Dental PPO Schedule of Benefits - UniCare Illinois
Coverage is provided ONLY for the services stated in the following schedules. To use these schedules, check your dentist's fee and then determine how much the plan pays. You can then easily calculate what you will pay for a specific service after your deductible has been met. 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 for both contracting (network) and non-contracting (non-network) dentists.
$1,000 CALENDAR YEAR MAXIMUM BENEFIT
All dental benefits are limited to a maximum $1,000 payment by UniCare for expenses incurred by each enrolled member during a calendar year. This maximum benefit applies to combined calendar year payments for Preventive and Diagnostic Dental Care, Basic Dental Care and Major Dental Care.
PREVENTIVE AND DIAGNOSTIC CARECOVERAGE BEGINS UPON APPROVAL OF YOUR APPLICATION. •
Calendar year deductible of $50 per person, with a maximum of three deductibles ($150) per family, is waived ONLY when preventive and diagnostic care services are rendered by a contracting dentist. •
Two oral examinations and two dental cleanings per member, per year. •
Total benefit for single and bitewing x-rays not to exceed benefit for full mouth - $43. •
|
| PROCEDURE | NETWORK: Plan Pays | NON-NETWORK: Plan Pays |
| Periodic Oral Exam | 100% | $15 |
| Initial Oral Exam (Limited to 2 per member, per year) | 100% | $15 |
| Bitewing X-rays — single film | 100% | $11 |
| 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% | $20 |
| Full mouth X-rays (Limited to 1 set every 3 years) | 100% | $43 |
| Routine cleaning (Limited to 2 per adult per year) | 100% | $33 |
| Routine cleaning (Limited to 2 per child per year) | 100% | $21 |
| Cleaning with fluoride (Limited to 2 per child per year) | 100% | $33 |
| Topical fluoride only (Limited to 2 per child per year) | 100% | $14 |
Notes: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 •
|
||
BASIC DENTAL CARECOVERAGE BEGINS AFTER THE PLAN HAS BEEN IF EFFECT FOR SIX (6) CONTINOUS MONTHS. •
Calendar year deductible of $50 per person, with a maximum of three deductibles ($150) per family, must be satisfied. •
The benefit schedule is the same for both contracting (network) and non-contracting (non-network) dentists, but you may have to pay a greater share of the costs if you choose a non-contracting (non-network) dentist. •
|
| PROCEDURE | NETWORK: Plan Pays | NON-NETWORK: Plan Pays |
| Filling — one surface, primary | $29 | $29 |
| Filling — one surface, permanent | $32 | $32 |
| Filling — two surfaces, primary | $38 | $38 |
| Filling — two surfaces, permanent | $41 | $41 |
| Filling — three surfaces, primary | $45 | $45 |
| Filling — three surfaces, permanent | $47 | $47 |
| Filling — four or more surfaces, primary | $50 | $50 |
| Filling — four or more surfaces, permanent | $55 | $55 |
| Extraction — single tooth (simple) | $36 | $36 |
| Extraction — each additional tooth (simple) | $36 | $36 |
| Surgical Extraction | $65 | $65 |
| Removal of impacted tooth — soft tissue | $90 | $90 |
| Removal of impacted tooth — partial bony | $110 | $110 |
| Removal of impacted tooth — complete bony | $135 | $135 |
MAJOR DENTAL CARECOVERAGE BEGINS AFTER THE PLAN HAS BEEN IF EFFECT FOR TWELVE (12) CONTINOUS MONTHS. •
Calendar year deductible of $50 per person, with a maximum of three deductibles ($150) per family, must be satisfied. •
The benefit schedule is the same for both contracting (network) and non-contracting (non-network) dentists, but you may have to pay a greater share of the costs if you choose a non-contracting (non-network) dentist. •
|
| PROCEDURE | NETWORK: Plan Pays | NON-NETWORK: Plan Pays |
| Scaling/root planing per quadrant | $41 | $41 |
| Gingivectomy — per tooth | $36 | $36 |
| Gingivectomy — per quadrant | $125 | $125 |
| Root canal — 1 canal | $135 | $135 |
| Root canal — 2 canals | $160 | $160 |
| Root canal — 3 canals | $205 | $205 |
| Crown (except stainless steel) | $215 | $215 |
| Stainless steel crown | $55 | $55 |
| Pontic | $215 | $215 |
| Complete denture (upper or lower) | $275 | $275 |
| Partial denture (upper or lower) | $255 | $255 |
| Denture reline (chairside) | $65 | $65 |
| Denture reline (lab) | $85 | $85 |
