United Healthcare PPO Dental • OMG! PPO
Amazing PPO
Plan Maximums
In Network*
Out Of Network*
In Network*
Out Of Network*
Calendar Year Deductible (single/family)
$50/$150
$50/$150
Calendar Year Maximum (per member)**
Year 1: $1,000 Dental Maxim Rollover Available
Year 1: $1,500 Dental Maxim Rollover Available
Preventative What You Pay What You Pay
Oral Examinations, Bitewing or Full Mouth X-rays, Cleanings
0% after deductible
10% after deductible
0%
0%
Basic
Fillings, Endodontics (root canal therapy), Periodontics, Sealants, Simple Oral Surgery and Simple Extractions
10% after deductible
20% after deductible 20% after deductible 30% after deductible
Major
Crowns, Inlays, Onlaysand Cast Restorations, Bridges And Dentures
40% after Deductible
50% after deductible
50% after deductible
50% after deductible
Orthodontic Procedures
Orthodontia 50% after deductible Lifetime Maximum: $1,000
Not Covered
* Reimbursement is based on PPO contracted fees for PPO dentists, and maximum allowable charges for non-United Healthcare dentists.
Sign up as a member online to print ID cards, locate providers, and view benefits and claims. www.myuhc.com
If you elect PPO Plan, members will not receive a card but can print one off www.myuhc.com
* Please refer to carrier booklet. Plan limits may apply. 20
Made with FlippingBook Ebook Creator