Medicare Advantage Health Solutions Dental Benefits

Medicare ADVANTAGE Benefit Plan for:

Office Visit Co-Pay:$10.00 per office visit

CDT ADA Service Description Basic
In-Network
Limitations
D0120 Periodic Oral Evaluation Recall Exam Covered in Full D0120- up to 2 per year OR 1- D0150 and 1- D0120 per year; (D0150 for new patients only; limited to 1 every 3 years)
D0150 Comprehensive Oral Evaluation Covered in Full
D1110 Prophylaxis- ages 14 to Adult Covered in Full 2 per year
D0272 Bitewing, Two Films Covered in Full 1 set per year, either D0272 or D0274
D0274 Bitewing, Four Films Covered in Full
D1204 Flouride- Adult Covered in Full 2 per year


Medicare ADVANTAGE Benefit Plan for:

Office Visit Co-Pay:$10.00 per office visit

CDT ADA Service Description Basic
In-Network
Limitations
D0120 Periodic Oral Evaluation Recall Exam Covered in Full 1 per year either D0120 or D0150; (D0150 for new patients only; limited to 1 every 3 years)
D0150 Comprehensive Oral Evaluation Covered in Full
D1110 Prophylaxis- ages 14 to Adult Covered in Full 1 per year
D0272 Bitewing, Two Films Covered in Full 1 set per year, either D0272 or D0274
D0274 Bitewing, Four Films Covered in Full


Medicare ADVANTAGE Benefit Plan for:

Office Visit Co-Pay:$0.00 per office visit

CDT ADA Service Description Basic
In-Network
Limitations
D0120 Periodic Oral Evaluation Recall Exam Covered in Full 1 per year either D0120 or D0150; (D0150 for new patients only; limited to 1 every 3 years)
D0150 Comprehensive Oral Evaluation Covered in Full
D1110 Prophylaxis- ages 14 to Adult Covered in Full 1 per year
D0272 Bitewing, Two Films Covered in Full 1 set per year, either D0272 or D0274
D0274 Bitewing, Four Films Covered in Full