Page 10 - AMT Gordian TEXAS EE Guide 01-2020

BENEFITS

Dental Insurance

UHC | PPO
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 network 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.

UHC | DHMO (Texas)
With the Dental Health Maintenance Organization (DHMO) plans through United Healthcare, you are required to select a
general dentist who is a member of the Select Managed Care DHMO network in Texas. 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.

UHC UHC
Plan Name Passive PPO DHMO D091N (TX)

National Options TX Select Managed Care
Network Name PPO 30 Non-Network DHMO
Dental Benefits

Office Visit Copay $0 Copay
$0 Copay $1,500
Calendar Year Maximum Unlimited

Calendar Year Deductible
- Individual $50 $50 $0
- Family $150 $150 $0
Preventive No Charge No Charge* No Charge for Most Services
Exams, X-Rays, Cleanings
Basic Services Deductible, 10% Deductible, 10%* See Copay Schedule
Fillings, Oral Surgery,
Endodontics, Periodontics

Major Services Deductible, 40% Deductible, 40%* See Copay Schedule
Crowns, Prosthetics
Orthodontia
- Child 50% - $1,500 Lifetime Max Benefit $1,895 Copay
- Adult 50% - $1,500 Lifetime Max Benefit $1,895 Copay
*Dentists who are out-of-network have not agreed to pricing, and may bill you for the difference between what United
Healthcare pays them and what the dentist usually charges.

Finding a Dental Provider
Go to www.myuhc.com. PPO participants should refer to the “National Options PPO 30” network,
and DHMO participants should refer to the “TX Select Managed Care DHMO plan” network when
prompted.

Note
We 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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