Medicare Advantage Health Solutions Dental Benefits
Medicare ADVANTAGE Benefit Plan for:
- ADVANTAGE Enhanced (PPO)
- ADVANTAGE Preferred (PPO)
- ADVANTAGE Select (PPO)
- ADVANTAGE Choice (PPO)
- ADVANTAGE Elite (PPO)
- ADVANTAGE Preferred Group (PPO)
- ADVANTAGE Network HMO (Wishard) (Community) (St. Francis)
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:
- Wishard Complete Care Basic (HMO)
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:
- ADVANTAGE Special Needs Plan HMO SNP (Wishard) (Community) (St. Francis)
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 |