Page 10 - California Eye Management EE Guide 2020

Dental Benefits

United HealthCare | HMO Dental Plan
With the Dental Health Maintenance Organization (DHMO) plan through United HealthCare, you are required to select a
general dentist 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 PPO 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 Dental
Plan Name Dental DHMO Plan PPO Dental Plan

Network Network Network Non-Network
Dental Benefits

Calendar Year Maximum N/A $1,500 $1,500
Deductible (Annual)
- Individual N/A $50 $50
- Family N/A $150 $150
Preventive (Plan Pays) 100% 100% 100%
Exams, X-Rays, Cleanings
Basic Services (Plan Pays) Deductible, 80% Deductible, 80%
Fillings, Oral Surgery, Endodontics,
Periodontics Refer to Summary
Major Services (Plan Pays) Deductible, 50% Deductible, 50%
Crowns, Prosthetics
Orthodontia (Children/Adult) $1,895 / $1,895 Not covered

Finding In-Network Dental Providers
Go to www.myuhc.com or call (877) 816-3596.

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