MetLife Dental Plan 12th District DHMO Dental Program HOW TO ENROLL-(MET185 Plan) 1. Complete all sections of the MetLife Dental enrollment form then sign and date at the bottom of the form. 2. Select a dentist by going to the MetLife link: www.metlife.com/mybenefits (Under account Sign in you type AFGE as your employer, Click on Managed Dental plan, select the MET185 plan and enter your zip code.) Find the Facility # for the dental provider you choose and enter that number on the enrollment form in the 1st Choice Dental Office # box. (You may call Customer Service at 866.348.9501 to be sure 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 federal agencies now require employees to initiate the payroll deduction process electronically. If your agency requires this, please refer to the Direct Deposit Form for the Bank Routing Number (Section 3) and the Account Number (Section 1, Part E). You can contact Benefit Architects for specific instructions on how to start the deductions thru Employee Express, MyPay, and the USDA National Finance Center. HOW MUCH DOES THE MET185 DENTAL COST? Bi-Weekly Semi-Annual Coverage Payroll Check Allotment Single $ 11.00 $ 143.00 Single +1 $ 18.00 $ 234.00 Family $ 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 along with your enrollment form. Payment by Credit card can be made over the telephone. Benefit Architects Administrators Attn: 12th District Dental Plan 1256 Main Street, Suite 249 Southlake, TX 76092 Fax 800-238-2104 (Please note the original 1199A must be turned in to your payroll center if you did not initiate the payroll 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 the 15th of the month for eligibility to begin the first of the following month. (Semi Annual checks 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 contact Customer Service at 866.348.9501. (This number can be used for both MetLife and MetLife dental) If at any time you have a change of address, or phone number, notify Benefit Architects Administrators 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 your coverage until your allotments begin again. QUESTIONS? Email: [email protected] or call 800.733.7236, X-105 SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* MET185 This SCHEDULE OF BENEFITS lists the Covered Services available to You and Your Dependents under Your dental plan, as well as Your and Your Dependent’s costs for each Covered Service. Your and Your Dependent’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 General Dentist is responsible for determining when the services of a Specialty Care Dentist are needed, and facilitating any necessary referral. You and Your Dependents will be advised of the name, address and telephone 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 notify the Selected General Dental Office as far in advance as possible. This will allow the Selected General Dental Office to accommodate another person in need of attention. If You or Your Dependents fail to do this in a timely fashion, You or Your Dependents may be charged a missed appointment fee. Your and Your Dependent’s Service Co-Payment • Broken Appointment (less than 24-hr notice) Not to exceed $25 • Office visit - per visit (including all fees for sterilization and/or infection $5 control) Your and Your Dependent’s Code Service Co-Payment Diagnostic Treatment D0120 Periodic oral evaluation - established patient $0 D0140 Limited oral evaluation - problem focused $0 D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver $0 D0150 Comprehensive oral evaluation - new or established patient $0 D0160 Detailed and extensive oral evaluation - problem focused, by report $0 D0170 Re-evaluation - limited, problem focused (established patient; not post- operative visit) $0 D0180 Comprehensive periodontal evaluation - new or established patient $0 D0190 Screening of a patient $0 D0191 Assessment of a patient $0 Radiographs / Diagnostic Imaging (X-rays) D0210 Intraoral – complete series of radiographic images $0 D0220 Intraoral – periapical first radiographic image $0 D0230 Intraoral – periapical each additional radiographic image $0 D0240 Intraoral – occlusal radiographic image $0 D0250 Extraoral – first radiographic image $0 D0260 Extraoral – each additional radiographic image $0 D0270 Bitewing – single radiographic image $0 D0272 Bitewings – two radiographic images $0 GCERT2010-DHMO-SOB CA sob 1 SCHEDULE OF BENEFITS (continued) Your and Your Dependent’s Service Co-Payment D0273 Bitewings – three radiographic images $0 D0274 Bitewings – four radiographic images $0 D0277 Vertical bitewings – 7 to 8 radiographic images $0 D0330 Panoramic radiographic image $0 D0340 Cephalometric radiographic image $0 D0350 Oral/facial photographic images $0 D0363 Cone beam – three dimensional image reconstruction using existing data, includes multiple images $160 D0364 Cone beam CT capture and interpretation with limited field of view – less than one whole jaw $180 D0365 Cone beam CT capture and interpretation with field of view of one full dental arch – mandible $180 D0366 Cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium $180 D0367 Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium $180 D0380 Cone beam CT image capture with limited field of view – less than one whole jaw $180 D0381 Cone beam CT image capture with field of view of one full dental arch – mandible $180 D0382 Cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium $180 D0383 Cone beam CT image capture with field of view of both jaws, with or without cranium $180 D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report $0 Tests and Examinations D0415 Collection of microorganisms for culture and sensitivity $0 D0425 Caries susceptibility tests $0 D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures $50 D0460 Pulp vitality tests $0 D0470 Diagnostic casts $0 D0472 Accession of tissue, gross examination, preparation and transmission of written report $0 D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report $0 D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report $0 D0480 Accession of exfoliative cytologic smears, microscopic examination, $0 preparation and transmission of written report D0486 Laboratory accession of transepithelial cytologic sample, microscopic $0 examination preparation and transmission of written report D0502 Other oral pathology procedures, by report $0 GCERT2010-DHMO-SOB sob 2 SCHEDULE OF BENEFITS (continued) Your and Your Dependent’s Service Co-Payment Preventive Services D1110 Prophylaxis – adult $0 • Additional-adult prophylaxis (maximum of 2 additional per year) $35 D1120 Prophylaxis – child $0 • Additional-child prophylaxis (maximum of 2 additional per year) $25 D1206 Topical application of fluoride varnish $0 D1208 Topical application of fluoride $0 D1310 Nutritional counseling for control of dental disease $0 D1320 Tobacco counseling for the control and prevention of oral disease $0 D1330 Oral hygiene instructions $0 • Includes periodontal hygiene instruction D1351 Sealant – per tooth $0 D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $0 D1510 Space maintainer – fixed – unilateral $25 D1515 Space maintainer – fixed – bilateral $25 D1520 Space maintainer – removable – unilateral $35 D1525 Space maintainer – removable – bilateral $35 D1550 Re-cementation of space maintainer $5 D1555 Removal of fixed space maintainer $5 Restorative Treatment D2140 Amalgam – one surface, primary or permanent $10 D2150 Amalgam – two surfaces, primary or permanent $15 D2160 Amalgam – three surfaces, primary or permanent $18 D2161 Amalgam – four or more surfaces, primary or permanent $20 D2330 Resin-based composite – one surface, anterior $10 D2331 Resin-based composite – two surfaces, anterior $15 D2332 Resin-based composite – three surfaces, anterior $18 D2335 Resin-based composite – four or more surfaces or involving