| Apply |
|
|
| Estimated
Monthly Premium |
|
|
| Deductible |
$50 |
$50 |
| Optional
Benefits |
|
|
Maximum
Family Deductible
per Calendar Year |
Three |
Three |
| Waiting
Period |
No waiting period for preventive
6 months waiting period for Basic Services
12 months waiting period for Major Services
|
No waiting period for preventive
6 months waiting period for Basic Services
12 months waiting period for Major Services
|
| Preventive
Care |
100%, no deductible |
100%, no deductible |
| Annual
Maximum Benefit |
$1,000 per covered person |
$1,000 per covered person |
| Basic
Services |
Covered
after 6 months at 80% and include: Simple fillings,
Extractions, X-rays and Treatment to ease dental
pain. |
Covered
after 6 months at 80% and include: Simple fillings,
Extractions, X-rays and Treatment to ease dental
pain. |
| Major
Services |
Covered
after 12 months at 50% and include but not limited
to: Root Canals, Crowns, Inlays, Onlays, Veeners,
Bridges, Dentures and oral surgery for impactions. |
Covered
after 12 months at 50% and include but not limited
to: Root Canals, Crowns, Inlays, Onlays, Veeners,
Bridges, Dentures and oral surgery for impactions. |
| Orthodontics |
Not
covered |
Not
covered |
| X-Rays |
Routine
X-rays covered once per calendar year with no
waiting period. Non-routine X-rays are subject
to a six month waiting period. |
Routine
X-rays covered once per calendar year with no
waiting period. Non-routine X-rays are subject
to a six month waiting period. |
| Out-of-Network
Dentist |
Benefits
paid based on the reasonable and customary charge |
Benefits
paid based on the network negotiated rate, which
is usually less than the reasonable and customary
charge |
|
|
|
|
|
| Not intended for use
in New Mexico.
UnitedHealthOne is a brand name used for products
underwritten, administered, and/or provided by:
Golden Rule Insurance Company (Indiana domiciled,
CA certificate of authority number 4407),
American Medical Security Life Insurance Company (Wisconsin
domiciled, CA certificate of authority number 08079),
PacifiCare Life and Health Insurance Company (Indiana
domiciled, CA certificate of authority number 5813),
PacifiCare Life Assurance Company (Colorado domiciled,
CA certificate of authority number 5814),
Oxford Health Insurance, Inc.
Oxford Health Plans (NJ), Inc.,
UnitedHealthcare Insurance Company,
UnitedHealthcare Services, Inc.,
Dental Benefit Providers, Inc., or
Spectera, Inc.
Health Insurance plans are medically underwritten
and availability varies by state. Coverage may be
provided by multiple policies/certificates.
Additional products provided by:
Careington International Corporation,
EyeMed Vision Care, or
International Medical Group, Inc. (Indiana domiciled)
|
