Page 14 - 2021 Master's University Benefit Brochure_Final3

UCCI Dental PPO Plans

DPPO Low
In- Network Out-of-Network*
$1,000 $1,000
Annual Benefit Maximum

Calendar Year Deductible: $50 / $150 $50 / $150
Individual / Family

Preventive & Diagnostic: Covered 100%** 20% after deductible
Office Exams / Cleanings / X-Rays

Basic Services: 20% after deductible 40% after deductible
Fillings / Root Canal / Oral Surgery

Major Services: 50% after deductible 50% after deductible
Crowns / Dentures / Bridges

Orthodontia Not covered Not covered

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*Out of Network services are covered up to the 90 percentile of reasonable & customary. Member is
responsible for any charges above allowable amounts. Out of network annual max is $1,000. Please refer to
carrier summary for detailed out of network benefits.
DPPO High
In- Network Out-of-Network*
$1,500 $1,500
Annual Benefit Maximum

Calendar Year Deductible: $50 / $150 $50 / $150
Individual / Family

Preventive & Diagnostic: Covered 100%** Covered 100%**
Office Exams / Cleanings / X-Rays

Basic Services: 10% after deductible 20% after deductible
Fillings / Root Canal / Oral Surgery

Major Services: 40% after deductible 50% after deductible
Crowns / Dentures / Bridges

Orthodontia – child and adult 50% up to $1,500 lifetime max 50% up to $1,500 lifetime max

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*Out of Network services are covered up to the 90 percentile of reasonable & customary. Member is responsible
for any charges above allowable amounts. Out of network annual max is $1,500. Please refer to carrier summary
for detailed out of network benefits.
**Deductible waived

The Master’s University & Seminary Page 13
2021 Employee Benefits Brochure