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Dental Benefits:

UNUM

Effective Bi-Weekly (26) Dependent Information

Employee Only $ 8.39 We offer our employees and eligible dependents
dental coverage. Children can join or remain on a
Employee + Spouse $16.36
parent’s dental plan until age 26. When a child
Employee + Child(ren) $22.63 turns 26, they will lose dental coverage on the last
Employee + Family $33.24 day of their birth month.

Amount You Pay — Traditional Plus
Type of Service
Non-Network Dentists are Reimbursed at Maximum Allowable Charge (MAC)

Preventive Services Covered at 100%; CYD Waived
Basic Services Covered at 80% after CYD

Major Services Covered at 50% after CYD
Annual Maximum $1,000

Annual Deductible (CYD) $50 Individual / $150 Family
$250 Carryover Benefit will be accrued and stored in the insured’s carryover
Carry Over Benefit
account to be used in the next benefit year.
(Ortho not Included)
($500 Threshold limit / $1,000 Carryover Account Limit)

Orthodontia (Child Only) Not Included

Type of Service Benefit Description
See Summary of Benefits and Policy for the age and frequency limitations of benefits.

Preventive Services Routine cleanings, exams, x-rays, oral cancer screenings. Fluoride,
sealants, space maintainers

Emergency Treatment (1 per 12 months) • Full mouth/panoramic x-rays (1
Basic Services per 36 months) Simple restorative services (fillings) – Posterior composite
restorations • Simple extractions

Crowns, bridges, dentures, inlays, on lays, dentures repair and relines /
rebases. endodontics (root canals), periodontics, oral surgery, and stainless
steel crowns.
Major Services
Implants are

of

Annual Maximum Applies January to December
Orthodontia Not Included

NOTE: This is only a brief overview. Please see Benefit Summary and policy for more details.
Website: www.unum.dentalcarecom or Customer Service: 888-400-9304

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