Sound Dental Plan Benefit Schedule - Illinois

Payment is provided as follows for incurred covered expense. All payments are subject to any maximum amounts, limitations and exclusions as indicated in this plan. If a network dentist provides services, any billed amount above covered expense will be a savings to you. Network dentists have agreed to accept the negotiated fee rate as payment in full. Non-network dentists have no such policy with UniCare, therefore, they will bill you, in addition to any deductible, for any amounts over covered expense.

BENEFITS WILL BE PROVIDED ONLY FOR THE SERVICES SPECIFIED IN THIS BENEFIT SCHEDULE. NO BENEFITS WILL BE PROVIDED FOR ANYTHING ELSE.

$500 CALENDAR YEAR MAXIMUM BENEFIT

All dental benefits are limited to a maximum payment of $500 for expense incurred by you during a year.

PREVENTIVE AND DIAGNOSTIC CARE

COVERAGE BEGINS UPON APPROVAL OF YOUR APPLICATION.

•

Your yearly deductible for covered services is $25. During each year, you are responsible for all expense incurred up to the deductible amount. Only covered expense counts toward the deductible, so amounts over covered expense charged by a non-network dentist wont count. The deductible does not apply to diagnostic and preventive services when performed by a network dentist.

•

PROCEDURE

NETWORK: Plan Pays

NON-NETWORK: Plan Pays

Periodic Oral Exam limited to 2 per year -	100%	$15
Limited Oral Exam¹	100%	$20
Initial Oral Exam¹	100%	$18
Detailed and extensive oral exam new or established patient¹	100%	$41
Re-evaluation exam-limited, problem-focused¹	100%	$23
Comprehensive periodontal exam new or established patient¹	100%	$20
Full mouth X-ray (limited to one set every 3 years)²	100%	$43
Single (periapical) X-ray first film	100%	$9
Single X-ray additional films	100%	$8
Intraoral Occlusal film	100%	$12
Extraoral First film	100%	$11
Extraoral Each additional film	100%	$7
Bitewing X-ray single film	100%	$11
Bitewing X-ray two films	100%	$14
Bitewing X-ray four films	100%	$20
Vertical bitewing X-ray	100%	$14
Posterior-anterior or lateral skull and facial bone survey film²	100%	$35
Panoramic X-ray²	100%	$26
Cephalometric film²	100%	$30
Prophylaxis teeth cleaning adult, limited to 2 per year -	100%	$33
Prophylaxis teeth cleaning child through age 18, limited to 2 per year -	100%	$21
Prophylaxis teeth cleaning child through age 18, with fluoride, limited to 2 per year -	100%	$33
Topical fluoride only child through age 18, limited to 2 per year -	100%	$14
Topical fluoride with Prophylaxis teeth cleaning adult, limited to 2 per year -	100%	$33
Notes: Exams are limited to 2 per year. ¹ Full mouth x-ray or its equivalent are limited to one set every 3 years. ²

FILLINGS

COVERAGE BEGINS UPON APPROVAL OF YOUR APPLICATION.

After the $25 deductible has been satisfied, benefits will be paid for fillings as specified in the following benefit schedule. Please note, you may have a greater share of the costs if services are performed by a non-network dentist.

PROCEDURE

NETWORK: Plan Pays

NON-NETWORK: Plan Pays

Amalgam filling one surface, primary or permanent	80%	$3
Amalgam filling two surfaces, primary or permanent	80%	$4
Amalgam filling three surfaces, primary or permanent	80%	$5
Amalgam filling four or more surfaces, primary or permanent	80%	$5
Resin-based composite filling one surface, anterior	80%	$3
Resin-based composite filling two surfaces, anterior	80%	$41
Resin-based composite filling three surfaces, anterior	80%	$50
Resin-based composite filling four surfaces, incisal	80%	$59
Resin-based composite crown anterior	80%	$65
Resin-based composite filling one surface, posterior³	80%	$32
Resin-based composite filling two surfaces, posterior³	80%	$41
Resin-based composite filling three surfaces, posterior³	80%	$50
Resin-based composite filling four surfaces, posterior³	80%	$59
Notes: If a tooth or teeth can be restored with amalgam (with the exception of composite resin on anterior teeth) any amount exceeding the cost of that material is not covered if another material is used. Anterior teeth exhibiting pathology eligible for composite restorations are central incisors, lateral incisors, cuspids and the facial surface of bicuspids. ³

CONDITIONS OF SERVICE

Services must be provided by a licensed dentist and must be for treatment of dental disease, defect or injury.

•

When the anticipated expense for any course of treatment exceeds $350, the Insured should submit to UniCare a request for pre-treatment benefit estimation as prepared by the attending Dentist on the appropriate form before the treatment commences.

•

EXCLUSIONS AND LIMITATIONS:

This Plan does not provide benefits for:

Unlisted Services: Services not specifically listed in the benefit schedule of this Plan

Any amounts in excess of the maximum amounts of Covered Expenses stated in this Plan

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.

Any amounts which exceed the Covered Expense as determined by UniCare

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

Services for someone other than the Insured: A ny person other than the Insured, including but not limited to your dependents, such as spouse, newborn, legal ward, natural and/or adopted child

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

Conditions caused by: (a) an act of war; (b) the inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) an Insured participating in the military service of any country; (d) an Insured participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an Insureds commission of, or attempt to commit a felony or as a direct result of the Insured being engaged in an illegal occupation; (f) an Insured being under the influence of illegal narcotics, alcohol, or non-prescribed controlled substances unless administered under the advice of a Physician. Any services provided by a local, state, county or federal government agency, except when payment under this Plan is expressly required by federal or state law

Services From Relatives: Professional services received from a person who lives in your home or who is related to you 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 Plan

Charges for treatment by other than a licensed Dentist, except charges for dental prophylaxis performed by a licensed dental hygienist, under the supervision and direction of a Dentist

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:

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

•

Any treatment, including crowns, caps and/or bridges to change the way the upper and lower teeth meet (Occlusion); or

•

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:

Changing the vertical dimension;

•

Replacing or stabilizing lost tooth structure by attrition, abrasion, or erosion;

•

Realignment of teeth;

•

Gnathological recording;

•

Occlusal equilibration;

•

Periodontal splinting

•

Oral examinations exceeding two visits per Year

Prophylaxis treatments, exceeding two treatments per Year

Fluoride applications if you are 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 in a three year period

Periapical and bitewing x-rays submitted singly will be combined and paid up to the amount of a full mouth series and are subject to the full-mouth x-ray limitation. No more than 2 bite wing x-ray series for standard in a Year will be covered. No more than 8 films for vertical bite wings in a 36 month period will be covered.

Correction of congenital or development malformation including but not limited to supernumerary and/or over retained deciduous teeth, 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 an Insured. 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.

Fillings exceeding one per year per surface per tooth if you are under the age of 19 and one every 3 (three) years per surface per tooth if you are over the age of 19

If a tooth or teeth can be restored with amalgam (with the exception of composite resin on anterior teeth) any amount exceeding the cost of that material is not covered if another material is used. Anterior teeth exhibiting pathology eligible for composite restorations are central incisors, lateral incisors, cuspids and the facial surface of bicuspids.

Replacement of existing fillings for any purpose other than restoring active decay

Transfer of care: If an Insured 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 including nitrous oxide

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 this Plan

Services or supplies that are not medically necessary

Services for oral surgery, for example, tooth extractions

Services for endodontics, for example, root canals. Endodontics means the branch of dentistry dealing with diseases of the tooth pulp.

Services for periodontics, for example, scaling and root planning. Periodontics is the dental specialty of treating periodontal disease.

Services for prosthodontics, for example, crowns. Prosthodontics is the branch of dentistry dealing with the construction of artificial appliances for the mouth, especially for the purpose of replacing missing teeth with bridges and dentures.

Space maintainers: Space maintainers are appliances that are designed to prevent tooth movement.

Sealants

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