Page 13 - 2022 Benefits Resource Guide

Dental benefits

The dental plan uses a passive PPO network which means benefit
coverage is the same whether you see an in or out-of-network provider.
However, you benefit from negotiated discounts with in-network
providers. Should you use an out-of-network provider, your benefits will
be subject to reasonable and customary cost limits. If your out-of-
network provider charges more than that limit, they may balance bill you
for the difference.
You may search for an in-network dentist by visiting
myuhcdental.com.

Dental benefits summary
Covered Services Benefit Guideline
Deductible $50 Individual / $100 Family
Annual Maximum Benefit $2,000
Preventive Care (includes 2 cleanings per calendar year, and 100%
deductible and annual benefit maximum do not apply)
Basic Care 80%
Major Care 50%
Orthodontia for Dependent Children (6-18 years old) 50% (no deductible)
Orthodontia Lifetime Maximum (per covered child) $2,000

Dental plan premiums for full-time employees
The following table shows the full monthly premium, the premium
amount TXM pays on your behalf, and your monthly cost. Your premium
deduction begins with the first pay period following your benefit
enrollment effective date.

Full Monthly TXM Employee
Coverage Option
Premium Contribution Monthly
Employee Only $58.00 $44.00 $14.00
Employee & Children $98.00 $64.00 $34.00
Employee & Spouse $105.00 $67.00 $38.00
Employee & Family $144.00 $84.00 $60.00

10 Employee Benefits Guide