UnitedHealthcare - Dental Rate Card
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- Brianna Garrett
- 5 years ago
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1 For Groups 2-9 Eligible Lives with Effective Dates Preferred Portfolio 1/1/219-3/31/219 1 Annual Max $ PIN41 No 1% 5% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 A7848 No 1% 8% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 P797 No 1% 8% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P3457 No 1%/9% 8%/7% 5% 5% 1, 5/15 N/A 85th/Options PPO 3 A88 No 1% 8% 5% 5% 1, 5/15 N/A 7th/Options PPO 3 P318 No 1% 8% 5% 5% 1,5 5/15 N/A 85th/Options PPO 3 Zone 1 Zip Codes: 14, 141, 142, 143, 144, 145, 14, 147 Zone 2 Zip Codes: 13, 131, 132, 133, 134, 135, 13, 137, 138, 139, 148, 149 (months) Zip Codes: 12, 121, 122, 123, Zone 4 Zip Codes: 125, 12 Zone 1 Zone 4 EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family PIN41 $22.21 $44.41 $44.25 $9.39 PIN41 $32.28 $4.5 $4.33 $1.88 A7848 $23.59 $47.19 $47.9 $74.5 A7848 $35.33 $7.7 $71.42 $ P797 $2.82 $53.3 $54.29 $84.77 P797 $4.99 $81.99 $82.99 $ P3457 $33.35 $.7 $.78 $14.58 P3457 $47.12 $94.25 $94.5 $ A88 $35.3 $7. $7.81 $11.1 A88 $49.8 $99. $1. $ P318 $4.7 $81.34 $82.15 $ P318 $58.82 $117.4 $ $185.3 Zone 2 EE Only EE & SP EE & Ch(ren) Family PIN41 $23.9 $47.39 $47.22 $74.5 A7848 $24.27 $48.54 $49. $7.3 P797 $27.95 $55.91 $5.59 $88.37 P3457 $4.3 $8. $79.8 $ A88 $42.15 $84.3 $85.19 $133.8 P318 $5.4 $1.8 $11.8 $ EE Only EE & SP EE & Ch(ren) Family PIN41 $27.91 $55.83 $55.3 $87.24 A7848 $29.59 $59.19 $59.82 $93.44 P797 $34.3 $8. $8.89 $17.57 P3457 $44.83 $89. $89.57 $14.3 A88 $47.44 $94.88 $95.89 $ P318 $55.98 $ $113.7 $17. CMM = Consume MaxMultiplier Specific Procedures within Endodontic, ontic, and benefits may pay at varying coinsurance levels. For detailed benefit information, please contact your sales representative to obtain a benefits summary for your plan(s). ''A'' s promote affordability through class shifting of higher procedures at traditional levels. As a result, coinsurance levels may differ between various endo, perio, and oral surgery procedures. For more details, speak to your representative and to request a detailed benefit summary. PPO s are not approved for sale in the following New York counties: Allegany, Cattaraugus, Chenango, Clinton, Delaware, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Lewis, Livingston, Madison, Ontario, Orleans, Otsego, Saint Lawrence, Schoharie, Schuyler, Seneca, Tioga, Washington, Wayne, and Yates. 1 of 8
2 For Groups 2-9 Eligible Lives with Effective Dates Preferred Portfolio 1/1/219-3/31/219 1 Annual Max $ P1258 No Voluntary 1%/8% 8%/% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 P122 No Voluntary 1% 8% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 P1259 No Voluntary 1%/8% 8%/% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P123 No Voluntary 1% 8% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 A7838 No Voluntary 1% 8% 5% 5% 1, 5/15 N/A 7th/Options PPO 3 12 P548 Yes Voluntary 1% 8% 5% 5% 1, 5/15 N/A 85th/Options PPO 3 Zone 1 Zip Codes: 14, 141, 142, 143, 144, 145, 14, 147 Zone 2 Zip Codes: 13, 131, 132, 133, 134, 135, 13, 137, 138, 139, 148, 149 (months) Zip Codes: 12, 121, 122, 123, Zone 4 Zip Codes: 125, 12 Zone 1 Zone 4 EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family P1258 $23.43 $4.8 $4.95 $73.51 P1258 $35.1 $7.33 $7.57 $11.4 P122 $24. $49.32 $49.81 $77.83 P122 $3.93 $73.8 $74. $11.5 CMM = Consume MaxMultiplier P1259 $2.11 $52.23 $52.32 $81.93 P1259 $4. $8. $8.28 $125.5 Specific Procedures within Endodontic, ontic, and P123 $27.48 $54.97 $55.51 $8.73 P123 $42.1 $84.2 $84.8 $ benefits may pay at varying coinsurance levels. For detailed benefit A7838 $3.17 $72.34 $73.11 $ A7838 $51.42 $12.84 $13.94 $12.3 information, please contact your sales representative to obtain a P548 $38.4 $7.91 $77.8 $ P548 $54.49 $18.98 $11.32 $172.2 benefits summary for your plan(s). ''A'' s promote affordability through class shifting of higher cost procedures utilized by less members while retaining routine procedures at traditional levels. As a result, coinsurance levels Zone 2 may differ between various endo, perio, and oral surgery procedures. For more details, speak to your representative and to request a EE Only EE & SP EE & Ch(ren) Family detailed benefit summary. P1258 $22.5 $45. $44.72 $7.19 P122 $25.37 $5.73 $51.24 $8.5 P1259 $25.42 $5.83 $5.51 $79.27 P123 $28.5 $57.3 $57.87 $9.41 A7838 $43.52 $87.4 $87.97 $ P548 $4.9 $93.38 $94.53 $ EE Only EE & SP EE & Ch(ren) Family P1258 $28.53 $57. $5.95 $89.27 P122 $3.93 $1.8 $2.48 $97.1 P1259 $32.17 $4.33 $4.22 $1. P123 $34.87 $9.75 $7.44 $11. A7838 $48.99 $97.97 $99.1 $154.7 P548 $52.32 $14.4 $15.92 $ of 8
3 For Groups 2-9 Eligible Lives with Effective Dates Preferred Portfolio 1/1/219-3/31/219 Zone 1 Zip Codes: 14, 141, 142, 143, 144, 145, 14, 147 Zone 2 Zip Codes: 13, 131, 132, 133, 134, 135, 13, 137, 138, 139, 148, Annual Max $ PIN41 No 1% 5% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 A7848 No 1% 8% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 A88 No 1% 8% 5% 5% 1, 5/15 N/A 7th/Options PPO 3 P3445 Yes 1% 8% 5% 8% 1, 5/ th/Options PPO 3 P344 Yes 1% 8% 5% 8% 1,5 5/15 N/A 85th/Options PPO 3 P3447 Yes 1% 8% 5% 8% 1,5 5/ th/Options PPO 3 (months) Zip Codes: 12, 121, 122, 123, Zone 4 Zip Codes: 125, 12 Zone 1 Zone 4 EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family PIN41 $18.3 $3. $3.4 $57.18 PIN41 $2. $53.2 $53.1 $83.13 A7848 $19.44 $38.89 $39.3 $1.39 A7848 $29.12 $58.24 $58.8 $91.94 CMM = Consume MaxMultiplier A88 $28.87 $57.73 $58.35 $91.15 A88 $41.4 $82.8 $82.95 $ Specific Procedures within Endodontic, ontic, and P3445 $34.71 $9.42 $75.25 $115.3 P3445 $49.18 $98.3 $17.33 $14.2 benefits may pay at varying coinsurance levels. For detailed benefit P344 $38.8 $77.3 $77.17 $12.98 P344 $55.95 $ $111.1 $ information, please contact your sales representative to obtain a P3447 $38.8 $77.3 $8.17 $ P3447 $55.95 $ $ $19.4 benefits summary for your plan(s). ''A'' s promote affordability through class shifting of higher cost procedures utilized by less members while retaining routine procedures at traditional levels. As a result, coinsurance levels Zone 2 may differ between various endo, perio, and oral surgery procedures. For more details, speak to your representative and to request a EE Only EE & SP EE & Ch(ren) Family detailed benefit summary. PIN41 $19.53 $39.5 $38.91 $1.2 A7848 $2. $4. $4.43 $3.15 A88 $34.73 $9.47 $7.21 $19.7 P3445 $42.14 $84.28 $91.5 $ P344 $47.59 $95.19 $94.95 $148.8 P3447 $47.59 $95.19 $15.42 $1.73 EE Only EE & SP EE & Ch(ren) Family PIN41 $23. $4.1 $45.84 $71.89 A7848 $24.39 $48.77 $49.29 $77. A88 $39.9 $78.19 $79.2 $ P3445 $47.22 $94.44 $12.41 $15.99 P344 $53.24 $1.49 $1.22 $1.52 P3447 $53.24 $1.49 $ $ of 8
4 For Groups 2-9 Eligible Lives with Effective Dates Preferred Portfolio 1/1/219-3/31/219 1 Annual Max $ PIN4 No Voluntary 1% 5% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P1258 No Voluntary 1%/8% 8%/% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 Zone 4 Zip Codes: 125, 12 P122 No Voluntary 1% 8% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 P1259 No Voluntary 1%/8% 8%/% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P123 No Voluntary 1% 8% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P875 Yes Voluntary 1% 8% 5% 8% 1,5 5/15 N/A MAC/Options PPO 2 A7838 No Voluntary 1% 8% 5% 5% 1, 5/15 N/A 7th/Options PPO 3 12 (months) Zone 1 Zip Codes: 14, 141, 142, 143, 144, 145, 14, 147 Zone 2 Zip Codes: 13, 131, 132, 133, 134, 135, 13, 137, 138, 139, 148, 149 Zip Codes: 12, 121, 122, 123, Zone 1 Zone 4 EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family PIN4 $19.4 $38.92 $38.73 $.75 PIN4 $28.27 $5.53 $5.25 $88.24 P1258 $19.31 $38.2 $38.9 $.58 P1258 $28.98 $57.9 $58.1 $91.2 CMM = Consume MaxMultiplier P122 $2.32 $4.4 $41.5 $4.13 P122 $3.43 $.87 $1.48 $9.5 Specific Procedures within Endodontic, ontic, and P1259 $21.52 $43.4 $43.11 $7.51 P1259 $32.9 $5.93 $.15 $13.54 benefits may pay at varying coinsurance levels. For detailed benefit P123 $22.5 $45.29 $45.75 $71.47 P123 $34.2 $9.24 $9.93 $19.2 information, please contact your sales representative to obtain a P875 $27.9 $54.18 $54.4 $84.72 P875 $41.41 $82.82 $82.1 $ benefits summary for your plan(s). A7838 $29.81 $59.1 $.25 $94.11 A7838 $42.37 $84.75 $85.5 $ ''A'' s promote affordability through class shifting of higher cost procedures utilized by less members while retaining routine procedures at traditional levels. As a result, coinsurance levels Zone 2 may differ between various endo, perio, and oral surgery procedures. For more details, speak to your representative and to request a EE Only EE & SP EE & Ch(ren) Family detailed benefit summary. PIN4 $2.7 $41.51 $41.3 $4.8 P1258 $18.54 $37.9 $3.85 $57.84 P122 $2.9 $41.81 $42.22 $5.97 P1259 $2.94 $41.89 $41.2 $5.33 P123 $23.1 $47.22 $47.9 $74.51 P875 $28.24 $5.48 $5.33 $88.32 A7838 $35.8 $71.73 $72.49 $ EE Only EE & SP EE & Ch(ren) Family PIN4 $24.45 $48.89 $48.5 $7.32 P1258 $23.51 $47.2 $4.93 $73.57 P122 $25.49 $5.98 $51.48 $8.44 P1259 $2.51 $53.2 $52.92 $82.95 P123 $28.74 $57.48 $58.5 $9.9 P875 $34.37 $8.75 $8.57 $17.5 A7838 $4.37 $8.73 $81.59 $ of 8
5 For Groups 1-5 Eligible Lives with Effective Dates Preferred Portfolio 1/1/219-3/31/219 1 Annual Max $ PIN41 No 1% 5% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 A7848 No 1% 8% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 A88 No 1% 8% 5% 5% 1, 5/15 N/A 7th/Options PPO 3 Zone 4 Zip Codes: 125, 12 P3445 Yes 1% 8% 5% 8% 1, 5/ th/Options PPO 3 P344 Yes 1% 8% 5% 8% 1,5 5/15 N/A 85th/Options PPO 3 P3447 Yes 1% 8% 5% 8% 1,5 5/ th/Options PPO 3 Zone 1 Zip Codes: 14, 141, 142, 143, 144, 145, 14, 147 Zone 2 Zip Codes: 13, 131, 132, 133, 134, 135, 13, 137, 138, 139, 148, 149 (months) Zip Codes: 12, 121, 122, 123, Zone Lives Lives 25-5 Lives * CMM = Consume MaxMultiplier EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family 1 Specific Procedures within PIN41 $17.31 $34.3 $34.5 $54.1 $15.58 $31.1 $31.4 $48.8 $15.49 $3.99 $3.87 $48.42 Endodontic, ontic, and A7848 $18.39 $3.79 $37.18 $58.8 $1.55 $33.1 $33.4 $52.2 $1.4 $32.92 $33.27 $51.98 benefits may pay at A88 $27.31 $54.2 $55.2 $8.24 $24.57 $49.15 $49.7 $77.59 $24.44 $48.88 $49.4 $77.17 varying coinsurance levels. For P3445 $32.84 $5.8 $71.19 $19.14 $29.55 $59.9 $4. $98.21 $29.39 $58.77 $3.71 $97.7 detailed benefit information, P344 $3. $73.19 $73.1 $114.4 $32.93 $5.8 $5.9 $12.99 $32.75 $5.5 $5.33 $12.43 please contact your sales P3447 $3. $73.19 $81.53 $ $32.93 $5.8 $73.3 $111.8 $32.75 $5.5 $72.9 $111.7 representative to obtain a benefits summary for your plan(s). Zone Lives Lives 25-5 Lives ''A'' s promote affordability EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family through class shifting of higher PIN41 $18.47 $3.95 $3.81 $57.73 $1.2 $33.24 $33.12 $51.94 $1.53 $33. $32.94 $51. cost procedures utilized by less A7848 $18.92 $37.85 $38.25 $59.75 $17.3 $34.5 $34.42 $53.7 $1.93 $33.87 $34.23 $53.47 members while retaining routine A88 $32.8 $5.72 $.42 $13.7 $29.57 $59.14 $59.77 $93.3 $29.41 $58.82 $59.44 $92.85 procedures at traditional levels. P3445 $39.87 $79.74 $8.14 $ $35.87 $71.75 $77.51 $ $35.8 $71.3 $77.9 $ As a result, coinsurance levels may P344 $45.3 $9. $89.83 $14.83 $4.52 $81.3 $8.83 $12.72 $4.3 $8.59 $8.39 $12.3 differ between various endo, perio, P3447 $45.3 $9. $99.74 $152. $4.52 $81.3 $89.75 $13.83 $4.3 $8.59 $89.2 $13.8 and oral surgery procedures. For more details, speak to your representative and to request a 1-2 Lives Lives 25-5 Lives detailed benefit summary. EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family PIN41 $21.7 $43.53 $43.37 $8.1 $19.58 $39.17 $39.2 $1.2 $19.48 $38.95 $38.81 $.87 Additional plan enhancements may A7848 $23.7 $4.14 $4.4 $72.85 $2.7 $41.52 $41.9 $5.55 $2.5 $41.29 $41.74 $5.19 be available. Please contact your A88 $3.99 $73.98 $74.7 $11.79 $33.28 $.5 $7.27 $15.8 $33.1 $.2 $.91 $14.51 UHC Specialty Benefits representative P3445 $44.8 $89.35 $9.89 $ $4.2 $8.4 $87.18 $133.4 $39.98 $79.9 $8.71 $ for availability and pricing on the P344 $5.37 $1.75 $1.49 $ $45.33 $9.5 $9.42 $141.7 $45.8 $9.1 $89.93 $14.99 following enhancements. P3447 $5.37 $1.75 $ $17.75 $45.33 $9.5 $1.9 $153.3 $45.8 $9.1 $1.35 $ FlexAppeal Max Multiplier: encourages preventive care by Zone 4 paying for those claims without 1-2 Lives Lives 25-5 Lives deducting them from the annual EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family maximum. PIN41 $25.17 $5.33 $5.15 $78.5 $22.5 $45.29 $45.13 $7.77 $22.52 $45.4 $44.88 $ FlexAppeal Enhanced: offers 3 A7848 $27.55 $55.1 $55.9 $8.99 $24.79 $49.58 $5.11 $78.27 $24.5 $49.31 $49.83 $77.84 major benefits -- any combination A88 $38.83 $77.5 $78.48 $ $34.94 $9.87 $7.2 $11.31 $34.75 $9.49 $7.23 $19.71 of 4 routine or periodontal cleanings, P3445 $4.53 $93. $11.54 $ $41.87 $83.74 $91.37 $ $41.4 $83.28 $9.87 $139.8 white filings for back teeth and P344 $52.93 $15.8 $15.59 $15.55 $47.3 $95.25 $95.1 $148.9 $47.37 $94.73 $94.49 $ dental implants. P3447 $52.93 $15.8 $118.7 $18.3 $47.3 $95.25 $1.78 $12.29 $47.37 $94.73 $1.2 $ of 8
6 For Groups 1-5 Eligible Lives with Effective Dates Preferred Portfolio 1/1/219-3/31/219 1 Annual Max $ (Ind/Fam) PIN4 No Voluntary 1%/1% 5% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P1258 No Voluntary 1%/8% 8%/% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 P122 No Voluntary 1%/1% 8% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 P1259 No Voluntary 1%/8% 8%/% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P123 No Voluntary 1%/1% 8% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P875 Yes Voluntary 1%/1% 8% 5% 8% 1,5 5/15 N/A MAC/Options PPO 2 A7838 No Voluntary 1%/1% 8% 5% 5% 1, 5/15 N/A 7th/Options PPO 3 12 * CMM = Consume MaxMultiplier Zone 1 1 Specific Procedures within 1-2 Lives Lives 25-5 Lives Endodontic, ontic, and EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family benefits may pay at PIN4 $18.41 $3.82 $3.4 $57.48 $1.57 $33.13 $32.97 $51.72 $1.48 $32.95 $32.79 $51.44 varying coinsurance levels. For P1258 $18.27 $3.54 $3. $57.31 $1.44 $32.88 $32.93 $51.57 $1.35 $32.7 $32.75 $51.29 detailed benefit information, P122 $19.23 $38.45 $38.84 $.8 $17.3 $34. $34.94 $54. $17.21 $34.41 $34.75 $54.3 please contact your sales P1259 $2.3 $4.72 $4.79 $3.87 $18.32 $3.4 $3.7 $57.47 $18.22 $3.44 $3.5 $57.1 representative to obtain a P123 $21.43 $42.85 $43.28 $7.2 $19.28 $38.5 $38.94 $.85 $19.17 $38.35 $38.73 $.51 benefits summary for your plan(s). P875 $25.3 $51.2 $51.13 $8.1 $23. $4.12 $4. $72.12 $22.93 $45.87 $45.75 $71.73 A7838 $28.2 $5.4 $57. $89.4 $25.37 $5.75 $51.29 $8.12 $25.24 $5.47 $51.1 $79.8 ''A'' s promote affordability through class shifting of higher cost procedures utilized by less members while retaining routine Zone 2 procedures at traditional levels. 1-2 Lives Lives 25-5 Lives As a result, coinsurance levels may EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family differ between various endo, perio, PIN4 $19.4 $39.27 $39.8 $1.31 $17.7 $35.34 $35.1 $55.1 $17.57 $35.15 $34.97 $54.8 and oral surgery procedures. For P1258 $17.54 $35.9 $34.87 $54.72 $15.79 $31.57 $31.37 $49.24 $15.7 $31.4 $31.2 $48.97 more details, speak to your P122 $19.78 $39.55 $39.95 $2.41 $17.79 $35.59 $35.94 $5.1 $17.7 $35.4 $35.75 $55.85 representative and to request a P1259 $19.81 $39.3 $39.38 $1.81 $17.83 $35. $35.43 $55.1 $17.73 $35.4 $35.24 $55.31 detailed benefit summary. P123 $22.34 $44.7 $45.12 $7.49 $2.1 $4.2 $4. $3.43 $19.99 $39.98 $4.38 $3.8 P875 $2.72 $53.43 $53.3 $83.5 $24.4 $48.8 $47.9 $75.18 $23.91 $47.82 $47.9 $74.77 Additional plan enhancements may A7838 $33.93 $7.8 $8.58 $17.14 $3.53 $1. $1.71 $9.4 $3.3 $.73 $1.38 $95.88 be available. Please contact your UHC Specialty Benefits representative for availability and pricing on the following enhancements. - FlexAppeal Max Multiplier: 1-2 Lives Lives 25-5 Lives encourages preventive care by EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family paying for those claims without PIN4 $23.13 $4.2 $4.3 $72.21 $2.81 $41.2 $41.42 $4.97 $2.7 $41.4 $41.19 $4.2 deducting them from the annual P1258 $22.24 $44.49 $44.4 $9. $2.1 $4.3 $39.95 $2.3 $19.9 $39.81 $39.74 $2.29 maximum. P122 $24.11 $48.23 $48.71 $7.1 $21.7 $43.4 $43.83 $8.48 $21.58 $43.1 $43.59 $8.1 - FlexAppeal Enhanced: offers 3 P1259 $25.8 $5.1 $5.7 $78.48 $22.57 $45.13 $45.5 $7.1 $22.44 $44.89 $44.8 $7.23 major benefits -- any combination P123 $27.19 $54.38 $54.92 $85.81 $24.4 $48.93 $49.42 $77.21 $24.33 $48. $49.15 $7.79 of 4 routine or periodontal cleanings, P875 $32.52 $5.4 $4.88 $11.71 $29.2 $58.52 $58.38 $91.52 $29.1 $58.21 $58. $91.2 white filings for back teeth and A7838 $38.19 $7.38 $77.2 $12.59 $34.3 $8.73 $9.4 $18.51 $34.18 $8.3 $9.8 $17.92 dental implants. Ortho Max $ OON Reimburse/Network Zone 1 Zip Codes: 14, 141, 142, 143, 144, 145, 14, 147 Zone 2 Zip Codes: 13, 131, 132, 133, 134, 135, 13, 137, 138, 139, 148, 149 (months) Zip Codes: 12, 121, 122, 123, of 8
7 For Groups 1-5 Eligible Lives with Effective Dates Preferred Portfolio 1/1/219-3/31/219 Zone 4 Zip Codes: 125, 12 1 Annual Max $ PIN4 No Voluntary 1%/1% 5% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P1258 No Voluntary 1%/8% 8%/% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 P122 No Voluntary 1%/1% 8% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 P1259 No Voluntary 1%/8% 8%/% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P123 No Voluntary 1%/1% 8% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P875 Yes Voluntary 1%/1% 8% 5% 8% 1,5 5/15 N/A MAC/Options PPO 2 A7838 No Voluntary 1%/1% 8% 5% 5% 1, 5/15 N/A 7th/Options PPO 3 12 * CMM = Consume MaxMultiplier Zone 4 1 Specific Procedures within 1-2 Lives Lives 25-5 Lives Endodontic, ontic, and EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family benefits may pay at PIN4 $2.74 $53.49 $53.22 $83.49 $24. $48.13 $47.88 $75.12 $23.93 $47.8 $47.2 $74.71 varying coinsurance levels. For P1258 $27.42 $54.83 $55.2 $8.12 $24.7 $49.34 $49.51 $77.49 $24.53 $49.7 $49.24 $77.7 detailed benefit information, P122 $28.79 $57.59 $58.1 $9.87 $25.91 $51.82 $52.33 $81.77 $25.77 $51.54 $52.5 $81.32 please contact your sales P1259 $31.19 $2.37 $2.59 $97.9 $28. $5.12 $5.32 $88.15 $27.91 $55.82 $5.1 $87.7 representative to obtain a P123 $32.75 $5.51 $.1 $13.37 $29.47 $58.94 $59.53 $93.1 $29.31 $58.2 $59.21 $92.51 benefits summary for your plan(s). P875 $39.18 $78.35 $78.1 $ $35.25 $7.5 $7.32 $11.25 $35. $7.12 $9.94 $19.5 A7838 $4.9 $8.18 $81.4 $12.58 $3.7 $72.15 $72.91 $113.9 $35.88 $71.75 $72.52 $ ''A'' s promote affordability through class shifting of higher cost procedures utilized by less members while retaining routine procedures at traditional levels. As a result, coinsurance levels may differ between various endo, perio, and oral surgery procedures. For more details, speak to your representative and to request a detailed benefit summary. (months) Additional plan enhancements may be available. Please contact your UHC Specialty Benefits representative for availability and pricing on the following enhancements. - FlexAppeal Max Multiplier: encourages preventive care by paying for those claims without deducting them from the annual maximum. - FlexAppeal Enhanced: offers 3 major benefits -- any combination of 4 routine or periodontal cleanings, white filings for back teeth and dental implants. 7 of 8
8 For Groups 2-5 Eligible Lives with Effective Dates Product and Underwriting Information 1/1/219-3/31/219 Rates are guaranteed for 12 months. Rates generated by UnitedHealthcare's rating systems may differ from this illustration. Orthodontia benefit paid at 5% and available to groups of 1 or more eligible employees, with a minimum of 8 enrollees. MAC: The non-network percentage of benefits is based on the allowable amount applicable for the same service that would have been rendered by a network provider (MAC = Maximum Allowable Charge). UCR: The non-network percentage of benefits is based on the schedule of usual and customary fees in the geographic area in which the expense are incurred. (UCR = Usual Customary and Reasonable). Assumed contract situs in. Rates assume a complete Carrier Replacement and standard Exclusions and Limitations. Rates listed above assume the plan design quoted. Rates may change, if plan design changes. Rates assume no change in legislation or regulation that affects the benefits payable, eligibility or contract. For PPO plans, the network and non-network annual maximum are combined. Deductibles and maximums are assumed on a calendar year basis unless otherwise noted. Dependent children are covered up to age 2. Dual option is available on groups of 1 or more eligible emlpoyees as long as the combination is a logical high/low offering. Employer Funded s: Employer must contribute at least 5% of the employee rate. A minimum participation of at least 75% (51%, including valid waivers) is required. Voluntary plans for 2-9 size groups require a waiting period for major services. However, this waiting period may be waived with proof of prior coverage for major services. Voluntary plans without ortho are available down to 2 employees. UnitedHealthcare applies SIC factors to rate calculations for our 2 to 5 small group segment. This will aid in providing your client with the most favorable and competitive dental rate based on their industry classification. Quotes provided from United eservices will have the appropriate factors automatically embedded in them. The information below will help you determine if a SIC factor applies to your client. SIC codes not listed below are base rates (industry factor 1.) and require no additional adjustments from the base rates on the preceding pages. Industry Category SIC Code Industry Factor Agriculture Production & Services 1-291; 7-783; Mining, Construction, Manufacturing ; ; 2-279; Additional Manufacturing 2-299; ; ; 3-39; Jewelry & Silverware Manufacturing Transportation, Communication, Electric, Gas, & Sanitary Services Wholesale Trade - Durable and Nondurable Goods Building Materials, Hardware, Garden Supply, and Mobile Home Dealers Automotive Dealers and Gasoline Service Stations Eating and Drinking Places Depository & Non-depository Institutions - 13 Other Finance, Insurance, & Real Estate Miscellaneous Services ; ; ; ; Beauty Shops, Advertising, Jewelry Repair, & Health Services ; ; ; 8-811; Legal & Educational Services ; Social Services, Museums/Gardens, Private Households, Services (NEC) ; ; Membership Organizations Public Administration & Other All other (except as noted below)* * For Dental Offices (SIC 82, 821), please contact your UnitedHealthcare Sales representative Your UnitedHealthcare Sales Representative will supply you with a very simple Microsoft Excel-based tool to apply the SIC factor (if applicable) to your group's final rates. The output from this tool should be included with a copy of the rate card used when submitting your group's enrollment materials for installation. Please contact your UnitedHealthcare Sales representative for more information Fully Insured quotes: The Dental and/or Vision premium includes expenses related to state & federal taxes, fees, and assessments. It may also include additional new taxes, fees and assessments from the Affordable Care Act. The rates and benefits provided are for general information and discussion purposes only and are not valid unless approved by UnitedHealthcare. This rate quote is not an offer or guarantee of coverage. The group should not, under any circumstances, cancel its existing coverage unless and until coverage is offered by UnitedHealthcare and final rates have been accepted by and initial premium paid by the group. Final rates are determined by UnitedHealthcare's underwriting guidelines and final enrollment. The insurance Policy, not general rates and descriptions on this rate sheet, will form the contract between the insured and UnitedHealthcare, and the Certificate of Coverage issued to the subscriber will provide the legal description of coverage. Specialty benefits and programs may not be available in all states or for all group sizes. Components subject to change. UnitedHealthcare Dental coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut, or its affiliates. Administrative services provided by Dental Benefit Providers, Inc., Dental Benefit Administrative Services (CA only), United HealthCare Services, Inc. or their affiliates. s sold in Texas use policy form number DPOL..TX (11/15/2) and associated COC form number DCOC.CER.. UHCUNY Nov United HealthCare Services, Inc. 8 of 8
UnitedHealthcare - Dental Rate Card
1 Annual Max $ PIN41 No 1% 5% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 A7848 No 1% 8% 5% 5% 1, 5/15 N/A MAC/Options PPO 2 P797 No 1% 8% 5% 5% 1,5 5/15 N/A MAC/Options PPO 2 P3457 No 1%/9% 8%/7% 5% 5% 1, 5/15
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For Groups 2-9 Eligible Lives with Effective Dates Preferred Portfolio 7/1/218-9/3/218 A7848 1% 8% 5% 1 5% 1, 5/15 MAC/Options PPO 2 A88 1% 8% 5% 5% 1, 5/15 7th/Options PPO 3 P318 1% 8% 5% 5% 1,5 5/15
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For Groups 2-9 Eligible Lives with Effective Dates Preferred Portfolio 4/1/218 - /3/218 A7848 1% 8% 5% 1 5% 1, 5/15 MAC/Options PPO 2 A88 1% 8% 5% 5% 1, 5/15 7th/Options PPO 3 P318 1% 8% 5% 5% 1,5 5/15
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For Groups 2-9 Eligible Lives with Effective Dates Preferred Portfolio 1/1/218-12/31/218 PIN41 1% 5% 5% 1 5% 1,5 5/15 MAC/Options PPO 2 A7848 1% 8% 5% 5% 1, 5/15 MAC/Options PPO 2 P797 1% 8% 5% 5% 1,5
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For Groups 2-9 Eligible Lives with Effective Dates Preferred Portfolio 4/1/218-6/3/218 Zone 1 Zip Codes: 8, 81 Zone 2 Zip Codes: 82, 83, 84 1% 5% 5% 1 5% 1,5 5/15 MAC/Options PPO 2 Zone 3 Zip Codes: 85,
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