Page 14 - SBCEO Benefit Guide 19-20_FINAL

Dental Benefits 14

Dental Plan Options (continued)

Unicare PPO Plan
When you receive services from In-Network dentists, your out-of-pocket costs are lower. In-Network dentists agree to
discount their charges while Out-of-Network dentists do not. Out-of-Network benefits are based on a specific Fee Schedule
for Unicare Dental.
Golden West Dental HMO (DHMO) Plan
With this plan, you select a General Dentist who provides and/or coordinates all of your dental care. There is no coverage for
Out-of-Network providers. Your costs are based on a Fee Schedule.

Unicare PPO Plan Golden West DHMO Plan
#2766960003 #2766960001
Dental In-Network Out-of-Network In-Network
Benefits Only

Calendar Year Maximum $1,000 Unlimited
Benefit
Calendar Year Deductible Individual: $50 None
Family: $150

1
Diagnostic & Preventive 100% 100% See fee schedule
Services (deductible waived)
1
Basic Services 80% 80% See fee schedule
1
Major Services 80% 80% See fee schedule

1
Prosthodontics Services 50% 50% See fee schedule
Implants Not covered Not covered Not covered
2
Orthodontia (All Ages) Child: $1,795 Not covered Child: $1,795
Adult: $1,795 Adult: $1,795

1. Based on a specific fee schedule.
2. For orthodontia coverage, treatment must be provided by a Golden West Orthodontic Panel.

Contact Information

 Unicare: Call 877-496-0068 or visit unicare.com.
 Golden West: Call 866-926-8078 or visit goldenwestdental.com.