcial inferior (1 prótesis parcial cada 5 años) $0 Rebasado Usted paga D5730/31 Rebasado de prótesis superior/inferior (consultorio) (1 cada 24 meses) $0 D5740/41 Rebasado de prótesis parcial superior/inferior (consultorio) (1 cada 24 meses) $0 D5750/51 Rebasado de prótesis superior/inferior (laboratorio) (1 cada 24 meses) $0 D5760/61 Rebasado de prótesis parcial superior/inferior (laboratorio) (1 cada 24 meses) $0 Prostodoncia (Fija) Usted paga D6210 Puente fundido a metal altamente noble (1 puente cada 5 años) $0 D6211 Puente fundido a metal base (1 puente cada 5 años) $0 D6212 Puente fundido a metal noble (1 puente cada 5 años) $0 D6240 Puente de porcelana, fundido a metal altamente noble (1 puente cada 5 años) $0 D6241 Puente de porcelana, fundido a metal base (1 puente cada 5 años) $0 D6242 Puente de porcelana, fundido a metal noble (1 puente cada 5 años) $0 D6750 Corona fundida a metal altamente noble (1 corona cada 5 años) $0 D6751 Corona fundida a metal base (1 corona cada 5 años) $0 D6752 Corona fundida a metal noble (1 corona cada 5 años) $0 D6790 Corona con colado completo, fundida a metal altamente noble (1 corona cada 5 años) $0 D6791 Corona con colado completo, fundida a metal base (1 corona cada 5 años) $0 D6792 Corona con colado completo, fundida a metal noble (1 corona cada 5 años) $0 Cirugía bucal Usted paga D7140 Extracción, pieza dental erupcionada o raíz expuesta $0 D7210 Extracción quirúrgica de pieza dental $0 D7220 Extracción de pieza dental impactada - tejido blando $0 D7230 Extracción de pieza dental impactada parcialmente en tejido óseo $0 D7240 Extracción de pieza dental impactada completamente en tejido óseo $0 D7310 Alveoloplastia junto con extracción, por cuadrante $0 Servicios varios Usted paga D9110 Tratamiento paliativo (de emergencia) $0 D9230 Analgesia (óxido nitroso durante 15 min.) $0 ****Estos beneficios están a disposición de los afiliados a H , H y H El área de servicio incluye los condados de Broward y Miami-Dade. 28

31 Plan Dental Complete Plus***** Beneficio máximo del plan: $6,000 Diagnóstico Usted paga D0120 Examen bucal periódico (1 cada 6 meses) $0 D0150 Evaluación bucal completa (1 cada 24 meses) $0 D0210 Radiografías bucales completas en serie (1 cada 36 meses) $0 D0272 Radiografías interproximales (1 juego cada 12 meses) $0 D0330 Radiografía panorámica (1 cada 36 meses) $0 D1110 Limpieza en adultos (1 cada 6 meses) $0 Restauración (Empastes) Usted paga D2140 Amalgama, una superficie (6 cada 12 meses) $0 D2150 Amalgama, dos superficies (6 cada 12 meses) $0 D2160 Amalgama, tres superficies (6 cada 12 meses) $0 D2161 Amalgama, cuatro más superficies (6 cada 12 meses) $0 D2330 Restauración con resinas - una superficie, anterior (6 cada 12 meses) $0 D2331 Restauración con resinas - dos superficies, anterior (6 cada 12 meses) $0 D2332 Restauración con resinas - tres superficies, anterior (6 cada 12 meses) $0 D2391 Compuesto de resina - una superficie, posterior (1 empaste cada 24 meses) $0 D2392 Compuesto de resinas - dos superficies, posterior (1 empaste cada 24 meses) $0 D2393 Compuesto de resinas - tres superficies, posterior (1 empaste cada 24 meses) $0 Restauración (Coronas) Usted paga D2750 Corona de porcelana, fundida a metal altamente noble (1 corona cada 12 meses) $0 D2751 Corona de porcelana, fundida a metal base (1 corona cada 12 meses) $0 D2752 Corona de porcelana, fundida a metal noble (1 corona cada 12 meses) $0 D2790 Corona con colado completo, fundida a metal altamente noble (1 corona cada 12 meses) $0 D2791 Corona con colado completo, fundida a metal base (1 corona cada 12 meses) $0 D2792 Corona con colado completo, de metal noble (1 corona cada 12 meses) $0 D2950 Construcción del núcleo, pernos incluidos (1 construcción cada 12 meses) $0 D2952 Poste y núcleo fundidos, además de la corona (1 poste y núcleo cada 12 meses) $0 Endodoncia (Conducto radicular) Usted paga D3310 Conducto radicular anterior $0 D3320 Conducto radicular bicúspide $0 D3330 Conducto radicular molar $0 Periodoncia (Tratamiento de encías) Usted paga D4210 Gingivectomía, por cuadrante (1 cada 24 meses) $0 D4260 Cirugía ósea, por cuadrante (1 cada 24 meses) $0 D4341 Raspado periodontal y pulido radicular (1 por cuadrante cada 3 años) $0 D4355 Desbridamiento de toda la cavidad bucal (1 por cuadrante cada 3 años) $0 D4910 Mantenimiento periodontal (1 cada 6 meses) $0 29