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