Unified Fire Authority
Dental Benefits
Administered by SelectHealth Network : Classic
Good oral care enhances overall physical health , appearance and mental well-being . Problems with the teeth and gums are common and easily treated health problems . Keep your teeth healthy and your smile bright with the Unified Fire Authority dental benefit plan .
Annual Deductible
In-Network No Deductible
Out-of-Network
Annual Benefit Maximum $ 1,500 $ 1,500 Diagnostic Periodic Oral Examinations Covered 100 % 20 % of in-network rate X-rays Covered 100 % 20 % of in-network rate Preventive Cleanings and Fluoride Solutions Covered 100 % 20 % of in-network rate
Sealants ( permanent molars only 15 and under )
Restorative
Covered 100 %
20 % of in-network rate
Amalgam Restoration 20 % of in-network rate 40 % of in-network rate Composite Restoration 20 % of in-network rate 40 % of in-network rate Endodontics Pulpotomy 20 % of in-network rate 20 % of in-network rate Root Canal 20 % of in-network rate 20 % of in-network rate Periodontics
Oral Surgery
20 % of in-network rate 40 % of in-network rate
Extractions 20 % of in-network rate 40 % of in-network rate Anesthesia ( General anesthesia in conjunction with oral surgery or impacted teeth only ) General Anesthesia 50 % of in-network rate 70 % of in-network rate Prosthodontic Benefits ( Preauthorization may be required ) Crowns 50 % of in-network rate 70 % of in-network rate Bridges 50 % of in-network rate 70 % of in-network rate Dentures ( partial ) 50 % of in-network rate 70 % of in-network rate Dentures ( full ) 50 % of in-network rate 70 % of in-network rate Implants All Related Services 50 % of in-network rate 70 % of in-network rate Orthodontic Benefits Maximum Lifetime Benefit per Member $ 1,500 Eligible Appliances and Procedures
50 % of eligible fees to plan maximum
20