Active Health Plan BenefitTabs™

 

This is a summary of benefits and not a substitute for the Southern California IBEW-NECA Health Plan Summary Plan Description, and to the extent it differs from the SPD, the terms of the SPD will govern.

  • United Concordia PPO |   CIGNA DHMO |   DeltaCare USA DHMO |   MetLife/SafeGuard DHMO |   United Concordia DHMO

    MetLife/SafeGuard Dental Plan (DHMO)

     

  • How the Plan Works

    Safeguard provides a list of DHMO dentists to you when you enroll. You must sign up with one of these dentists and receive all dental services from that provider or dental practice. You can change dentists by phoning Safeguard at the number shown below. Only procedures listed on the schedule of benefits are covered.
     

  • Sample Procedures

    Code Procedure
    Your Copay
    Plan Pays
    00120 Periodic Oral Exam
    $0.00
    100%
    01120 Prophylaxis - Child
    $0.00
    100%
    02150 2 Surface Amalgam
    $0.00
    100%
    02792 Full Gold Crown
    $45.00
    100% (after copay)
    03330 Molar Root Canal
    $0.00
    100%

    Schedule of Procedures


     

  • Annual Maximum

    There is no annual maximum benefit .
     

  • Orthodontics

    Covered with a copayment of $1,500 for children and $2,000 for adults.
     

  • Additional Information

    Customer Service Phone Number: 1-800-750-4303
    Web Site/Provider Lookup: www.safeguard.net

    Plan Number: 4950-0I
    Group Number: 2464