Page 10 - Goodwill Columbus 2022 Benefit Guide
P. 10
A Guide to Your Benefits | 2022
Dental Coverage – United Healthcare Dental
Regular dental exams can help you and your dentist detect problems in the early stages when treatment is
simpler, and costs are lower. Keeping your teeth and gums clean and healthy will help prevent most tooth decay
and periodontal disease and is an important part of maintaining your medical health.
Low Plan High Plan
Plan Provision
*National Options PPO 20 *National Options PPO 30
Annual Deductible (Individual/Family) $50/$150 No Deductible
Annual Maximum (per person) $1,000 $1,000
Diagnostic and preventive care: Includes
cleanings, fluoride treatments, sealants 100% 100%
and x-rays
Basic services: Includes fillings,
periodontics, scaling and root planning, 50% 80%
and oral surgery
Major services: Includes crowns, bridges
50% 50%
and full and partial dentures
Orthodontia
(Children only; treatment must begin 50% 50%
th
before 19 birthday)
Orthodontia Lifetime Maximum $1,000 $1,000
NOTE: If you choose an out of network dentist, you may be billed for the additional cost.
*Provider Network
Your Cost per Pay (based on 26 pays) Low Plan High Plan
Employee Only $6.40 $13.69
Employee + Spouse $14.46 $25.71
Employee + Child $14.46 $25.71
Employee + Family $22.70 $37.69
10 | 2021.11.15.05
