Unified Fire Authority Benefit Guide 2022-2023 | Page 20

Unified Fire Authority

Dental Benefits
Administered by PEHP
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
Preferred Dental Care In-Network Out-of-Network
No Deductible Annual Benefit Maximum $ 1,500 $ 1,500 Diagnostic Periodic Oral Examinations Covered 100 % 20 % of in-network rate X-rays 20 % of in-network rate 40 % of in-network rate
Preventive Cleanings and Fluoride Solutions 20 % of in-network rate 40 % of in-network rate
Sealants ( permanent molars only through age 17 )
Restorative
20 % of in-network rate 40 % 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
20 % of in-network rate
40 % 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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