UnitedHealthcare®
dental plan
Options PPO 30/covered dental services
P0006 /U85
NETWORKNETWORK
NON-ORTHODONTICS
NON-NETWORK
ORTHODONTICS
NON-NETWORK
Individual Annual Deductible
$0
$50
$50
$0
Family Annual Deductible
$0
$150
$150
$0
Annual Maximum Benefit
(The total benefit payable by the plan will not exceed the highest
listed maximum amount for either Network or Non-Network services.)
$1500 per person per
calendar year
$1500 per person
per lifetime
$1500 per person per
calendar year
$1500 per person
per lifetime
Annual Deductible Applies to Preventive and Diagnostic Services
No
Annual Deductible Applies to Orthodontic Services
No
Waiting Period
12 months for major and orthodontic services
Orthodontic Eligibility Requirement
Up to age 19
COVERED SERVICES*
NETWORK
PLAN PAYS**
BENEFIT GUIDELINES
NON-NETWORK
PLAN PAYS***
DIAGNOSTIC SERVICES
Periodic Oral Evaluation
Radiographs
Lab and Other Diagnostic Tests
Limited to 2 times per consecutive 12 months.
Bitewing: Limited to 1 series of films per calendar year. Complete/Panorex: Limited to
1 time per consecutive 36 months.
100%
100%
100%
90%
90%
90%
PREVENTIVE SERVICES
Dental Prophylaxis (Cleanings)
100%
90%
Limited to 2 times per consecutive 12 months.
Fluoride Treatments
Sealants
Space Maintainers
Limited to covered persons under the age of 16 years and limited to 2 times per
consecutive 12 months.
Limited to covered persons under the age of 16 years and once per first or second
permanent molar every consecutive 36 months.
For covered persons under the age of 16 years, limit 1 per consecutive 60 months.
100%
90%
100%
90%
90%100%
BASIC DENTAL SERVICES
Restorations
(Amalgam or Anterior Composite)*
Multiple restorations on one surface will be treated as a single filling.
80%
70%
General Services
(including Emergency Treatment)
Palliative Treatment: Covered as a separate benefit only if no other service was done
during the visit other than X-rays.
General Anesthesia: when clinically necessary.
Occlusal Guard: Limited to 1 guard every consecutive 36 months.
80% 70%
Simple Extractions
Limited to 1 time per tooth per lifetime.
80%
70%
Oral Surgery
(includes surgical extractions)
80%
70%
Periodontics
Perio Surgery: Limited to 1 quadrant or site per consecutive 36 months per surgical
area.
Scaling and Root Planing: Limited to 1 time per quadrant per consecutive 24 months.
Periodontal Maintenance: Limited to 2 times per consecutive 12 months following active
and adjunctive periodontal therapy, exclusive of gross debridement.
80% 70%
Endodontics
80%
70%
Root Canal Therapy: Limited to 1 time per tooth per lifetime.
MAJOR DENTAL SERVICES
Inlays/Onlays/Crowns*
Limited to 1 time per tooth per consecutive 60 months.
50%
50%
Dentures and other Removable Prosthetics
Full Denture/Partial Denture: Limited to 1 per consecutive 60 months. No additional
allowances for precision or semi-precision attachments.
50%50%
Fixed Partial Dentures (Bridges)*
Limited to 1 time per tooth per consecutive 60 months.
50%
50%
ORTHODONTIC SERVICES
Diagnose or correct misalignment of the teeth or bite
50%
50%
* Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. If you
and your dentist have agreed on a treatment which is more costly than the treatment on which the plan benefit is based, you will be responsible for the difference between the fee for service rendered and
the fee covered by the plan. In addition, a pre-treatment estimate is recommended for any service estimated to cost over $500; please consult your dentist.
** The network percentage of benefits is based on the discounted fee negotiated with the provider.
*** The non-network percentage of benefits is based on the schedule of usual and customary fees in the geographic area in which the expenses are incurred.
In accordance with the Illinois state requirement, a partner in a Civil Union is included in the definition of Dependent. For a complete description of Dependent Coverage, please refer to your Certificate of Coverage.
The Prenatal Dental Care (not available in WA) and Oral Cancer Screening programs are covered under this plan. The material contained in the above table is for informational purposes only and is not an offer of coverage. Please note
that the above provides only a brief, general description of coverage and does not constitute a contract. For a complete listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your
Certificate of Coverage or contact your benefits administrator. If differences exist between this Summary Benefits and your Certificate of Coverage/benefits administrator, the Certificate/benefits administrator will govern. All terms and
conditions of coverage are subject to applicable state and federal laws. State mandates regarding benefit levels and age limitations may supersede plan design features.
UnitedHealthcare Dental® Options PPO Plan is either underwritten or provided by: UnitedHealthcare Insurance Company, Hartford, Connecticut; UnitedHealthcare Insurance Company of New York, Hauppage, New York; Unimerica
Insurance Company, Milwaukee, Wisconsin; Unimerica Life Insurance Company of New York, New York, New York; or United HealthCare Services, Inc.
02/13
©2013-2014 United HealthCare Services, Inc.
100-3264
UnitedHealthcare/dental exclusions and limitations
Dental Services described in this section are covered when such services are:
A. Necessary;
B. Proviced by or under the direction of a Dentist or other appropriate provider as specifically described;
C. The least costly, clinically accepted treatment; and
D. Not excluded as described in the Section entitled, General Exclusions.
GENERAL LIMITATIONS
PERIODIC ORAL EVALUATION Limited to 2 times per consecutive 12 months.
COMPLETE SERIES OR PANOREX RADIOGRAPHS Limited to 1 time per
consecutive 36 months.
BITEWING RADIOGRAPHS Limited to 1 series of films per calendar year.
EXTRAORAL RADIOGRAPHS Limited to 2 films per calendar year.
DENTAL PROPHYLAXIS Limited to 2 times per consecutive 12 months.
FLUORIDE TREATMENTS Limited to covered persons under the age of 16
years, and limited to 2 times per consecutive 12 months.
SPACE MAINTAINERS Limited to covered persons under the age of 16 years,
limited to 1 per consecutive 60 months. Benefit includes all adjustments within 6
months of installation.
SEALANTS Limited to covered persons under the age of 16 years, and once per
first or second permanent molar every consecutive 36 months.
RESTORATIONS Multiple restorations on one surface will be treated as a
single filling.
PIN RETENTION Limited to 2 pins per tooth; not covered in addition to cast
restoration.
INLAYS AND ONLAYS Limited to 1 time per tooth per consecutive 60 months.
Covered only when a filling cannot restore the tooth.
CROWNS Limited to 1 time per tooth per consecutive 60 months. Covered only
when a filling cannot restore the tooth.
POST AND CORES Covered only for teeth that have had root canal therapy.
SEDATIVE FILLINGS Covered as a separate benefit only if no other service,
other than x-rays and exam, were performed on the same tooth during the visit.
SCALING AND ROOT PLANING Limited to 1 time per quadrant per
consecutive 24 months.
PERIODONTAL MAINTENANCE Limited to 2 times per consecutive 12
months following active or adjunctive periodontal therapy, exclusive of gross
debridement.
FULL DENTURES Limited to 1 time every consecutive 60 months. No
additional allowances for precision or semi-precision attachments.
PARTIAL DENTURES Limited to 1 time every consecutive 60 months. No
additional allowances for precision or semi-precision attachments.
RELINING AND REBASING DENTURES Limited to relining/rebasing
performed more than 6 months after the initial insertion. Limited to 1 time per
consecutive 12 months.
REPAIRS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES
Limited to repairs or adjustments performed more than 12 months after the initial
insertion. Limited to 1 per consecutive 6 months.
PALLIATIVE TREATMENT Covered as a separate benefit only if no other
service, other than the exam and radiographs, were performed on the same tooth
during the visit.
OCCLUSAL GUARDS Limited to 1 guard every consecutive 36 months and
only covered if prescribed to control habitual grinding.
FULL MOUTH DEBRIDEMENT Limited to 1 time every consecutive 36 months.
GENERAL ANESTHESIA Covered only when clinically necessary.
OSSEOUS GRAFTS Limited to 1 per quadrant or site per consecutive 36 months.
PERIODONTAL SURGERY Hard tissue and soft tissue periodontal surgery
are limited to 1 quadrant or site per consecutive 36 months per surgical area.
REPLACEMENT OF COMPLETE DENTURES, FIXED OR REMOVABLE
PARTIAL DENTURES, CROWNS, INLAYS OR ONLAYS Replacement of
complete dentures, fixed or removable partial dentures, crowns, inlays or onlays
previously submitted for payment under the plan is limited to 1 time per
consecutive 60 months from initial or supplemental placement. This includes
retainers, habit appliances, and any fixed or removable interceptive orthodontic
appliances.
GENERAL EXCLUSIONS
The following are not covered:
1. Dental Services that are not necessary.
2. Hospitalization or other facility charges.
3. Any dental procedure performed solely for
cosmetic/aesthetic reasons. (Cosmetic procedures are
those procedures that improve physical appearance.)
4. Reconstructive Surgery regardless of whether or not the
surgery is incidental to a dental disease, injury, or
Congenital Anomaly when the primary purpose is to
improve physiological functioning of the involved part of
the body.
5. Any dental procedure not directly associated with dental
disease.
6. Any dental procedure not performed in a dental setting.
7. Procedures that are considered to be Experimental,
Investigational or Unproven. This includes
pharmacological regimens not accepted by the American
Dental Association (ADA) Council on Dental
Therapeutics. The fact that an Experimental,
Investigational or Unproven Service, treatment, device or
pharmacological regimen is the only available treatment
for a particular condition will not result in coverage if the
procedure is considered to be Experimental,
Investigational or Unproven in the treatment of that
particular condition.
8. Services for injuries or conditions covered by Worker’s
Compensation or employer liability laws, and services
that are provided without cost to the covered person
by any municipality, county, or other political
subdivision. This exclusion does not apply to any
services covered by Medicaid or Medicare.
9. Expenses for dental procedures begun prior to the
covered person becoming enrolled under the Policy.
10. Dental Services otherwise covered under the Policy,
but rendered after the date individual coverage under
the Policy terminates, including Dental Services for
dental conditions arising prior to the date individual
coverage under the Policy terminates.
11. Services rendered by a provider with the same legal
residence as a covered person or who is a member of
a covered person’s family, including spouse, brother,
sister, parent or child.
12. Foreign Services are not covered unless required as
an Emergency.
13. Replacement of crowns, bridges, and fixed or
removable prosthetic appliances inserted prior to plan
coverage unless the patient has been covered under
the policy for 12 continuous months. If loss of a tooth
requires the addition of a clasp, pontic, and/or
abutment(s) within this 12 month period, the plan is
responsible only for the procedures associated with
the addition.
14. Replacement of missing natural teeth lost prior to the
onset of plan coverage until the patient has been
covered under the Policy for 12 continuous months.
15. Replacement of complete dentures, fixed and removable
partial dentures, or crowns, if damage or breakage was
directly related to provider error. This type of
replacement is the responsibility of the Dentist. If
replacement is necessary because of patient
non-compliance, the patient is liable for the cost of
replacement.
16. Fixed or removable prosthodontic restoration
procedures for complete oral rehabilitation or
reconstruction.
17. Attachments to conventional removable prostheses or
fixed bridgework. This includes semi-precision or
precision attachments associated with partial
dentures, crown or bridge abutments, full or partial
overdentures, any internal attachment associated
with an implant prosthesis, and any elective
endodontic procedure related to a tooth or root
involved in the construction of a prosthesis of this
nature.
18. Procedures related to the reconstruction of a patient’s
correct vertical dimension of occlusion (VDO).
19. Placement of dental implants, implant-supported
abutments and prostheses
20. Placement of fixed partial dentures solely for the
purpose of achieving periodontal stability.
21. Treatment of benign neoplasms, cysts, or other
pathology involving benign lesions, except
excisional removal. Treatment of malignant
neoplasms or Congenital Anomalies of hard or soft
tissue, including excision.
22. Setting of facial bony fractures and any treatment
associated with the dislocation of facial skeletal hard
tissue.
23. Services related to the temporomandibular joint
(TMJ), either bilateral or unilateral. Upper and lower
jaw bone surgery (including that related to the
temporomandibular joint). No coverage is provided
for orthognathic surgery, jaw alignment, or treatment
for the temporomandibular joint.
24. Acupuncture; acupressure and other forms of
alternative treatment, whether or not used as
anesthesia.
25. Drugs/medications, obtainable with or without a
prescription, unless they are dispensed and utilized
in the dental office during the patient visit.
26. Charges for failure to keep a scheduled appointment
without giving the dental office 24 hours notice.
27. Occlusal guards used as safety items or to affect
performance primarily in sports-related activities.
28. Dental Services received as a result of war or any act
of war, whether declared or undeclared or caused
during service in the armed forces of any country.
Plans sold in Texas use associated COC form number: DCOC.CER.06
29. Orthodontic coverage does not include the
installation of a space maintainer, any treatment
related to treatment of the temporomandibular joint,
any surgical procedure to correct a malocclusion,
replacement of lost or broken retainers and/or habit
appliances, and any fixed or removable interceptive
orthodontic appliances previously submitted for
payment under the plan.
ROOT CANAL THERAPY Limited to 1 time per tooth per lifetime.
