Unified Fire Authority Benefit Guide (1)_ (003) | Page 20

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)
Covered 100 %
20 % of in-network rate
Restorative 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
20 % of in-network rate
40 % of in-network rate
Oral Surgery 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
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