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

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
 

Monthly rates for:
Effective date:

Employee

 

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
$15.00
Type II – Basic Services Patient Pays
One surface silver filling
Two surface white filling, anterior
Single tooth extraction
Surgical removal of erupted tooth		 $20.00
$45.00
$25.00
$45.00
Type III – Major Services Patient Pays*
Porcelain crown (high noble)
Porcelain bridge
One surface inlay, metallic
Molar root canal therapy
Complete upper dentures		 $310.00
$310.00
$115.00
$300.00
$325.00
Type IV – Orthodontics Patient Pays*
Treatment for children/adults 25% discount off
usual fees
* Some services require additional lab fees.  
   
Calendar Year Deductible None
Annual Maximum Benefit None
Pre-Existing Condition Exclusion No pre-existing condition exclusion applies
Exclusions and Limitations 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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