10 Copayment Preventive Plan - Dominion Dental Services, Inc.

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Kaiser Permanente Preventive Dental Plan $10 Copayment Directory The benefit information provided in this directory is only a summary, and does not fully describe your dental coverage. For complete details of your coverage, please refer to your group Evidence of Coverage with Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser Permanente). In the event of ambiguity, or a conflict between this summary and the Evidence of Coverage, the Evidence of Coverage shall control. This directory lists only dental providers. For a list of physicians, please refer to your provider directory. Preventive dental plan The preventive dental plan offered by Kaiser Permanente and administered by Dominion Dental Services USA, Inc. (Dominion) provides cost-effective dental care. We emphasize healthy smiles through prevention and the early detection of dental problems. Our preventive dental plan promotes healthy teeth and gums to reduce the need for costly procedures in the future. The combination of predictable costs, no deductibles, and no annual maximums helps you reach a state of good oral health without the financial barriers to treatment typically found with many dental plans. With the preventive dental plan, you pay a fixed rate of $10 for each preventive care office visit, which includes oral evaluation, cleaning, and certain X-ray procedures. Other covered dental services are provided at a reduced fee. Participating dentists have agreed to accept the associated dental fee as payment in full for covered dental services. Neither Kaiser Permanente nor Dominion is liable for payment of these dental fees or for any fees incurred for non-covered dental services. 2 Choosing a dentist You may select a general dentist from the list of participating dental providers for yourself and your eligible family members. Specialty care is also available. You may call Dominion’s Member Services Department at 703-518-5338 or toll free at 1-888-518-5338, Monday through Friday, 7:30 a.m. to 6 p.m., (TTY 711) for a list of participating specialists. To receive treatment from a participating specialist, please contact your participating general dentist to arrange a referral. Specialists are available in many locations throughout the community, but your discounted fees will be higher for care you receive from a network specialist. Services received from non-participating dentists are not covered under this plan. Quality dental care With the preventive dental plan, you can be confident that your dentist was carefully selected to offer quality care. All dentists go through a strict quality assurance program developed in accordance with the National Association of Dental Plans recommendations. This process confirms that each dentist has the required credentials and has passed a thorough on-site office evaluation.
Dedicated customer service We also know that quality customer service is an important component of any dental plan. Knowledgeable Dominion Member Services Specialists are available Monday through Friday, 7:30 a.m. to 6 p.m. at 703-518-5338 or toll free at 1-888-518-5338 to answer questions about coverage or to help you find a participating dentist. Hearing-impaired members can use the Internet at IP-RELAY.com or call our TTY phone number at 711 for assistance. Dominion’s integrated voice response system is available 24 hours a day for information about participating dental providers in your area or to help you select a participating dental provider. The most up-todate list of participating dental providers can be 3 found at DominionDental.com/kaiserdentists. Dominion also provides many other secure features online at DominionDental.com. Finding a participating dentist using the Internet couldn’t be easier. Plan benefits include: • $10 fixed charge for most diagnostic and preventive care services • No deductibles • No annual benefit maximums • Virtually no claim forms to fill out A complete list of discounted services is enclosed.
Page 1: $10 PREVENTIVE DENTAL PLAN 2013 kp.
Page 5 and 6: How we protect your rights to priva
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Page 17 and 18: District of Columbia Roy Baptiste,
Page 19 and 20: Cynthia Burns (51007) Arundel Mills
Page 21 and 22: Marlene Dahne (396) The Dental Care
Page 23 and 24: Steven R. McKane, DDS, PC (2458) 13
Page 25 and 26: Shideh Emdadi (37761) H & M Cosmeti
Page 27 and 28: Maryam Norouzi, DDS (2457) 9045 Sha
Page 29 and 30: Harry J. Klapper, DDS (187) 5749 Cr
Page 31 and 32: Jiten P. Gohel, DMD (37762) 913 E.
Page 33 and 34: *Roger Strause (1341) Centerville F
Page 35 and 36: Fairfax County Mazin Alayssami (117
Page 37 and 38: *Quan Le (115) Le Smile 2070 Chain
Page 39 and 40: Mojdeh Vessali Family Dentistry (28
Page 41 and 42: Rustico Dumlau (79069) Golden Pedia
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10 Copayment Preventive Plan - Dominion Dental Services, Inc.

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