Page 13 - Dragados 2022 Benefits Guide

Dental Plans
Administered by UnitedHealthcare
Good oral care enhances overall physical health, appearance, and mental well-being. Problems with teeth and gums are common and easily treated. Keep your teeth healthy and your smile bright with the Dragados dental benefit plan.
Calendar Year Deductible
Preventive Services (deductible waived)
Basic Services
Major Services
Calendar Year Maximum Orthodontia Lifetime Max Orthodontia (child only)
For any questions about the dental plan and resources available to you, call UnitedHealthcare’s toll free Enrollment Information Line at 1-877-816-3596.
Dental PPO Plan Provisions
In-Network
$50 single $150 family
UNITEDHEALTHCARE DENTAL PPO PLAN*
100% of billed discounted charges
90% of billed discounted charges
60% of billed discounted charges
$2,000 (per person) $2,000 (per child under age 19)
50% of billed discounted charges
Out-of-Network**
$50 single $150 family
100% of R&C
80% of R&C 50% of R&C
50% of R&C
* Please refer to your benefit summary for further details on plan coverage provisions.
** Reasonable & Customary (R&C) refers to the plan reimbursement for out-of-network services.
A PPO plan ID card will be mailed to your home address and can be accessed via your myUHC app.
Dental INO Plan Provisions
UNITEDHEALTHCARE DENTAL INO PLAN – BENEFIT HIGHLIGHTS*
UnitedHealthcare Dentist
$50 single $150 family
100% of billed discounted charges
50% of billed discounted charges
50% of billed discounted charges
Calendar Year Deductible Preventive Services Basic Services
Major Services
Calendar Year Maximum Orthodontia Lifetime Max Orthodontia
$1,500 (per person)
$1,000 (per person – adult and child) 50% of billed discounted charges
*Please refer to your benefit summary for further details on plan coverage provisions.
An INO plan ID card will be mailed to your home address and can be accessed via your myUHC app.
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