DENTAL INSURANCE
Kisinger Campo & Associates offers dental coverage through UHC. The Dental PPO Plan allows you to use in-network or out- of-network benefits. To find in-network providers go to www.FloridaBlue.com and select “Find a Doctor and More”, search based on your specifics within the “PPO” network. If out-of-network dentists are used, you will be responsible for pay the difference between Guardian’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plan.
Base PPO Plan
Premium PPO Plan
In-Network
Deductible (applies to Basic & Major services)
$
$
Individual
$
$
Family
Annual Maximum (per covered member)
$
$
Preventive Services
Covered in full
Covered in full
Exams, Cleanings, & Fluoride
Basic Services
Fillings, Simple Extractions, Perio & Endo (other than those listed below)
__% after deductible
__% after deductible
Major Services Crowns, Bridges, Surgical
__% after deductible
__% after deductible
Extractions, Root Canal, Dentures, Osseus Surgery & Endo Molars
Orthodontia (child only)
Member% $ lifetime maximum per person
None
Out-of Network 1
__ th % Usual & Customary Charges
Basis of Payment
Deductible (applies to Basic & Major services)
$ / $
$ / $
Annual Maximum (per covered member)
$
$
Services Preventive
Covered in full __% after deductible __% after deductible
Covered in full __% after deductible __% after deductible
Basic Major
Orthodontia (child only)
Member% $ lifetime maximum per person
None
Cost for coverage per paycheck
Employee only
$
$
Employee + Spouse
$
$
Employee + Child(ren)
$
$
Employee + Family
$
$
1 Subject to balance billing. Please refer to your plan document for specific details.
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