Page 23 - ABC Company 2018 Open Enrollment Guide

Dental Benefits
Good oral care enhances overall physical health, appearance and mental well-being. Problems with the teeth and gums are common and easily treated health problems. Keep your teeth healthy and your smile bright with the ABC Company Dental Benefit Plan.
UHC
PPO Basic Dental Plan
PPO Enhanced Dental Plan
Employee
$6
Employee
$12
Employee Contributions:
(Semi-Monthly)
Employee and Spouse
Employee and Children
$12
Employee and Spouse
$25
$17
Employee and Children
$32
Family
$26
Family
$50
Benefit Plan Details
In-Network
Out-of-Network
In-Network
Out-of-Network
Referral Required
Dependents are covered until the end of the month in which the dependent turns 26.
No
Deductible (Annual)
$100 Individual / $200 Family*
$25 Individual / $50 Family*
Diagnostic / Preventive Care Services
Cleanings, Fluoride Treatments, Sealants, Periodic Oral Evaluation, Radiographs
100% (Deductible
Waived)
Basic Services- Filling Restorations (amalgams or composite), Simple extractions, Oral Surgery (including surgical extractions), Periodontics, Labs and Other Diagnostic Tests
20% After deductible
40% Afte
r deductible
100% After deductible
20% After deductible
Major Services (You Pay) – Inlays, Onlays, Crowns, Fixed Partial Dentures (Bridges)
40% After deductible
50% Afte
r deductible
50% (Adult and
30% After deductible
40% After deductible
Orthodontia
Child)
Out-of-Network Reimbursement
N/A
Based on 80% R & C
N/A
Based on 80% R & C
Annual Maximum Benefit
Orthodontia Lifetime Maximum
$1,000
$2,000
* Family includes employee + spouse, employee + children, and employee + family coverage tiers.
UnitedHealthcare ID & Debit Cards
No changes, no new card.
You will receive a new card if you:
» Make a new election or change between Dental Plans
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