UniCare Dental Plan - for Illinois Residents
- Popular UniCare PPO Dental Coverage
- Submit UniCare Dental Plan Application
Benefit Limitations and Exclusions
The UniCare Individual and Family Dental PPO plan does not provide benefits for:
- Unlisted services: Services not specifically listed in the benefit schedule of this policy
- Excess amounts: Any amounts in excess of the maximum amount stated in the "calendar year maximum benefit" section or listed in the benefit schedule
- Experimental or investigative procedures: Services or supplies that are mainly limited to laboratory and/or animal research, but which are not generally accepted as proven and effective procedures and are considered experimental within the organized medical community
- Expenses before coverage begins: Services received before your effective date
- End of coverage: Services received after your coverage ends
- Services for which you are not legally obligated to pay: Services for which no charge would be made to you in the absence of insurance coverage
- Workers' compensation: Any condition for which benefits could be recovered, either by adjudication, settlement or otherwise, under any workers compensation, employers liability law or occupational disease law, even if you do not claim those benefits
- War: Disease contracted or injuries sustained as result of war declared or undeclared, conditions caused by the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy
- Government services: Any services provided by a local, state, county or federal government agency including any foreign government
- Services from relatives: Professional services received from a person who lives in the insured person's home or who is related to the insured person by blood, marriage or adoption
- Cosmetic dentistry: Any services performed for cosmetic purposes are not covered under this plan, unless they are for the correction of functional disorders or as a result of an accidental injury occurring while you were covered under this policy
- Charges for treatment by other than a licensed dentist or physician, except charges for dental prophylaxis performed by a licensed dental hygienist, under the supervision and direction of a dentist
- Replacement of an existing prosthesis which has been lost or stolen; or which in the opinion of the dentist is or can be made satisfactory
- Replacement of a fixed or removable prosthesis if such replacement occurs within five years of the original placement, unless the denture is a stay plate used during the healing period for recently extracted anterior teeth
- Orthodontic services, braces, appliances and all related services
- Diagnosis or treatment of the joint of the jaw and/or occlusion (the way upper and lower teeth meet) services, supplies or appliances provided in connection with: (a) any treatment to alter, correct, fix, improve, remove, replace, reposition, restore or otherwise treat the joint of the jaw (temporomandibular joint) or associated musculature, nerves and other tissues for any reason or by any means; or (b) any treatment, including crowns, caps and/or bridges to change the way the upper and lower teeth meet (occlusion); or (c) treatment to change vertical dimension (the space between the upper and lower jaw) for any reason or by any means including the restoration of vertical dimension because teeth have worn down
- Procedures requiring appliances or restorations (other than those for replacement of structure loss from caries) that are necessary to alter, restore or maintain occlusions. These include but are not limited to: (a) changing the vertical dimension; (b) replacing or stabilizing lost tooth structure by attrition, abrasion, or erosion; (c) realignment of teeth; (d) gnathological recording; (e) occlusal equilibration; (f) periodontal splinting
- Oral examinations exceeding two visits per insured per year
- Prophylaxis treatments, exceeding two treatments per insured per year
- Fluoride applications for patients over eighteen (18) years of age. Fluoride applications exceeding two visits per year
- More than one set of full-mouth x-rays or its equivalent per insured in a three year period
- Correction of congenital or developmental formation for a uninsured person including but not limited to cleft palate, maxillary or mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth), and anodontia (congenitally missing teeth). This exclusion does not apply to otherwise eligible charges incurred for the treatment of a congenital defect or defects in a dependent child who is eligible to be covered under this Policy and who has been so covered continuously from the date of her or his birth until the date the expense is incurred
- Adjustment, repairs or relines to prosthesis except following 6 months from initial placement and if the prosthesis was paid for under this plan
- Fixed bridges, removable cast partials and/or cast crown with or without veneers for patients under sixteen years of age
- Replacement of crowns and cast restorations including porcelain crowns, if such replacement occurs within five years of the original placement
- Transfer of care: If a policyholder transfers from the care of one dentist to that of another dentist during the course of treatment, or if more than one dentist renders services for one dental procedure, UniCare shall be liable only for the amount it would have been liable for had one dentist rendered the services
- Prescribed drugs, pre-medication or analgesia
- Oral hygiene instruction
- Malignancies and neoplasms: Services for treatment of malignancies and neoplasms are not covered services
- All hospital costs and any additional fees charged by the dentist for hospital treatment
- Implants: (materials implanted into or on bone or soft tissue), or the removal of implants are not benefits under the policy. However, if implants are provided in association with a covered prosthetic appliance, UniCare will allow the benefit for a standard complete or partial denture or a bridge toward the cost of implants and the prosthetic appliances
- Services or supplies that are not medically necessary
- Replacement of teeth missing prior to the effective date of coverage
- Services for periodontics, fixed or removable prosthodontics within the first 12 months of the insured person's effective date
This is a brief summary of the plan. Please refer to the Certificate of Coverage for more complete details, including benefits, limitations and exclusions.
