UniCare Dental PPO Benefit Summary for Indianas Residents

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UniCare Dental PPO Schedule of Benefits -- Indiana*

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 CARE COVERAGE 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 — $39.
Procedure	Network - The Plan Pays	Non-Network - The Plan Pays
Initial Oral Exam	100%	$13
Periodic Oral Exam Limited to 2 per member, per year	100%	$13
Bitewing X-rays - single film	100%	$10
Bitewing X-rays - two films	100%	$13
Single (periapical) X-rays - first film	100%	$7
Single X-rays - additional films	100%	$7
Bitewing X-rays - four films	100%	$19
Full mouth X-rays Limited to one set every 3 years	100%	$39
Routine cleaning Limited to 2 per adult per year	100%	$30
Routine cleaning Limited to 2 per child per year	100%	$21
Cleaning with fluoride Limited to 2 per child per year	100%	$30
Topical fluoride only Limited to 2 per child per year	100%	$12
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 CARE COVERAGE BEGINS AFTER THE PLAN HAS BEEN IN EFFECT FOR SIX (6) CONTINUOUS 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 - The Plan Pays	Non-Network - The Plan Pays
Filling - one surface, primary	$30	$30
Filling - one surface, permanent	$33	$33
Filling - two surfaces, primary	$39	$39
Filling - two surfaces, permanent	$43	$43
Filling - three surfaces, primary	$46	$46
Filling - three surfaces, permanent	$50	$50
Filling - four or more surfaces, primary	$54	$54
Filling - four or more surfaces, permanent	$58	$58
Extraction - single tooth (simple)	$38	$38
Extraction - each additional tooth (simple)	$38	$38
Surgical extraction	$72	$72
Removal of impacted tooth - soft tissue	$95	$95
Removal of impacted tooth - partial bony	$120	$120
Removal of impacted tooth - complete bony	$144	$144

MAJOR DENTAL CARE COVERAGE BEGINS AFTER THE PLAN HAS BEEN IN EFFECT FOR TWELVE (12) CONTINUOUS 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-contracting) dentist.
Procedure	Network - The Plan Pays	Non-Network - The Plan Pays
Scaling/root planing per quadrant	$43	$43
Gingivectomy - per tooth	$30	$30
Gingivectomy - Per quadrant	$107	$107
Root canal - 1 canal	$125	$125
Root canal - 2 canals	$150	$150
Root canal - 3 canals	$195	$195
Crown (except stainless steel)	$225	$225
Stainless steel crown	$50	$50
Pontic	$225	$225
Complete denture (upper or lower)	$300	$300
Partial denture (upper or lower)	$285	$285
Denture reline (chairside)	$65	$65
Denture reline (lab)	$88	$88

*	This is a brief summary of the plan. Please refer to the Certificate of Coverage for more complete details including benefits, limitations and exclusions.

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