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Dental Option
C-250 DHMO Overview
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Dental Option
CS-150 DHMO Overview
CS-150 DHMO Schedule
CS-150 DHMO
Frequently Asked Questions
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Dental Option
Elite 75 Overview
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CS-150 DHMO Overview

Plan Information

The DHMO plan provides a wide variety of benefits through your participating provider. At the time of services, you pay the dentist for any applicable copayments according to your schedule of benefits. The plan features:

bulletNo claims to file
bulletNo hidden costs
bulletNo maximums
bulletNo waiting periods

Type I – Preventive Services Patient Pays
Office Visit
Initial Exam
X-Rays (Bitewings)
Semi-Annual Cleaning
Sealant - per tooth		 $5.00
No charge
No charge
No charge
$10.00
Type II – Basic Services Patient Pays
One surface silver filling
Two surface white filling, anterior
Single tooth extraction
Surgical removal of erupted tooth		 No charge
$40.00
No charge
$40.00
Type III – Major Services Patient Pays*
Porcelain crown (high noble)
Porcelain bridge
One surface inlay
Molar root canal therapy
Complete upper dentures		 $280.00
$280.00
$95.00
$250.00
$300.00
Type IV – Orthodontics Patient Pays*
Treatment for children to age 19
Evaluation
Treatment Planning
Orthodontic Treatment
$35.00
$250.00
$1800.00
* Some services require additional lab fees.
 
Calendar Year Deductible None
Annual Maximum Benefit None
Pre-Existing Condition Exclusion



Exclusions and Limitations		 No pre-existing condition exclusion applies

Certain exclusions and limitations apply

This schedule shows only a few of the covered procedures. Please see your Benefit Administrator for a complete schedule. This schedule is intended for comparison purposes only. The benefits for each plan will be determined by the contract. For a complete listing of benefits and exclusions and limitations, please reference your certificate of coverage.

 
 

 

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