UnitedHealthcare Dental Options PPO Dental Plan Code
Covered Dental Services (Custom-With Orthodontics) P3288/73288
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
Individual Annual Deductible $50 $50 $0 $0
Family Annual Deductible $150 $150 $0 $0
Maximum (combined for both $1,000 per person per $1,000 per person per $1,000 per person per $1,000 per person per
In-Network and Out-of-Network services) calendar year calendar year lifetime lifetime
Annual deductible applies to preventive and diagnostic services No
Annual deductible applies to orthodontic services No
For new enrollees, a 12-month waiting period applies to major and orthodontic services No
COVERED SERVICES IN-NETWORK OUT-OF-NETWORK BENEFIT GUIDELINES
PLAN PAYS* PLAN PAYS**
PREVENTIVE AND DIAGNOSTIC DENTAL SERVICES
Periodic Oral Examinations 80% 80% Covered as a separate benefit only if no other service was done
during the visit other than X-rays. Limited to once every 6 months.
Bite-Wing X-rays 80% 80% Limited to 1 series of films per calendar year.
Complete Series or Panorex X-rays 80% 80% Limited to one time per 36 months.
Dental Prophylaxis (Cleanings) 80% 80% Limited to once every 6 months.
Fluoride Treatments 80% 80% Limited to covered persons under the age of 16 years, and limited to
once per six month period. Treatment should be done in conjunction
with dental prophylaxis.
Sealants 80% 80% Limited to covered persons under the age of 16 years and once per first
or second permanent molar every 3 years.
BASIC DENTAL SERVICES
Amalgam Restorations (Fillings) 80% 80% Multiple restorations on one surface will be treated as a single filling.
Composite Resin Restorations (Fillings) 80% 80% Multiple restorations on one surface will be treated as a single filling.
Space Maintainers 80% 80% Limited to covered persons under the age of 16 years, once per
lifetime. Benefit includes all adjustments within 6 months of installation.
Root Canal Treatment 80% 80%
Root Planing 80% 80% Limited to 1 time per quadrant per 24 months.
Periodontal Surgery 80% 80% Once in any 36 month period.
Simple Extraction 80% 80%
Surgical Extraction including Impacted Wisdom Teeth 80% 80%
General Anesthesia 80% 80% When clinically necessary.
Palliative Treatment (Relief of Pain) 80% 80% Covered as a separate benefit only if no other service, other than
exam and X-rays were performed during the visit.
MAJOR DENTAL SERVICES
Crowns 50% 50% Limited to one time per tooth every 5 calendar years. Covered only
when a filling cannot restore the tooth.
Fixed Bridges 50% 50% Limited to one time per tooth every 5 calendar years. Covered only
when a filling cannot restore the tooth (alternate benefits for a partial
denture may be applied).
Full Dentures 50% 50% Once every 60 months. No additional allowances for overdentures or
Inlays and Onlays 50% 50% Limited to one time per 5 calendar years. Covered only when silver
fillings cannot restore the tooth.
Partial Dentures 50% 50% Once every 60 months. No additional allowances for precision or
Recement Bridges, Crowns, Inlays 50% 50% Once every 6 months per restoration.
Relining Dentures 50% 50% Limited to relining done more than 6 months after the initial insertion.
Limited to 1 time per calendar year.
Repairs to Full Dentures, Partial Dentures, Bridges 50% 50% Limited to repairs or adjustments done after 12 months following the
Diagnose or correct misalignment of the 50% 50% Preauthorization required.
teeth or bite including Phase I and Phase II
*The in-network percentage of benefits is based on the discounted fee negotiated with the provider. **The out-of-network percentage of benefits is paid at 85th percentile of the usual and customary rates prevailing in the geographic
area in which the expenses are incurred. The material contained in the above table is for informational purposes only and is not an offer of coverage. Please note that the above table 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 of 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 Exclusions and Limitations
General Limitations General Exclusions
ORAL EXAMINATIONS Covered as a separate The following are not covered: 19. Full mouth debridement (ADA Code 4355) in excess of
benefit only if no other service was done during
1. Dental Services that are not necessary. once every 36 months.
the visit other than X-rays. Limited to 2 per 12
consecutive months. 2. Hospitalization or other facility charges. 20. Replacement of complete or partial dentures, fixed
bridgework, or crowns previously submitted for payment
COMPLETE SERIES OR PANOREX 3. Any dental procedure performed solely for under the Plan within sixty (60) months of initial or
RADIOGRAPHS Limited to one time per 36 cosmetic/aesthetic reasons. (Cosmetic procedures are supplemental placement. This includes retainers, habit
months. those procedures that improve physical appearance.) appliances, and any fixed or removable interceptive
BITEWING RADIOGRAPHS Limited to 1 series orthodontic appliances.
4. Reconstructive Surgery regardless of whether or not the
of films per calendar year. surgery which is incidental to a dental disease, injury, or 21. Replacement of complete or partial dentures, crowns, or
EXTRAORAL RADIOGRAPHS Limited to 2 Congenital Anomaly when the primary purpose is to fixed bridgework if damage or breakage was directly
films per calendar year. improve physiological functioning of the involved part of related to provider error. This type of replacement is the
the body. responsibility of the Dentist. If replacement is necessary
DENTAL PROPHYLAXIS Limited to 2 per 12 because of patient non-compliance, the patient is liable
consecutive months. 5. Any dental procedure not directly associated with dental
for the cost of replacement.
DIAGNOSTIC CASTS Limited to one time per 22. Denture relines for complete or partial conventional
24 consecutive months. 6. Any procedure not performed in a dental setting.
dentures for the 6 month period following the insertion of
FLUORIDE TREATMENTS Limited to Covered 7. Procedures that are considered to be Experimental, a prosthesis. Tissue conditioning and soft and hard
Persons under the age of 16 years, and limited Investigational or Unproven. This includes relines for immediate full and partial dentures for the first
to 2 per 12 consecutive months. Treatment pharmacological regimens not accepted by the American six 6 months. After the six month waiting period, relines
should be done in conjunction with dental Dental Association (ADA) Council on Dental are covered not more than once every 12 months.
prophylaxis. Therapeutics. The fact that an Experimental,
23. Fixed or removable prosthodontic restoration procedures
Investigational or Unproven Service, treatment, device or
SEALANTS Limited to Covered Persons under for complete oral rehabilitation or reconstruction.
pharmacological regimen is the only available treatment
the age of 16 years and once per first or for a particular condition will not result in Coverage if the 24. Attachments to conventional removable prostheses or
second permanent molar every 36 consecutive procedure is considered to be Experimental, fixed bridgework. This includes semi-precision or
months. Investigational or Unproven in the treatment of that precision attachments associated with partial dentures,
particular condition. crown or bridge abutments, full or partial overdentures,
SPACE MAINTAINERS Limited to Covered
Persons under the age of 16 years, once per any internal attachment associated with an implant
8. Services for injuries or conditions covered by Worker’s
lifetime. Benefit includes all adjustments within prosthesis, and any elective endodontic procedure
Compensation or employer liability laws, and services
6 months of installation. related to a tooth or root involved in the construction of a
that are provided without cost to the Covered Person by
prosthesis of this nature.
any municipality, county, or other political subdivision.
AMALGAM RESTORATIONS Multiple
This exclusion does not apply to any services covered 25. Procedures related to the reconstruction of a patient’s
restorations on one surface will be treated as a
by Medicaid or Medicare. correct vertical dimension of occlusion (VDO).
9. Expenses for dental procedures begun prior to the 26. Placement of dental implants, implant-supported
PIN RETENTION Limited to 2 pins per tooth;
Covered Person’s eligibility with the Plan. abutments and prostheses. This includes
not covered in addition to Cast Restoration.
pharmacological regimens and restorative materials not
10. Dental Services otherwise Covered under the Policy, but
GOLD INLAYS AND ONLAYS Limited to one accepted by the American Dental Association (ADA)
rendered after the date individual Coverage under the
time per 60 consecutive months. Covered only Council on Dental Therapeutics.
Policy terminates, including Dental Services for dental
when silver fillings cannot restore the tooth.
conditions arising prior to the date individual Coverage 27. Placement of fixed bridgework solely for the purpose of
CROWNS Limited to one time per tooth every under the Policy terminates. achieving periodontal stability.
60 consecutive months. Covered only when a
11. Services rendered by a provider with the same legal 28. Billing for incision and drainage (ADA Code 7510) if the
filling cannot restore the tooth.
residence as a Covered Person or who is a member of a involved abscessed tooth is removed on the same date
POST AND CORES Covered only for teeth that Covered Person’s family, including spouse, brother, of service.
have had root canal therapy. sister, parent or child.
29. Treatment of malignant or benign neoplasms, cysts, or
SEDATIVE FILLINGS Covered as a separate 12. Dental Services provided in a foreign country, unless other pathology, except excisional removal. Treatment of
benefit only if no other service, other than X- required as an Emergency. congenital malformations of hard or soft tissue, including
rays and exam, were done during the visit. excision.
13. Replacement of crowns, bridges, and fixed or removable
SCALING AND ROOT PLANING Limited to 1 prosthetic appliances inserted prior to plan coverage 30. Setting of facial bony fractures and any treatment
time per quadrant per 24 consecutive months. unless the patient has been eligible under the plan for 12 associated with the dislocation of facial skeletal hard
continuous months. If loss of a tooth requires the tissue.
PERIODONTAL MAINTENANCE Limited to 2 addition of a clasp, pontic, and/or abutment(s) within this
times per 12 consecutive months following 12 month period, the plan is responsible only for the 31. Services related to the temporomandibular joint (TMJ),
active and adjunctive periodontal therapy within procedures associated with the addition. either bilateral or unilateral. Upper and lower jaw bone
the prior 24 months, exclusive of gross surgery (including that related to the temporomandibular
debridement. 14. Replacement of missing natural teeth lost prior to the joint). No Coverage is provided for orthognathic surgery,
onset of plan coverage until the patient has been eligible jaw alignment, or treatment for the temporomandibular
FULL DENTURES No additional allowances for for 12 continuous months. joint.
over-dentures or customized dentures.
15. Full mouth radiograph series in excess of once every 36 32. Acupuncture; acupressure and other forms of alternative
PARTIAL DENTURES No additional months. Panoramic radiographs in excess of once every treatment.
allowances for precision or semi precision 36 months, except when taken for diagnosis of third
attachments. molars, cysts, or neoplasms. 33. General Anesthesia, except if clinically necessary.
RELINING DENTURES Limited to relining 16. Hard tissue periodontal surgery and soft tissue 34. Drugs/medications, obtainable with or without a
done more than 6 months after the initial periodontal surgery per surgical area in excess of once prescription, unless they are dispensed and utilized in
insertions. Limited to 1 time per 12 in any 36 month period. This includes gingivectomy, the dental office during the patient visit.
consecutive motnhs. gingivoplasty, gingival curettage (with or without a flap 35. Occlusal guards except if prescribed to control of
REPAIRS TO FULL DENTURES, PARTIAL procedure), osseous surgery, pedicle grafts, and free soft habitual grinding, including those specifically used as
DENTURES, BRIDGES Limited to repairs or tissue grafts. safety items or to affect performance primarily in sports-
adjustments done more than 12 months after 17. Osseous grafts, with or without resorbable or non- related activities.
the initial insertion. resorbable GTR membrane placement in excess of once 36. Charges for failure to keep a scheduled appointment
PALLIATIVE TREATMENT Covered as a every 36 months per quadrant or surgical site. without giving the dental office 24 hours notice.
separate benefit only if no other service, other 18. Root planing and scaling (ADA Code 4341) in excess of
than exam and radiographs, were done during once every 24 months per quadrant.
the visit. 10/12/05 DPPOW288 100-8008
OCCLUSAL GUARDS Limited to one guard
every 36 consecutive months.