|
Dental
Benefit Schedule | Preventive
& Diagnostic Care
| Basic
Dental Care | Major
Dental Care | Dental
Rates
UNICARE Life &
Health Insurance Company has created the Individual
Dental PPO Plan to help keep your teeth healthy and
your smile bright. The UNICARE Individual Dental
PPO Plan offers you the choice of going to any dentist
you choose. Hundreds of dedicated professionals
have contracted with UNICARE Life & Health Insurance
Company to provide a wide range of dental services such
as routine check-ups, cleanings, fillings, crowns and
dental surgery. When you choose a contracting
dentist, you will receive care at negotiated, discounted
rates.
The UNICARE Individual Dental
PPO Plan carries a yearly $50 deductible per person
(maximum of three deductibles per family). The
deductible is waived for Preventive and Diagnostic Care
only at Contracting Plan dentists. All dental
benefits are limited to a maximum payment of $1,000
for expenses incurred by each enrolled member during
a calendar year. Should you choose a noncontracting
dentist, the plan still provides benefits, but your
out-of-pocket expenses may be greater, as the negotiated
fees do not apply to noncontracting dentists.
You will be responsible for any charges in excess of
the stated benefit. Your current dentist already
may be a contracting dentist. Be sure to check
the UNICARE
dental directory before you choose a dentist.
It could save you money.
Counties with strong network
access:
Clark
Washoe
Counties without strong
network access:
A fewer number of contracted
dentists are available in other areas. UNICARE
plan members are entitled to the benefits of the negotiated
amounts if they choose one of those contracted dentists.
Benefits are still available for noncontracting dentists,
as specified by the plan. If you would like your
dentist to become a contracted dentist, please have
him or her contact us.
Dental
Benefit Schedules
Coverage is provided ONLY for
the services stated in the following schedules.
To use these schedules, determine your dentist's fee
then look up how much the plan pays. Then you
can easily calculate what you will pay for a specific
service after your deductible has been met. The
dollar amounts are maximums. The plan pays either the
specified amount, or the actual amount charged by your
dentist, whichever is lower. You are responsible
for any charges in excess of the stated benefit.
| Contracting
Dentist |
|
Noncontracting
Dentist |
If
the billed charges are
$755 |
|
If
the billed charges are
$755 |
And
UNICARE's negotiated rate is
$512 |
|
UNICARE
will pay the amount specified in the benefit schedule
$225* |
UNICARE
will pay the amount specified in the benefit schedule
$225* |
|
Therefore,
you pay the difference between the negotiated amount
and the scheduled benefit
$287 |
|
Therefore,
you pay the difference between the billed amount
and the scheduled benefit
$530 |
* This assumes any deductible
has been met and you have not reached your annual out-of-pocket
maximum.
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Preventive
& Diagnostic Care
- Begins upon
approval of your application
- Two oral examinations
and two dental cleanings per member, per year
|
The Plan
Pays |
| Procedure |
At a Contracting
Dentist |
At a Noncontracting
Dentist |
| Initial
Oral Exam |
100% |
$15 |
| Periodic
Oral Exam, Limited to 2 per member, per year |
100% |
$15 |
| Bitewing
X-rays - single film |
100% |
$9 |
| Bitewing
X-rays - two films |
100% |
$14 |
| Single
(periapical) X-rays - first film |
100% |
$9 |
| Single
X-rays - additional films |
100% |
$9 |
| Bitewing
X-rays - four films |
100% |
$21 |
| Full mouth
X-rays, limited to one set every 3 years |
100% |
$38 |
| Routine
cleaning, limited to 2 per adult per year |
100% |
$40 |
| Routine
cleaning, limited to 2 per child per year |
100% |
$26 |
| Cleaning
with fluoride, limited to 2 per child per year |
100% |
$36 |
| Topical
fluoride only, limited to 2 per child per year |
100% |
$12 |
Notes:
Total benefit for single
and bitewing x-rays not to exceed cost of full mouth
- $40 at noncontracting dentists.
Adult - Any person
or dependent 19 years or older covered by this policy.
Child - Any person or dependent
18 years or younger covered by this policy.
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Basic
Dental Care
Coverage begins after the plan
has been in effect for six continuous months.
| Procedure |
The Plan
Pays |
| Filling
- one surface, primary |
$34 |
| Filling
- one surface, permanent |
$42 |
| Filling
- two surfaces, primary |
$45 |
| Filling
- two surfaces, permanent |
$54 |
| Filling
- three surfaces, primary |
$54 |
| Filling
- three surfaces, permanent |
$65 |
| Filling
- four or more surfaces, primary |
$68 |
| Filling
- four or more surfaces, permanent |
$78 |
| Extraction
- single tooth (simple) |
$39 |
| Extraction
- each additional tooth (simple) |
$39 |
| Surgical
extraction |
$72 |
| Removal
of impacted tooth - soft tissue |
$100 |
| Removal
of impacted tooth - partial bony |
$120 |
| Removal
of impacted tooth - complete bony |
$150 |
|
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|
Major Dental
Care
Coverage begins after the plan
has been in effect for twelve continuous months.
| Procedure |
The Plan
Pays |
| Scaling/root
planing per quadrant |
$43 |
| Gingivectomy
- per tooth |
$30 |
| Gingivectomy
- Per quadrant |
$97 |
| Root canal
- 1 canal |
$127 |
| Root canal
- 2 canals |
$155 |
| Root canal
- 3 canals |
$205 |
| Crown
(except stainless steel) |
$225 |
| Stainless
steel crown |
$55 |
| Pontic |
$225 |
| Complete
denture (upper or lower) |
$300 |
| Partial
denture (upper or lower) |
$275 |
| Denture
reline (chairside) |
$55 |
| Denture
reline (lab) |
$80 |
|
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|
UNICARE
Individual PPO Plan Monthly Rates
| One adult |
$27.00 |
| Two adults |
$54.50 |
| Adult
with 1 child |
$42.00 |
| Adult
with 2 children |
$56.50 |
| Adult
with 3+ children |
$79.00 |
| Family
(1 child) |
$69.00 |
| Family
(2 children) |
$84.00 |
| Family
(3+ children) |
$106.00 |
| One child |
$15.00 |
| Two children |
$29.50 |
| Three+
children |
$51.50 |
|
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|
Dental
Plan Limitations & Exclusions
Apply
Online Now!
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