Page 16 - Revelations - Benefit Guide 2020 - Revised May 15

Dental Option:

United Healthcare

Rate Per Pay Period

Dependent Information
Employee Only $17.50
The Revelations HealthCare Group Company offers
Employee + Spouse $35.00 employees the opportunity to cover their dependent
children. Children can join or remain on a parent’s
Employee + Child(ren) $40.65
dental plan until age 26.

Employee + Family $61.26 When a child turns 26, they will lose dental coverage
on the last day of their birth month.

Type of Service (In-Network) Amount Paid

Out of Network is Paid @ 90% of R&C
Preventive Services Covered at 100%; No Deductible
Basic Services Covered at 80% after Calendar Year Deductible

Major Services Covered at 50% after Calendar Year Deductible
Orthodontia Services Covered at 50% No Deductible to a Lifetime Maximum of $1,000
Calendar Year Deductible $50 Individual / $150 Family
Annual Maximum $1,000 per person

Waiting Periods for Major Services or Ortho NONE if you enroll during your enrollment period
The MaxMultipiler Benefit can increase your annual maximum each
year $250 or $350 for (In-Network) providers to a maximum of
Max Rewards
$1,000 in your MaxMultiplier Account. See policy summary for de-
tails!

Type of Service Benefit Description

Preventive Services Oral Exams, Cleanings, X-rays, Sealants, Fluoride Treatment

Fillings, Simple Extractions, Space Maintainers, Oral Surgery,
Basic Services
General Anesthesia, Endodontics and Periodontics
Major Services Crowns, Bridges, Dentures, Inlays & Onlays and Implants

Annual Maximum Applies January 1 to December 31

Orthodontia Only applies to children under age 19

NOTE: This is only a brief overview. Please see the Benefit Summary for more details.

Website: myuhc.com or Customer Service : 877-816-3596

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