Page 16 - Open Enrollment Guide Sample
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Dental
How the Plan Works
Want to save money on
dental care? Dental insurance helps you pay for preventive, basic, major services, and
The active PPO network helps you orthodontia services for dependents under the age of 19.
and the Company save on dental
expenses. To ind a participating [Client] offers an active PPO Dental Plan. This means if you go to a
network provider in your area, dentist in the Advantage Plus network, you pay less—your portion and
log onto www.ucci.com or call toll the Company’s portion of the bill are lower due to provider discounts.
free 1-800-332-0366. If you go to a dentist out-of-network, both you and the Company pay a
Make sure you are looking for higher portion of the bill. Refer to the chart below.
providers in the Advantage Plus
network.
If your current provider is in the network, these providers have agreed
to charge within the Reasonable and Customary (R&C) limits. If you
visit providers outside the network, they may charge more than what is
considered by the plan to be Reasonable and Customary—and you will be
responsible for charges over the R&C amount.
What It Covers
In-Network Out-of-Network
Annual Deductible (Class II and III $25 per person $50 per person
only) (maximum of $50 (maximum of $100
per family) per family)
Annual Maximum Beneit $1,500 per person $1,500 per person
Preventive and Diagnostic Care 100% with no 90% after
Including x-rays and two routine deductible deductible
Bi-Weekly Dental Contributions exams/cleanings per calendar year
60% after
Team member $5.07 Basic Services 80% after deductible
Including simple extractions, minor
deductible
Team member + Spouse $10.64 oral surgery, illings, and root canals
Team member + $9.12 Major Services 50% after 50% after
Child(ren)* Including periodontics, full and partial deductible deductible
Family** $16.21 dentures, crowns, and ixed bridges
Orthodontia 50% 50%
* Team member + Child(ren) includes For dependent children up to age 19 $1,500 lifetime $1,500 lifetime
the Team member plus any number of only orthodontia orthodontia
children maximum maximum
** Family includes the Team member, a
Spouse, and any number of children
Dental Plan Changes in 2015
Dependents are now eligible through age 26 for coverage
Preventive services do not accumulate toward your calendar year
maximum
[Client]
Dental
How the Plan Works
Want to save money on
dental care? Dental insurance helps you pay for preventive, basic, major services, and
The active PPO network helps you orthodontia services for dependents under the age of 19.
and the Company save on dental
expenses. To ind a participating [Client] offers an active PPO Dental Plan. This means if you go to a
network provider in your area, dentist in the Advantage Plus network, you pay less—your portion and
log onto www.ucci.com or call toll the Company’s portion of the bill are lower due to provider discounts.
free 1-800-332-0366. If you go to a dentist out-of-network, both you and the Company pay a
Make sure you are looking for higher portion of the bill. Refer to the chart below.
providers in the Advantage Plus
network.
If your current provider is in the network, these providers have agreed
to charge within the Reasonable and Customary (R&C) limits. If you
visit providers outside the network, they may charge more than what is
considered by the plan to be Reasonable and Customary—and you will be
responsible for charges over the R&C amount.
What It Covers
In-Network Out-of-Network
Annual Deductible (Class II and III $25 per person $50 per person
only) (maximum of $50 (maximum of $100
per family) per family)
Annual Maximum Beneit $1,500 per person $1,500 per person
Preventive and Diagnostic Care 100% with no 90% after
Including x-rays and two routine deductible deductible
Bi-Weekly Dental Contributions exams/cleanings per calendar year
60% after
Team member $5.07 Basic Services 80% after deductible
Including simple extractions, minor
deductible
Team member + Spouse $10.64 oral surgery, illings, and root canals
Team member + $9.12 Major Services 50% after 50% after
Child(ren)* Including periodontics, full and partial deductible deductible
Family** $16.21 dentures, crowns, and ixed bridges
Orthodontia 50% 50%
* Team member + Child(ren) includes For dependent children up to age 19 $1,500 lifetime $1,500 lifetime
the Team member plus any number of only orthodontia orthodontia
children maximum maximum
** Family includes the Team member, a
Spouse, and any number of children
Dental Plan Changes in 2015
Dependents are now eligible through age 26 for coverage
Preventive services do not accumulate toward your calendar year
maximum
[Client]
