Page 10 - Adolph's Litho Services - 2023 CLASS 1 - Benefit guide
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Dental Option:
United Healthcare
2023 Rate — Per Pay Period
Weekly Employee Cost Dependent Information
Adolph’s Litho Services offers employees the
Employee Only $ 7.50
opportunity to cover their spouse and
Employee + Spouse $15.00 dependent children. Children can join or
Employee + Child(ren) $15.15 remain on a parent’s dental plan until age 26.
When a child turns 26, they will lose dental
Employee + Family $23.34 coverage on the last day of their birth month.
(In-Network) Amount Paid
Type of Service (Out of Network Paid at the In Network Discount
Reimbursement level)
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
Calendar Year Deductible $50 Individual / $150 Family
Annual Maximum $1,000 per person
Orthodontic Services to age 19 Covered at 50%
Waiting Period 12 Month Waiting Period for Major and Ortho
Type of Service Benefit Description
Preventive Services Oral Exams, Cleanings, X-rays, Sealants, Fluoride Treatment
Basic Services Restorations and General Services
Simple Extractions, Crowns, Bridges, Dentures, Endodontics,
Major Services
Periodontics and Oral Surgery
Annual Maximum Applies January 1 to December 31
NOTE: This is only a brief overview. Please see Benefit Summary for more details.
Website: www.myuhc.com or Customer Service : 866-633-2446
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