Page 11 - MCU Benefits Guide
P. 11
Voluntary Dental Benefits
Unum Dental Benefits
100%
• Routine exams - 2 per 12 months
• Routine cleaning (prophylaxis) - 2 per 12 months
• Bitewing x-rays – 1 per 12 months
• Full mouth x- ray – 1 per 24 months
Type I: Preventive Services • Emergency pain – 1 per 12 months
• Fluoride- 1 treatment per 12 months (covered only for dependent children to age 16)
• Sealants – 1 per 36 months (to age 16)
• Space maintainers - covered only for dependent children to 16
• Adjunctive pre-diagnostic oral cancer screening – 1 per 12 months for ages 40+
80%
• Fillings
• Posterior composite restorations
• Anesthesia (subject to review, covered with complex oral surgery)
Type II: Basic Services • Endodontics (root canals)
• Simple extractions
• Non-surgical periodontics
• Surgical periodontics (gum treatment)
• Repairs: crown, denture, and bridges
50%
• Oral surgery (surgical extractions & impactions)
• Inlays
Type III: Major Services • Onlays
• Crowns, bridges, dentures and endosteal implants (in lieu of an approved 3 unit
bridge)
50%
• Orthodontia Lifetime/ Annual Maximum: $1,000/None
Type IV: Orthodontics • Dependent Children to age 19 only
• Up to 25% of lifetime allowance may be payable on initial banding
Waiting Periods None
Late Entrant Waiting Periods 12 months for Basic, Major and Orthodontics
UCR (Usual Customary th
90 Percentile
Reasonable)
$50 (waived Type I services; applies to Type II and Type III services)
Plan Year Deductible
$150 (waived Type I services; applies to Type II and Type III services)
Plan Year Maximum $1,000
10 |
