Copayments. Effective January 1, 2019, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Service In-Network Out-of-Network Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics* 80% after deductible 50% after deductible
Copayments. Members shall be required to pay applicable Copayments at the time of service. Payment of a Copayment does not exclude the possibility of an additional billing if the service is determined to be a non-Covered Service or if other Cost Shares apply.
Copayments. Effective January 1, 2018, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist.
Copayments. Except where stated otherwise, after You have satisfied the Deductible as described above, You must pay the Copayments, or fixed amounts, in the Schedule of Benefits section of this Contract for Covered Services. However, when the Allowed Amount for a service is less than the Copayment, You are responsible for the lesser amount.
Copayments. Effective with the 2022 insurance contract year, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan are subject to the managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.
Copayments. A copayment is a set dollar amount you are responsible for paying to a health care provider for a covered service. A copayment is also called a copay. COINSURANCE Coinsurance is the percentage of the covered service that you are responsible to pay when you receive covered services.
Copayments. You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment due for specific Covered Services, benefit limitations and out-of-pocket maximums can be found in the Schedule of Copayments and Benefit Limits. The Copayment amount shall not exceed 50% of the total cost of the services provided. Out-of-Pocket Maximums Copayments paid by You or on Your behalf in a Calendar Year shall not exceed 200% of the total annual Premium. HMO will determine when maximums have been reached for Covered Services and for Covered Drugs based on information provided to HMO by You and Participating Providers to whom You have made payments for Covered Services and for Covered Drugs. Out-of-pocket maximums will include Copayments for Covered Services and any eligible dental expenses payment obligations from the indemnity dental Rider. Once You reach the out-of-pocket maximum, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the family out-of-pocket maximum amount shown in the Schedule of Copayments and Benefit Limits. When the family out-of-pocket maximum amount is reached, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. Requirements All Covered Services, unless otherwise specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS; • may have limitations, restrictions or exclusions described in Limitations and Exclusions; and • may require Prior Authorization.
Copayments. Providers will use this information to determine the copayment they may collect from Members at the time a service is rendered. Members should use the following list as a reference: PCP $$ -- PCP office visit copayment SPC $$ -- specialist office visit copayment ER $$ -- emergency room visit copayment UC $$ -- urgent care visit copayment AH $$ -- after normal business hours PCP office visit copayment (This copayment is in addition to the PCP office visit copayment) The Member’s ID card may also contain information regarding coverage for dental, vision, and prescription drug benefits. Preauthorization: The term preauthorization alerts providers that this element of a Member’s coverage is present. Members should refer to the Preauthorization Program attachment to this Agreement for more information. On the back of the ID card, members can find important additional information on: Preauthorization instructions and toll-free telephone number. General instructions for filing claims. Members should remember to destroy old ID cards and use only their latest ID card. Members should also contact Keystone’s Customer Service if any information on their ID card is incorrect or if they have questions. Listed below are some important things to do and to remember about a Member ID Card: Check the information on the ID Card for completeness and accuracy. Check that one ID Card is received for each enrolled family Member. Check that the name of the Primary Care Physician (or office) that was selected is shown on the ID Card. Also, please check the ID Card for each family Member to be sure the information on it is accurate. Call Keystone’s Customer Service Department if the ID Card is lost or there is an error on the card. Carry the ID Card at all times. Members must present an ID Card whenever they receive Medical Care. On the reverse side of the ID Card, Members will find information about medical services. There is even a toll-free number for use by Hospitals if they have questions about a Member’s coverage.
Copayments. Provider shall collect and retain a Member’s applicable Copayment for Covered Services provided pursuant to this Agreement. Provider shall not waive a Member’s Copayment obligation. Notwithstanding the foregoing, Provider acknowledges that cost sharing for Members eligible for both Medicare and Medicaid/Medi-Cal (“Dual Eligible Members”) is limited to the cost sharing limits established by Medicaid/Medi-Cal. With respect to Covered Services provided to Dual Eligible Members, Provider shall accept payment by Blue Shield as payment-in-full for such Covered Services, or will separately bill the appropriate State source for any amounts above the Medicaid/Medi-Cal cost sharing limits.
Copayments. There are no Copayments for Covered Services under this Policy.
