Page 14 - Heritage Oaks_Benefit Guide 7-1-2021a

Dental Option:

United Healthcare

2021 Rate Per Pay Period

Employee Only $16.95 Dependent Information

Employee + Spouse $33.91 The Heritage Oaks Company offers employees the
opportunity to cover their dependent children.
Employee + Child(ren) $39.49 Children can join or remain on a parent’s dental plan
until age 26. When a child turns 26, they will lose dental
Employee + Family $59.45

Type of Service (In-Network) Amount Paid

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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