Page 9 - Roll-A-Shade Ben Guide 6-2020

Benefits

Dental Insurance

United Healthcare | DHMO Dental Plan
With the Dental Health Maintenance Organization (DHMO) plan through United Healthcare, you are required to select a general
dentist from the “CA Select Managed Care DHMO Plan” network to provide your dental care. You will contact your general dentist
for all of your dental needs, such as routine check‐ups and emergency situations. If specialty care is needed, your general dentist
will provide the necessary referral. For covered procedures, you'll pay the pre‐set copay or coinsurance fee described in your
DHMO plan booklet. Please keep a copy of your booklet to refer to when utilizing your dental care. This will show the applicable
copays that apply to all of the dental services that are covered under this plan.

United Healthcare | PPO Dental Plan
With the United Healthcare Preferred Provider Organization (PPO) dental plan, you may visit a “National Options PPO 20” network
dentist and benefit from the negotiated rate or visit a non‐network dentist. When you utilize a PPO dentist, your out-of-pocket
expenses will be less. You may also obtain services using a non-network dentist; however, you will be responsible for the difference
between the covered amount and the actual charges and you may be responsible for filing claims.

United Healthcare United Healthcare
D176C DHMO P8152 PPO

Network Name CA Select Managed Care DHMO Plan National Options PPO 20 Non-Network*
Dental Benefits
Calendar Year Maximum Unlimited $1,500

Deductible (Annual)
- Individual $0 $50
- Family $0 $150
Preventive (Plan Pays) 100% for Most Services 100% 80%
Exams, X-Rays, Cleanings Deductible Waived Deductible Waived

Basic Services (Plan Pays) See Copay Schedule 80% 60%
Fillings, Oral Surgery,
Endodontics, Periodontics
Major Services (Plan Pays) See Copay Schedule 50% 50%
Crowns, Bridges, Dentures
Orthodontia
- Covered Members Children & Adults Children & Adults
- Copay $1,895 Child / $1,895 Adult N/A
- Coinsurance N/A 50%
- Lifetime Benefit Maximum N/A $1,500
*Based on Fee Schedule

Finding a Dental Provider
Go to www.myuhc.com or call (877) 813-4259 for DHMO or (877) 816-3596 for PPO. DHMO participants
should refer to the “CA Select Managed Care DHMO Plan” network and PPO participants should refer to the
“National Options PPO 20” network when prompted.

Note
We strongly recommend you ask your dentist for a predetermination if total charges are expected to exceed $300.
Predetermination enables you and your dentist to know in advance what the payment will be for any service that may be in
question.
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