DENTAL INSURANCE
Jagged Peak offers dental coverage through UHC. The PPO Dental Plan allows you to use in-network or out-of-network benefits. If out-of-network dentists are used, you will be responsible for paying the difference between UHC’s allowed amount and what the dentist may charge, also known as “balance billing”. If you enroll in the DHMO plan, you will be required to receive treatment from your Primary Dentist and/ or authorized care from a network specialist. The chart below provides a brief overview of the two plans.
DHMO Pre Paid Plan
PPO Plan
Calendar Year Maximum
N/A
$1,500 (per person)
In-Network only (primary dentist required)
In or Out of Network Office Visit Copay
In-Network
Out of Network*
$5 per visit
N/A
N/A
Deductible
$50 (x3 for family)
$100 (x3 for family)
Yes
Yes
Waived for Preventive
Coinsurance:
Copay Schedule Applies
Preventive Services
100%
100%*
Basic Services Major Services
Covered 100% after deductible Covered 80% after deductible* Covered 60% after deductible Covered 50% after deductible*
* Out of Network benefits are subject to reasonable and customary charges.
VISION INSURANCE
Jagged Peak offers vision coverage through UHC. The UHC vision network consists of optometrists, ophthalmologists, opticians and optical retailers. You have the option of visiting any provider, however by choosing a participating provider, you will receive the highest level of benefits.
Participating Provider
Non-Participating Provider
Exam
$10 Copay
$40 Allowance
Single: $40Allowance Bifocal: $60 Allowance Trifocal: $80 Allowance
Lenses
$10 Copay
Contact Lenses
$150 Allowance $150 Allowance
$150 Allowance $45 Allowance
Frames
Frequency Exam
Once every 12 months Once every 12 months Once every 24 months
Lenses or Contact Lenses
Frames
See bi-weekly costs on page 7
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