Who may enroll in this Plan: All Federal employees, annuitants, and certain TRICARE beneficiaries in the United States and overseas who are eligible to enroll in the Federal Employees Dental and Vision Insurance Program.
Enrollment Options for this Plan: • High Option – Self Only • High Option – Self Plus One • High Option – Self and Family
• Standard Option – Self Only • Standard Option – Self Plus One • Standard Option – Self and Family
This Plan has 5 enrollment regions, including international; please see the end of this brochure to determine your region and corresponding rates
Introduction
On December 23, 2004, President George W. Bush signed the Federal Employee Dental and Vision Benefits Enhancement Act of 2004 (Public Law 108-496). The law directed the Office of Personnel Management (OPM) to establish supplemental dental and vision benefit programs to be made available to Federal employees, annuitants, and their eligible family members. In response to the legislation, OPM established the Federal Employees Dental and Vision Insurance Program (FEDVIP). OPM has contracted with dental and vision insurers to offer an array of choices to Federal employees and annuitants. Section 715 of the National Defense Authorization Act for Fiscal Year 2017 (FY 2017 NDAA), Public Law 114-38,expanded FEDVIP eligibility to certain TRICARE-eligible individuals.
This brochure describes the benefits of UnitedHealthcare Dental Plan under UnitedHealthcare Dental Plan's contract OPM02-FEDVIP-02AP-15 with OPM, as authorized by the FEDVIP law. The address for our administrative office is:
UnitedHealthcare Dental 10175 Little Patuxent Parkway 6th Floor Columbia, MD 21044 1-866-315-2321 or TTY 711 www.myuhcdental.com/fedvip
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One, you and your designated family member are entitled to these benefits. If you are enrolled in Self and Family coverage, each of your eligible family members is also entitled to these benefits, if they are also listed on the coverage. You and your family members do not have a right to benefits that were available before January 1, 2022 unless those benefits are also shown in this brochure.
OPM negotiates rates with each carrier annually. Rates are shown at the end of this brochure.
UnitedHealthcare Dental Plan is responsible for the selection of in-network providers in your area. Contact us at 1-866-315-2321 or TTY 711 - for the names of participating providers. You may view the most current directory via our web site at www.myuhcdental.com/fedvip. Continued participation of any specific provider cannot be guaranteed. Thus, you should choose your plan based on the benefits provided, not for a specific provider’s participation. When you phone for an appointment, please remember to verify that the provider is currently in- network. If your provider is not currently participating in the provider network, you may nominate him or her to join. Nomination forms are available on our web site, or call us and we will have a form sent to you. You cannot change plans outside of Open Season because of changes to the provider network.
Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all areas. If you require the services of a specialist and one is not available in your area, please contact us for assistance.
Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all areas. If you require the services of a specialist and one is not available in your area, please contact us for assistance. Please be aware that the UnitedHealthcare Dental network may be different from the network of your health plan.
This UnitedHealthcare Dental Plan and all other FEDVIP plans are not a part of the Federal Employees Health Benefits (FEHB) Program.
We want you to know that protecting the confidentiality of your individually identifiable health information is of the utmost importance to us. To review full details about our privacy practices, our legal duties, and your rights, please visit our website at www.myuhcdental.com/fedvip, and then click on the "Legal and Privacy Notices" link at the bottom of the page. If you do not have access to the internet or would like further information, please contact us by calling 1-866-315-2321 or TTY 711.
Discrimination is Against the Law UnitedHealthcare Dental complies with all applicable Federal civil rights laws, to include both Title VII of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, UnitedHealthcare Dental does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.
Table of Contents
(Page numbers solely appear in the printed brochure)
Table of Content
Introduction
Table of Contents
FEDVIP Program Highlights
A Choice of Plans and Options
Enroll Through BENEFEDS
Dual Enrollment
Coverage Effective Date
Pre-Tax Salary Deduction for Employees
Annual Enrollment Opportunity
Continued Group Coverage After Retirement
Waiting Period
Section 1 Eligibility
Federal Employees
Federal Annuitants
Survivor Annuitants
Compensationers
Family Members
Not Eligible
TRICARE-eligible individual
Section 2 Enrollment
Enroll Through BENEFEDS
Enrollment Types
Dual Enrollment
Opportunities to Enroll or Change Enrollment
When Coverage Stops
Continuation of Coverage
FSAFEDS/High Deductible Health Plans and FEDVIP
Section 3 How You Obtain Care
Identification Cards/Enrollment Confirmation
Where You Get Covered Care
Plan Providers
In-Network
Out-of-Network
Emergency Services
Maximum Amount Allowed
Precertification
Alternate Benefit
Dental Review
FEHB First Payor
Coordination of Benefits
Rating Areas
Limited Access Area
Section 4 Your Cost For Covered Services
Deductible
Coinsurance
Annual Benefit Maximum
Lifetime Benefit Maximum
In-Network Services
Out-of-Network Services
Calendar Year
Emergency Services
Section 5 Dental Services and Supplies Class A Basic
Class B Intermediate
Class C Major
Class D Orthodontic
Section 6 International Services and Supplies
Section 7 General Exclusions – Things We Do Not Cover
Section 8 Claims Filing and Disputed Claims Processes
Section 9 Definitions of Terms We Use in This Brochure
Non-FEDVIP Benefits
Summary of Benefits
Notes
Stop Health Care Fraud!
Rate Information
FEDVIP Program Highlights
Term
Definition
A Choice of Plans and Options
You can select from several nationwide, and in some areas, regional dental Preferred Provider Organization (PPO) or Health Maintenance Organization (HMO) plans, and high and standard coverage options. You can also select from several nationwide vision plans. You may enroll in a dental plan or a vision plan, or both. Some TRICARE beneficiaries may not be eligible to enroll in both. Visit www.opm.gov/dental or www.opm.gov/vision for more information.
Enroll Through BENEFEDS
You enroll online at www.BENEFEDS.com. Please see Section 2, Enrollment, for more information.
Dual Enrollment
If you or one of your family members is enrolled in or covered by one FEDVIP plan, that person cannot be enrolled in or covered as a family member by another FEDVIP plan offering the same type of coverage; i.e., you (or covered family members) cannot be covered by two FEDVIP dental plans or two FEDVIP vision plans.
Coverage Effective Date
If you sign up for a dental and/or vision plan during the 2021 Open Season, your coverage will begin on January 1, 2022. Premium deductions will start with the first full pay period beginning on/after January 1, 2022. You may use your benefits as soon as your enrollment is confirmed.
Pre-Tax Salary Deduction for Employees
Employees automatically pay premiums through payroll deductions using pre-tax dollars. Annuitants automatically pay premiums through annuity deductions using post-tax dollars. TRICARE enrollees automatically pay premiums through payroll deduction or automatic bank withdrawal (ABW) using post-tax dollars.
Annual Enrollment Opportunity
Each year, an Open Season will be held, during which you may enroll or change your dental and/or vision plan enrollment. This year, Open Season runs from November 8, 2021 through midnight EST December 13, 2021. You do not need to re-enroll each Open Season, unless you wish to change plans or plan options; your coverage will continue from the previous year. In addition to the annual Open Season, there are certain events that allow you to make specific types of enrollment changes throughout the year. Please see Section 2, Enrollment, for more information.
Continued Group Coverage After Retirement
Your enrollment or your eligibility to enroll may continue after retirement. You do not need to be enrolled in FEDVIP for any length of time to continue enrollment into retirement. Your family members may also be able to continue enrollment after your death. Please see Section 1, Eligibility, for more information.
Waiting Period
There is no waiting period for orthodontic services.
Section 1 Eligibility
Term
Definition
Federal Employees
If you are a Federal or U.S. Postal Service employee, you are eligible to enroll in FEDVIP, if you are eligible for the Federal Employees Health Benefits (FEHB) Program or the Health Insurance Marketplace (Exchange) and your position is not excluded by law or regulation, you are eligible to enroll in FEDVIP. Enrollment in the FEHB Program or a Health Insurance Marketplace (Exchange) plan is not required.
Federal Annuitants
You are eligible to enroll if you:
retired on an immediate annuity under the Civil Service Retirement System (CSRS), the Federal Employees Retirement System (FERS) or another retirement system for employees of the Federal Government;
retired for disability under CSRS, FERS, or another retirement system for employees of the Federal Government.
Your FEDVIP enrollment will continue into retirement if you retire on an immediate annuity or for disability under CSRS, FERS or another retirement system for employees of the Government, regardless of the length of time you had FEDVIP coverage as an employee. There is no requirement to have coverage for 5 years of service prior to retirement in order to continue coverage into retirement, as there is with the FEHB Program.
Your FEDVIP coverage will end if you retire on a Minimum Retirement Age (MRA) + 10 retirement and postpone receipt of your annuity. You may enroll in FEDVIP again when you begin to receive your annuity.
Advise BENEFEDS of your new payroll office number.
Survivor Annuitants
If you are a survivor of a deceased Federal/U.S. Postal Service employee or annuitant and you are receiving an annuity, you may enroll or continue the existing enrollment.
Compensationers
A compensationer is someone receiving monthly compensation from the Department of Labor’s Office of Workers’ Compensation Programs (OWCP) due to an on-the-job injury/illness who is determined by the Secretary of Labor to be unable to return to duty. You are eligible to enroll in FEDVIP or continue FEDVIP enrollment into compensation status.
TRICARE-eligible individual
An individual who is eligible for FEDVIP dental coverage based on the individual's eligibility to previously be covered under the TRICARE Retiree Dental Program or an individual eligible for FEDVIP vision coverage based on the individual's enrollment in a specified TRICARE health plan.
Retired members of the uniformed services and National Guard/Reserve components, including “gray-area” retirees under age 60 and their families are eligible for FEDVIP dental coverage. These individuals, if enrolled in a TRICARE health plan, are also eligible for FEDVIP vision coverage. In addition, uniformed services active duty family members who are enrolled in a TRICARE health plan are eligible for FEDVIP vision coverage.
Family Members
Except with respect to TRICARE-eligible individuals, family members include your spouse and unmarried dependent children under age 22. This includes legally adopted children and recognized natural children who meet certain dependency requirements. This also includes stepchildren and foster children who live with you in a regular parent- child relationship. Under certain circumstances, you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support. FEDVIP rules and FEHB rules for family member eligibility are NOTthe same. For more information on family member eligibility visit the website at www.opm.gov/healthcare-insurance/dental-vision/ or contact your employing agency or retirement system.
With respect to TRICARE-eligible individuals, family members include your spouse, unremarried widow, unremarried widower, unmarried child, an unremarried former spouse who meets the U.S Department of Defense's 20-20-20 or 20-20-15 eligibility requirements, and certain unmarried persons placed in your legal custody by a court.
Children include legally adopted children, stepchildren, and pre-adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.
Not Eligible
The following persons are not eligible to enroll in FEDVIP, regardless of FEHB eligibility or receipt of an annuity or portion of an annuity:
Deferred annuitants
Former spouses of employees or annuitants. Note: Former spouses of TRICARE-eligible individuals may enroll in a FEDVIP vision plan.
FEHB Temporary Continuation of Coverage (TCC) enrollees
Anyone receiving an insurable interest annuity who is not also an eligible family member
Active duty uniformed service members. Note: If you are an active duty uniformed service member, your dental and vision coverage will be provided by TRICARE. Your family members will still be eligible to enroll in the TRICARE Dental Plan (TDP).
Section 2 Enrollment
Term
Definition
Enroll Through BENEFEDS
You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan. BENEFEDS is a secure enrollment website (www.BENEFEDS.com) sponsored by OPM. If you do not have access to a computer, call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 to enroll or change your enrollment.
If you are currently enrolled in FEDVIP and do not want to change plans, your enrollment will continue automatically. Please Note: Your plans’ premiums may change for 2022.
Note: You cannot enroll or change enrollment in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency self-service system, such as Employee Express, PostalEase, EBIS, MyPay, or Employee Personal Page. However, those sites may provide a link to BENEFEDS.
Enrollment Types
Self Only: A Self Only enrollment covers only you as the enrolled employee or annuitant. You may choose a Self Only enrollment even though you have a family; however, your family members will not be covered under FEDVIP.
Self Plus One: A Self Plus One enrollment covers you as the enrolled employee or annuitant plus one eligible family member whom you specify. You may choose a Self Plus One enrollment even though you have additional eligible family members, but the additional family members will not be covered under FEDVIP.
Self and Family: A Self and Family enrollment covers you as the enrolled employee or annuitant and all of your eligible family members. You must list all eligible family members when enrolling.
Dual Enrollment
If you or one of your family members is enrolled in or covered by one FEDVIP plan, that person cannot be enrolled in or covered as a family member by another FEDVIP plan offering the same type of coverage; i.e., you (or covered family members) cannot be covered by two FEDVIP dental plans or two FEDVIP vision plans.
Opportunities to Enroll or Change Enrollment
Open Season
If you are an eligible employee, annuitant, or TRICARE-eligible individual, you may enroll in a dental and/or vision plan during the November 8, through midnight EST December 13, 2021, Open Season. Coverage is effective January 1, 2022.
During future annual Open Seasons, you may enroll in a plan, or change or cancel your dental and/or vision coverage. The effective date of these Open Season enrollments and changes will be set by OPM. If you want to continue your current enrollment, do nothing. Your enrollment carries over from year to year, unless you change it.
New hire/Newly eligible
You may enroll within 60 days after you become eligible as:
a new employee;
a previously ineligible employee who transferred to a covered position;
a survivor annuitant if not already covered under FEDVIP; or
an employee returning to service following a break in service of at least 31 days.
a TRICARE-eligible individual
Qualifying Life Event
A qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled, allows you to change your enrollment outside of an Open Season.
The following chart lists the QLEs and the enrollment actions you may take.
Qualifying Life Event: Marriage From Not Enrolled to Enrolled: Yes Increase Enrollment Type: Yes Decrease Enrollment Type: No Cancel: No Change from One Plan to Another: Yes
Qualifying Life Event: Acquiring an eligible family member (non-spouse) From Not Enrolled to Enrolled: No Increase Enrollment Type: Yes Decrease Enrollment Type: No Cancel: No Change from One Plan to Another: No
Qualifying Life Event: Losing a covered family member From Not Enrolled to Enrolled: No Increase Enrollment Type: No Decrease Enrollment Type: Yes Cancel: No Change from One Plan to Another: No
Qualifying Life Event: Losing other dental/vision coverage (eligible or covered person) From Not Enrolled to Enrolled: Yes Increase Enrollment Type: Yes Decrease Enrollment Type: No Cancel: No Change from One Plan to Another: No
Qualifying Life Event: Moving out of regional plan's service area From Not Enrolled to Enrolled: No Increase Enrollment Type: No Decrease Enrollment Type: No Cancel: No Change from One Plan to Another: Yes
Qualifying Life Event: Going on active military duty, non- pay status (enrollee or spouse) From Not Enrolled to Enrolled: No Increase Enrollment Type: No Decrease Enrollment Type: No Cancel: Yes Change from One Plan to Another: No
Qualifying Life Event: Returning to pay status from active military duty (enrollee or spouse) From Not Enrolled to Enrolled: Yes Increase Enrollment Type: No Decrease Enrollment Type: No Cancel: No Change from One Plan to Another: No
Qualifying Life Event: Returning to pay status from Leave without pay From Not Enrolled to Enrolled: Yes (if enrollment cancelled during LWOP) Increase Enrollment Type: No Decrease Enrollment Type: No Cancel: No Change from One Plan to Another: Yes (if enrollment cancelled during LWOP)
Qualifying Life Event: Annuity/ compensation restored From Not Enrolled to Enrolled: Yes Increase Enrollment Type: No Decrease Enrollment Type: No Cancel: No Change from One Plan to Another: No
Qualifying Life Event: Transferring to an eligible position* From Not Enrolled to Enrolled: No Increase Enrollment Type: No Decrease Enrollment Type: No Cancel: Yes Change from One Plan to Another: No
Term
Definition
Opportunities to Enroll or Change Enrollment
*Position must be in a Federal agency that provides dental and/or vision coverage with 50 percent or more employer-paid premium.
The timeframe for requesting a QLE change is from 31 days before to 60 days after the event. There are two exceptions:
There is no time limit for a change based on moving from a regional plan’s service area and
You can not request a new enrollment based on a QLE before the QLE occurs, except for enrollment because of loss of dental or vision insurance. You must make the change no later than 60 days after the event.
Generally, enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change. BENEFEDS will send you confirmation of your new coverage effective date.
Once you enroll in a plan, your 60-day window for that type of plan ends, even if 60 calendar days have not yet elapsed. That means once you have enrolled in either plan, you can not change or cancel that particular enrollment until the next Open Season, unless you experience a QLE that allows such a change or cancellation.
Canceling an Enrollment
You may cancel your enrollment only during the annual Open Season. An eligible family member’s coverage also ends upon the effective date of the cancellation.
Your cancellation is effective at the end of the day before the date OPM sets as the Open Season effective date.
When Coverage Stops
Coverage ends for active and retired Federal, U.S. Postal employees, and TRICARE-eligible individuals when you:
no longer meet the definition of an eligible employee, annuitant, or TRICARE-eligible individual;
as a Retired Reservist you begin active duty;
as sponsor or primary enrollee leaves active duty
begin a period of non-pay status or pay that is insufficient to have your FEDVIP premiums withheld and you do not make direct premium payments to BENEFEDS;
are making direct premium payments to BENEFEDS and you stop making the payments;
cancel the enrollment during Open Season;
a Retired Reservist begins active duty; or
the sponsor or primary enrollee leaves active duty.
Coverage for a family member ends when:
you as the enrollee lose coverage; or
the family member no longer meets the definition of an eligible family member.
NOTE: Coverage ends for a covered individual when UnitedHealthcare Dental does not receive premium payment for that covered individual.
Continuation of Coverage
Under FEDVIP, there is no 31-day extension of coverage. The following are also NOT available under the FEDVIP plans:
Temporary Continuation of Coverage (TCC);
spouse equity coverage; or
right to convert to an individual policy (conversion policy).
FSAFEDS/High Deductible Health Plans and FEDVIP
If you are planning to enroll in an FSAFEDS Health Care Flexible Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA), you should consider how coverage under a FEDVIP plan will affect your annual expenses, and thus the amount that you should allot to an FSAFEDS account.
Using your FSA pre-tax dollars for your dental needs is a great way to get more out of your benefit dollar. UnitedHealthcare Dental will submit your eligible FSAFEDS out-of-pocket expenses electronically via Paperless Reimbursement (PR). To enroll in PR, visit www.FSAFEDS.com and click on My Account Summary, then Paperless Reimbursement. Please note that insurance premiums are not eligible expenses for either type of FSA.
If you have an HCFSA or LEX HCFSA FSAFEDS account and you haven’t exhausted your funds by December 31st of the plan year, FSAFEDS can automatically carry over up to $500 of unspent funds into another health care or limited expense account for the subsequent year. To be eligible for carryover, you must be employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31. You must also actively reenroll in a health care or limited expense account during the NEXT Open Season to be carryover eligible. Your reenrollment must be for at least the minimum of $100. If you do not reenroll, or if you are not employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31st, your funds will not be carried over.
Because of the tax benefits an FSA provides, the IRS requires that you forfeit any money for which you did not incur an eligible expense and file a claim in the time period permitted. This is known as the “Use-It-Or-Lose-It” rule. Carefully consider the amount you will elect.
For a health care or limited expense account, each participant must contribute a minimum of $100 to a maximum of $2,750.
Current FSAFEDS participants must re-enroll to participate next year. See www.fsafeds.com or call 1-877-FSAFEDS (372-3337) or TTY: 1-866-353-8058. Note: FSAFEDS is not open to retired employees, or to TRICARE eligible individuals.
If you enroll or are enrolled in a high deductible health plan with a health savings account (HSA) or health reimbursement arrangement (HRA), you can use your HSA or HRA to pay for qualified dental/vision costs not covered by your FEHB and FEDVIP plans. You will be required to submit your claim to the FSAFEDS Health Care Flexible Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA).
Section 3 How You Obtain Care
Term
Definition
Identification Cards/Enrollment Confirmation
Enroll online at www.benefeds.com. Upon confirmation of your enrollment, you will be sent a UnitedHealthcare Dental Plan identification card with your welcome packet.
Where You Get Covered Care
You may visit any provider in the UnitedHealthcare Dental network. Log on to www.myuhcdental.com/fedvip and select the provider locator option. You may also contact UnitedHealthcare Dental's 24-hour, toll-free Interactive Voice Response (IVR) system dedicated to Federal employees and annuitants at 1-866-315-2321 or TTY 711. You may elect to visit any dental provider to utilize your benefit, even if they are not part of the UnitedHealthcare Dental provider network.
Plan Providers
We list plan providers on our Web site at www.myuhcdental.com/fedvip. In addition, you can call UnitedHealthcare Dental Plan’s 24-hour, toll-free Interactive Voice Response (IVR) system dedicated to Federal employees and annuitants at 1-866-315-2321 or TTY 711.
In-Network
Once you locate an in-network provider, call the provider directly to schedule your appointment. Identify yourself as having UnitedHealthcare Dental coverage and provide the primary insured’s subscriber number and patient’s name and date of birth. You can find participating providers at www.myuhcdental.com/fedvip.
Out-of-Network
If you use a dentist outside the network, you may need to pay the difference between what the plan covers and what your dentist charges for the services. Plus, you may need to submit your own claims to the following address:
UnitedHealthcare Dental Attention: Claims Department P.O. Box 30567 Salt Lake City, UT 84130-0567
Emergency Services
All expenses for emergency services are payable as any other expense, subject to plan provisions. If you receive emergency services from an out-of-network dentist, benefits will be paid under the out-of-network plan provisions. You are responsible for the difference between the maximum allowed amount and the billed charge.
Maximum Amount Allowed
The maximum amount of reimbursement we allow for a specific procedure. When you use an in-network provider, the provider cannot bill you for the difference between the Maximum Allowed Amount and the billed charge. When you use an out-of-network provider, you are responsible for the difference between the Maximum Allowed Amount and the billed charge in addition to applicable coinsurance and deductible amounts.
Precertification
You and your dentist may request us to precertify dental procedures that your dentist plans to perform. We will provide an explanation of benefits to both you and your dentist that will indicate if procedures are covered and what we will pay for those specific services.
Alternate Benefit
If more than one service or procedure can be used to treat the covered person’s dental condition, UnitedHealthcare Dental may decide to authorize coverage only for the less costly covered service or procedure when that service is an appropriate method of treatment and the service meets broadly accepted national standards of dental practice. For example, this may apply but not limited to include: an amalgam or composite filling may be the alternate benefit of a crown or; a partial denture may be an alternate benefit for implants. Should the member and the dentist choose the more expensive treatment, the member is responsible for the additional charges beyond the allowance for the alternate service, even if an in-network provider.
Dental Review
UnitedHealthcare Dental Plan's claim review is conducted by licensed dental professionals who review the clinical documentation submitted by your treating dentist. These licensed dental professionals review the records checking for dental necessity for certain procedures such as crowns, bridges, onlays, implants, periodontal treatments, as well as other services. The licensed dental professionals may also recommend that an alternate benefit be applied to a service in accordance with the terms of the plan.
FEHB First Payor
When you visit a provider who participates with both your FEHB plan and your FEDVIP plan, the FEHB plan will pay benefits first. The FEDVIP plan allowance will be the prevailing charge in these cases. You are responsible for the difference between the FEHB and FEDVIP benefit payments and the FEDVIP plan allowance. UnitedHealthcare Dental is responsible for facilitating the process with the FEHB first payor. It is important to bring your FEDVIP and FEHB identification cards to every dental appointment to ensure that you are receiving the maximum allowable benefit under each program.
Coordination of Benefits
If you are covered under a non-FEHB plan, your UnitedHealthcare Dental benefits will be coordinated using traditional COB provisions for determining payment.
We will coordinate benefit payments with the payment of benefits under other group health benefits coverage (non-FEHB) you may have and the payment of dental costs under no-fault insurance that pays benefits without regard to fault.
Here is an example of how we would coordinate benefits if a non-FEHB plan was primary. This example assumes all deductibles have been met and annual maximums have not been reached. The amounts listed in the chart below are for example purposes only and do not reflect your non-FEHB or UnitedHealthcare Dental benefits. The example does not include your copay which you are responsible for paying.
UnitedHealthcare Dental coverage is secondary to non-FEHB coverage
In-Network Dentist's Fee: $200.00*
Plan Allowance: $150.00
Primary Plan's Scheduled Amount: $125.00
Primary Plan's Payment: $125.00
FEDVIP Payment: $25.00 ($150.00-$125.00)
Member Payment: $0.00
*You are not responsible for the $50.00 difference between the dentist’s fee and the plan allowance, when you use an in-network dentist. The dentist cannot bill you for this amount.
Rating Areas
Your rates are determined based on where you live. This is called a rating area. If you move, you must update your address through BENEFEDS. Your rates might change because of the move. Your rates will not be impacted if you temporarily reside at another location.
Limited Access Area
If you live in a limited access area* (defined as driving distance greater than 15 miles urban areas/ greater than 35 miles in rural areas) and you receive covered dental services from an out-of-network provider, we will pay the same plan allowances as if you utilized an in-network provider. It is important to note that you will be responsible for the difference between the billed amount and our payment. If you have any questions about limited access areas or you are having problems locating an in-network dentist in your area, please call us at 1-866-315-2321 or TTY 711
*NOTE: Access Standards
Limited Access does not apply to International Members.
Urban and suburban zip codes: at least 90% of Federal eligibles (employees and annuitants) in a network access area (zip code plus 15 driving-miles) must have access to a dental care preferred provider.
Rural zip codes: at least 80% of Federal eligibles (employees and annuitants) in a network access area (zip code plus 35 driving-miles) must have access to a dental care preferred provider.
Section 4 Your Cost For Covered Services
This is what you will pay out-of-pocket for covered care:
Term
Definition
Deductible
A deductible is a fixed amount of expenses you must incur for certain covered services and supplies before we will pay for covered services. Covered charges credited to the deductible are also counted towards the Plan maximum and limitations.
Class A In-Network High Option: $0 In-Network Standard Option: $0 Out-of-Network High Option: $0 Out-of-Network Standard Option: $100 (Self), $200 (Self Plus One), $300(Family)
Class B In-Network High Option: $0 In-Network Standard Option: $0 Out-of-Network High Option: $50 (Self), $100 (Self Plus One), $150 (Family) Out-of-Network Standard Option: $100 (Self), $200 (Self Plus One), $300(Family)
Class C In-Network High Option: $0 In-Network Standard Option: $0 Out-of-Network High Option: $50 (Self), $100 (Self Plus One), $150 (Family) Out-of-Network Standard Option: $100 (Self), $200 (Self Plus One), $300(Family)
Orthodontics In-Network High Option: $0 In-Network Standard Option: $0 Out-of-Network High Option: $0 Out-of-Network Standard Option: $0
Coinsurance
Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you meet your deductible, if applicable.
Class A In-Network High Option: 0% In-Network Standard Option: 0% Out-of-Network High Option: 10% Out-of-Network Standard Option: 10%
Class B In-Network High Option: 30% In-Network Standard Option: 45% Out-of-Network High Option: 40% Out-of-Network Standard Option: 60%
Class C In-Network High Option: 50% In-Network Standard Option: 65% Out-of-Network High Option: 60% Out-of-Network Standard Option: 80%
Orthodontics In-Network High Option: 50% In-Network Standard Option: 50% Out-of-Network High Option: 50% Out-of-Network Standard Option: 50%
Annual Benefit Maximum
Once you reach this amount, you are responsible for all additional charges. The Annual Benefit Maximums within each option are combined between in and out-of-network services. The total Annual Benefit Maximum will never be greater than the In-Network Maximum Annual Benefit.
Maximum Annual Benefits:
In-Network High Option: Unlimited In-Network Standard Option: $1,500 per person Out-of-Network High Option: Unlimited Out-of-Network Standard Option: $1,000 per person
Lifetime Benefit Maximum
The Lifetime Maximum is applicable to Orthodontia benefits only. The Lifetime Maximums within each option are combined between in and out-of-network services. There are no other lifetime maximums under this Plan.
Lifetime Orthodontic Maximum In-Network High Option: $4,000 per person In-Network Standard Option: $2,000 per person Out-of-Network High Option: $4,000 per person Out-of-Network Standard Option: $2,000 person
In-Network Services
You pay the coinsurance percentage of our network allowance for covered services. You are not responsible for charges above that allowance.
Out-of-Network Services
If the dentist you use is not part of our network, benefits will be considered at the out-of- network level. All services provided by an out-of-network dentist will be paid at out-of-network levels, except for limited access benefits. All benefit payments are based on UnitedHealthcare Dental’s Plan Allowance Amounts, which is a schedule of fixed dollar maximums established by UnitedHealthcare Dental for services by out-of-network providers. If a member chooses to go out of network, payments will be made directly to the member.
Calendar Year
The calendar year refers to the plan year, which is defined as January 1, 2022 to December 31, 2022.
Emergency Services
Emergency services are defined as those dental services needed to relieve pain or prevent the worsening of a condition that would be caused by a delay.
In-Progress Treatment
In-progress treatment for dependents of retiring active duty service members who were enrolled in the TRICARE Dental Program (TDP) will be covered for the 2022 plan year; regardless of any current plan exclusion for care initiated prior to the enrollee's effective date.
This requirement includes assumption of payments for covered orthodontia services up to the FEDVIP policy limits, and full payment where applicable up to the terms of FEDVIP policy for covered services completed (but not initiated) in the 2022 plan year such as crowns and implants.
This is not a requirement for carriers to provide in-progress coverage for orthodontia in a plan where an enrollee must meet a waiting period.
FEDVIP carriers will not cover in-progress treatment if you enroll in a FEDVIP plan that has a waiting period, or does not cover the service. Several FEDVIP dental plans have options that offer orthodontia coverage without a 12-month waiting period, and without age limits.
Section 5 Dental Services and Supplies Class A Basic
Important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are necessary for the prevention, diagnosis, care, or treatment of a covered condition and meet generally accepted dental protocols.
The calendar year deductible is $0 if you use an in-network provider. If you elect to use an out-of-network provider, the Standard Option has deductible amounts of $100 for Self, $200 for Self Plus One, and $300 for Family for Class A, B, and C services; High Option has deductible amounts of $50 for Self, $100 for Self Plus One, and $150 for Family for Class B and C services.
The Annual Benefit Maximums within each option are combined between in and out-of-network services. The total Annual Benefit Maximum will never be greater than the in-network Maximum Annual Benefit. The Standard Option Annual Benefit Maximum is $1,500 per person for in-network services or $1,000 per person for out-of-network services for Class A, B, and C services. The High Option does not have Annual Benefit Maximums for in-network services or out-of-network services for Class A, B, and C services.
The frequencies between your FEHB and UnitedHealthcare Dental policy are combined not separate. (ex. If 2 oral exams are covered under your FEHB policy, and 2 oral exams are covered under UnitedHealthcare Dental a total of 2 oral exams will be covered and coverage will coordinate between both policies)
All Exams, oral evaluations and treatments such as fluorides and some images are combined under one limitation under the plan. Complete set of radiographic images (D0210) and /or panoramic radiographic image (D0330) are combined and limited to one every 60 months. Periodic oral exam, (D0120) Oral evaluations (D0140, D0145), and Comprehensive oral exam (D0150, D0180) are combined and limited to two exams per calendar year.
All services requiring more than one visit are payable once all visits are completed.
The following list is an all-inclusive list of covered services. UnitedHealthcare Dental will provide benefits for these services, subject to the exclusions and limitations shown in this section and Section 7.
Included with your plan benefits is comprehensive coverage for various methods of annual oral cancer screenings for all adults. In addition included in your plan is a Supplemental Oral Cancer Benefit. Any UnitedHealthcare Dental member who receives a diagnosis of Oral, Head and Neck Cancer, and who has an impact to their teeth and supporting structures, is eligible for a one-time single lump sum payment of $2,000 to cover expenses such as lost wages, child care, and more. This added financial benefit can be used at the member’s discretion as they navigate the various demands this diagnosis may bring. This is a fixed oral cancer benefit to aid with the unexpected dental care and personal disruptions often bringing an added financial burden.
Any dental service or treatment not listed as a covered service is not eligible for benefits.
You Pay:
High Option
In-Network: Preventive and Diagnostic services - $0 for covered services as defined by the plan subject to plan maximums.
Out-of-Network: Preventive and Diagnostic services – After deductible, you pay 10% of the plan allowance, subject to plan maximums. You are responsible for the difference between the plan payment and the amount billed by the provider.
Standard Option
In-Network: Preventive and Diagnostic services - $0 for covered services as defined by the plan subject to plan maximums.
Out-of-Network: Preventative and Diagnostic services - After deductible, you pay 10% of the plan allowance, subject to plan maximums. You are responsible for the difference between the plan payment and the amount billed by the provider.
Details
Diagnostic and Treatment Services
D0120 Periodic oral evaluation - Limited to 2 times per calendar year
D0140 Limited oral evaluation - problem focused- Limited to 2 times per calendar year
D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver - Limited to 2 times per calendar year
D0150 Comprehensive oral evaluation - new or established patient- Limited to 2 times per calendar year
D0170 Re-evaluation, limited, problem focused- Limited to 2 times per calendar year
D0180 Comprehensive periodontal evaluation - new or established patient - Limited to 2 times per calendar year
D0210 Intraoral - complete set of radiographic images including bitewings – Limited to 1 per 60 months
D0220 Intraoral - periapical first film- 8 images per calendar year
D0230 Intraoral - each additional periapical film - 8 images per calendar year
D0240 Intraoral - occlusal radiographic image - 4 images per calendar year
D0250 Extraoral - 2D projection radiographic image - Limited to 2 images per calendar year
D0251 Extraoral - posterior dental radiographic image - Limited to 2 images per calendar year
D0270 Bitewing - single film – Limited to 1 series of images per calendar year
D0272 Bitewings - two films - Limited to 1 series of images per calendar year
D0273 Bitewings - three films -Limited to 1 series of images per calendar year
D0274 Bitewings - four films - Limited to 1 series of images per calendar year
D0277 Bitewings - Seven to eight radiographic images - Limited to 1 series of images per calendar year
D0330 Panoramic radiographic image - 1 complete series or a panoramic radiographic image per 60 months.
D0350 Oral/facial images (including intra and extraoral images)- Limited to 1 time per consecutive 36 months
D0391 Interpretation of Diagnostic Image
D0414 Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report
D0415 Collection of microorganisms for culture and sensitivity
D0416 Viral culture
D0422 Collection and preparation of genetic sample material for laboratory analysis and report- Limited to 1 per 60 months
D0423 Genetic test for susceptibility to disease - specimen analysis- Limited to 1 per 60 months
D0425 Caries susceptibility tests- Limited to 1 per 60 months
D0486 Accession of brush biopsy
D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesion. – Limited to 1 time per calendar year for adults
D0460 Pulp vitality tests- Limited to 1 charge per visit, regardless of how many teeth are tested.
D0470 Diagnostic casts- Limited to 1 time per consecutive 24 months
D0600 Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin and cementum- Limited to 1 per 36 months
D0601 Caries risk assessment and documentation, with a finding of low risk- Limited to 2 times per calendar year
D0602 Caries risk assessment and documentation, with a finding of moderate risk- Limited to 2 times per calendar year
D0603 Caries risk assessment and documentation, with a finding of high risk- Limited to 2 times per calendar year
D9995 Teledentistry - synchronous; real-time encounter- Limited to 2 times per calendar year
D9996 Teledentistry - asynchronous; information stored and forwarded to dentist for subsequent review- Limited to 2 times per calendar year
Preventive Services
D1110 Prophylaxis – Adult: Age 13 and under will be processed as D1120 - Limited to 2 times per calendar year
D1120 Prophylaxis – Child: Age 14 and over will be processed as D1110 - Limited to 2 times per calendar year
D1206 Topical Fluoride - Varnish - Limited to 2 times per calendar year
D1208 Topical application of fluoride - Limited to 2 times per calendar year
D1351 Sealant - per tooth - Limited to covered persons under the age of 19 years and once per first or second permanent molar every consecutive 36 months
D1352 Preventive resin restorations in a moderate to high caries risk patient - permanent tooth- Limited to covered persons under the age of 19 years and once per first or second permanent molar every consecutive 36 months
D1353 Sealant repair -per tooth - Limited to covered persons under the age of 19 years and once per first or second permanent molar every 36 months
D1354 Interim caries arresting medicament application - Limited per permanent (molars & premolars) tooth per 36 months, excludes wisdom teeth
D1510 Space maintainer - fixed - unilateral - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation
D1516 Space maintainer – fixed – bilateral, maxillary - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation
D1517 Space maintainer – fixed – bilateral, mandibular - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation
D1520 Space maintainer - removable – unilateral - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation
D1526 space maintainer – removable – bilateral, maxillary - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation
D1527 space maintainer – removable – bilateral, mandibular - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation
D1551 Re-cement or re-bond bilateral space maintainer – maxillary- Limited to 1 per consecutive 6 months after initial insertion
D1552 Re-cement or re-bond bilateral space maintainer – mandibular- Limited to 1 per consecutive 6 months after initial insertion
D1553 Re-cement or re-bond unilateral space maintainer – per quadrant- Limited to 1 per consecutive 6 months after initial insertion
D1556 Removal of fixed unilateral space maintainer - per quadrant
D1557 Removal of fixed bilateral space maintainer - maxillary
D1558 Removal of fixed bilateral space maintainer - mandibular
D1575 Distal shoe space maintainer - Fixed – Unilateral - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation
D9110 Palliative treatment of dental pain - minor procedure - Covered as a separate benefit only if no other services, other than exam and radiographs were done on the same tooth during the visit
D9440 Office visit after regularly scheduled hours- Limited to 1 per calendar year. Subject to clinical review and necessity
Services Not Covered
Refer to Section 7 for a list of general exclusions
Class B Intermediate
Important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are necessary for the prevention, diagnosis, care, or treatment of a covered condition and meet generally accepted dental protocols.
The calendar year deductible is $0 if you use an in-network provider. If you elect to use an out-of-network provider, the Standard Option has deductible amounts of $100 for Self, $200 for Self Plus One, and $300 for Family for Class A, B, and C services; High Option has deductible amounts of $50 for Self, $100 for Self Plus One, and $150 for Family for Class B and C services.
The Annual Benefit Maximums within each option are combined between in and out-of-network services. The total Annual Benefit Maximum will never be greater than the in-network Maximum Annual Benefit. The Standard Option Annual Benefit Maximum is $1,500 per person for in-network services or $1,000 per person for out-of-network services for Class A, B, and C services. The High Option does not have Annual Benefit Maximums for in-network services or out-of-network services for Class A, B, and C services.
The frequencies between your FEHB and UnitedHealthcare Dental policy are combined not separate. (ex. If 2 oral exams are covered under your FEHB policy, and 2 oral exams are covered under UnitedHealthcare Dental a total of 2 oral exams will be covered and coverage will coordinate between both policies).
If more than one service or procedure can be used to treat the covered person’s dental condition, UnitedHealthcare Dental may decide to authorize coverage only for the less costly covered service or procedure when that service is an appropriate method of treatment and the service meets broadly accepted national standards of dental practice. This may apply but not limited to include: an amalgam or composite filling may be the alternate benefit of a crown or only, a partial denture may be an alternate benefit for implants. Should the member and the dentist choose the more expensive treatment, the member is responsible for the additional charges beyond the allowance for the alternate service, even if an in-network provider.
All services requiring more than one visit are payable once all visits are completed.
Amalgam/Resin - Multiple restorations on one surface will be treated as a single filling
D2391 – D2934 Resin-based composite - Alternate benefitting for molars only
The following list is an all-inclusive list of covered services. UnitedHealthcare Dental will provide benefits for these services, subject to the exclusions and limitations shown in this section and Section 7.
Included with your plan benefits is comprehensive coverage for various methods of annual oral cancer screenings for all adults. In addition included in your plan is a Supplemental Oral Cancer Benefit. Any UnitedHealthcare Dental member who receives a diagnosis of Oral, Head and Neck Cancer, and who has an impact to their teeth and supporting structures, is eligible for a one-time single lump sum payment of $2,000 to cover expenses such as lost wages, child care, and more. This added financial benefit can be used at the member’s discretion as they navigate the various demands this diagnosis may bring. This is a fixed oral cancer benefit to aid with the unexpected dental care and personal disruptions often bringing an added financial burden.
Any dental service or treatment not listed as a covered service is not eligible for benefits.
You Pay:
High Option
In-Network: 30% for covered services as defined by the plan subject to plan maximums.
Out-of-Network: After deductible, you pay 40% of the plan allowance, subject to plan maximums. You are responsible for the difference between the plan payment and the amount billed by the provider.
Standard Option
In-Network: 45% for covered services as defined by the plan subject to plan maximums.
Out-of-Network: After deductible, you pay 60% of the plan allowance, subject to plan maximums. You are responsible for the difference between the plan payment and the amount billed by the provider.
Details
Minor Restorative Services
D2140 Amalgam – one surface, primary or permanent
D2150 Amalgam – two surfaces, primary or permanent
D2160 Amalgam – three surfaces, primary or permanent
D2161 Amalgam – four or more surfaces, primary or permanent
D2330 Resin-based composite – one surface, anterior
D2331 Resin-based composite – two surfaces, anterior
D2332 Resin-based composite – three surfaces, anterior
D2335 Resin-based composite – four or more surfaces or involving incisal angle (anterior)
D2391 Resin-based composite – one surface, posterior
D2392 Resin-based composite – two surfaces, posterior
D2393 Resin-based composite – three surfaces, posterior
D2394 Resin-based composite – four or more surfaces, posterior
D2610 Inlay - porcelain/ceramic, one surface- Limited to 1 time per tooth per consecutive 60 months
D2620 Inlay - porcelain/ceramic, two surfaces- Limited to 1 time per tooth per consecutive 60 months.
D2630 Inlay - porcelain/ceramic, three or more surfaces- Limited to 1 time per tooth per consecutive 60 months.
D2910 Re-cement inlay - Limited to 1 per consecutive 12 months. Limited to those performed more than 12 months after the initial insertion
D2915 Re-cement cast or prefab post and core - Limited to 1 per consecutive 12 months. Limited to those performed more than 12 months after the initial insertion
D2920 Re-cement crown - Limited to 1 per consecutive 12 months. Limited to those performed more than 12 months after the initial insertion
D2921 Re-attachment of tooth fragment – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months.
D2929 Prefabricated porcelain/ceramic crown – primary tooth – Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling can not restore the tooth. Prefabricated esthetic coated stainless steel crown- primary tooth are limited to primary anterior teeth
D2930 Prefabricated stainless steel crown - primary tooth – Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling can not restore the tooth. Prefabricated esthetic coated stainless steel crown- primary tooth are limited to primary anterior teeth.
D2931 Prefabricated stainless steel crown – permanent tooth – Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling can not restore the tooth.
D2940 Protective Restoration- Covered as a separate benefit only if no other service, other than x-rays and exam, were performed on the same tooth during the visit
D2951 Pin retention – per tooth, in addition to restoration- Limited to 2 pins per tooth; not Covered in addition to cast restoration. Limited to 1 time per consecutive 60 months.
Endodontic Services
D3110 Pulp cap - direct (excluding final restoration)- Not Covered if utilized solely as a liner or base underneath a restoration
D3120 Pulp cap - indirect (excluding final restoration)- Not Covered if utilized solely as a liner or base underneath a restoration
D3220 Therapeutic pulpotomy (excluding final restoration) - Limited to 1 time per primary or secondary tooth per lifetime
D3221 Pulpal debridement, primary and permanent teeth- Limited to 1 time per tooth per lifetime. Not covered on the same day as other endodontic services
D3222 Partial pulpotomy for apexogenesis – permanent teeth with incomplete root development- Limited to 1 time per primary or secondary tooth per lifetime.
D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) - Limited to 1 per tooth per lifetime.
D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) - Limited to 1 per tooth per lifetime.
D3331 Treatment of root canal obstruction, non-surgical access- Limited to 1 time per tooth per lifetime
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth- Limited to 1 time per tooth per lifetime
D3333 Internal tooth repair of performation defects- Limited to 1 time per tooth per lifetime
D3355 Pulpal regeneration - initial visit- Limited to 1 time per tooth per lifetime
D3356 Pulpal regeneration - interim medication replacement- Limited to 1 time per tooth per lifetime
D3357 Pulpal regeneration - completion of treatment- Limited to 1 time per tooth per lifetime
D3427 Periradicular surgery without apioectomy- Limited to 1 time per tooth per lifetime
D3430 Retrograde filling - per root- Limited to 1 time per tooth per lifetime
Periodontal Services
D4230 Anatomical crown exposure - four or more contiguous teeth or bounded spaces per quadrant- Limited to 1 per quadrant or site per consecutive 36 months
D4231 Anatomical crown exposure - one to three teeth or tooth bounded tooth spaces per quadrant- Limited to 1 per quadrant or site per consecutive 36 months
D4245 Apically positioned flap- Limited to 1 per quadrant or site per consecutive 36 months
D4264 Bone replacement graft - each additional site in quadrant- Limited to 1 per consecutive 36 months. For D4263 see Class C services.
D4265 Biologic materials to aid in soft and osseous tissue regeneration- Limited to 1 per consecutive 36 months
D4266 Guided tissue regeneration - resorbable barrier, per site- Limited to 1 per consecutive 36 months
D4267 Guided tissue regeneration - nonresorbable barrier, per site (Includes membrane removal)- Limited to 1 per consecutive 36 months
D4268 Surgical revision procedure, per tooth- Limited to 1 per quadrant or site per consecutive 36 months. For D4263 see Class C services.
D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) - Limited to 1 per quadrant or site per consecutive 36 months
D4276 Combined connective tissue and double pedicle graft, per tooth- Limited to 1 per quadrant or site per consecutive 36 months
D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous Tooth- Limited to 1 per quadrant or site per consecutive 36 months
D4320 Provisional splinting – intracoronal- Cannot be used to restore vertical dimension or as part of full mouth rehabilitation, should not include use of laboratory based crowns and or fixed partial dentures (bridges) Exclusion of laboratory based crowns or bridges for the purposes of provisional splinting
D4321 Provisional splinting – extracoronal- Cannot be used to restore vertical dimension or as part of full mouth rehabilitation, should not include use of laboratory based crowns and or fixed partial dentures (bridges) Exclusion of laboratory based crowns or bridges for the purposes of provisional splinting
D4341 Periodontal scaling and root planing -Limited to 1 time per quadrant per consecutive 24 months
D4342 Periodontal scaling and root planing - one to three teeth per quadrant – Limited to 1 time per quadrant per consecutive 24 months.
D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation- Limited to 2 times per calendar year in combination with prophylasis and periodontal maintenance
D4381 Localized delivery of antimicrobial agents- Limited to 3 sites per quadrant or 12 sites total for refractory pockets or in conjunction with Periodontal Scaling and Root Planing
D4910 Periodontal maintenance - Limited to the maximum of 4 per calendar year in combination with adult prophylasis and scaling in presence of generalized moderate or severe gingival inflammation
D4920 Unscheduled dressing change (by someone other than treating dentist)- Limited to 1 per consecutive 6 months Limited to 1 per day
D4999 Periodontal procedure, unspecified by report- Subject to clinical review and necessity.
Prosthodontic Services
D5410 Adjust complete denture – maxillary - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5411 Adjust complete denture – mandibular - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5421 Adjust partial denture – maxillary - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5422 Adjust partial denture – mandibular - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5511 Repair broken complete denture base mandibular - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5512 Repair broken complete denture base, maxillary - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5520 Replace missing or broken teeth – complete denture (each tooth) - Limit 1 beginning 6 months after the initial installation
D5611 Repair resin denture base mandibular - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5612 Repair resin partial denture base, maxillary - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5621 Repair cast framework - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5622 Repair cast partial framework, maxillary - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5630 Repair or replace broken retentive/clasping materials per tooth - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5640 Replace broken teeth – per tooth - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5650 Add tooth to existing partial denture - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5660 Add clasp to existing partial denture - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5670 Replace all teeth and acrylic on cast metal framework, maxillary – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5671 Replace all teeth and acrylic on cast metal framework, mandibular – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D5710 Rebase complete maxillary denture – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5711 Rebase complete mandibular denture – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5720 Rebase maxillary partial denture – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5721 Rebase mandibular partial denture - Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5730 Reline complete maxillary denture (chairside) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5731 Reline complete mandibular denture (chairside) - Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5740 Reline maxillary partial denture (chairside) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5741 Reline mandibular partial denture (chairside) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5750 Reline complete maxillary denture (lab) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5751 Reline complete mandibular denture (lab) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5760 Reline maxillary partial denture (lab) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5761 Reline mandibular partial denture (lab) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months
D5850 Tissue conditioning (maxillary)- Limited to 1 time per consecutive 12 months
D5851 Tissue conditioning (mandibular)- Limited to 1 time per consecutive 12 months
D6092 Re-cement Implant / Abutment supported crown- Limited to 1 time per consecutive 6 months
D6093 Re-cement Implant / Abutment supported fixed partial denture- Limited to 1 time per consecutive 6 months
D6930 Re-cement fixed partial denture - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months.
D6980 Fixed partial denture repair, by report- Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months.
D7260 Oroantral fistula closure- Limited to one per site per visit
D7261 Primary closure of a sinus perforation- Limited to 1 time per tooth per lifetime
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth- Limited to 1 per site per lifetime
D7272 Tooth transplantation - includes splinting or stabilization- Limited to 1 per site per lifetime
D7280 Surgical access of an unerupted tooth- Limited to 1 per tooth per lifetime
D7282 Mobilization of erupted or malpositioned tooth to aid eruption- Limited to 1 per tooth per lifetime
D7283 Placement of device to facilitate eruption of impacted tooth- Limited to 1 per tooth per lifetime
D7285 Biopsy of oral tissue - hard (bone, tooth)- Limited to 1 per site per visit
D7286 Biopsy of oral tissue - soft (all others)- Limited to 1 per site per visit
D7287 Exfolliative cytological sample collection – Limited to 1 per site visit
D7288 Brush biopsy - transepithelial sample collection- Limited to 1 per site per visit
D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report- Limited to 1 per tooth per lifetime
D7310 Alveoloplasty in conjunction with extractions – per quadrant
D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant
D7320 Alveoloplasty not in conjunction with extractions – per quadrant
D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant
D7410 Excision of benign lesion up to 1.25 cm- Limited to 1 per site per visit
D7411 Excision of benign lesion greater than 1.25 cm- Limited to 1 per site per visit
D7412 Excision of benign lesion, complicated- Limited to 1 per site per visit
D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm- Limited to 1 per site per visit
D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm- Limited to 1 per site per visit
D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm- Limited to 1 per site per visit
D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm- Limited to 1 per site per visit
D7471 Removal of exostosis- Limited to 1 per site per visit
D7510 Incision and drainage of abscess – intraoral soft tissue- Limited to 1 per site per visit
D7511 Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)- Limited to 1 per site per visit
D7520 Incision and drainage of abscess - extraoral soft tissue- Limited to 1 per site per visit
D7521 Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces)- Limited to 1 per site per visit
D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue- Limited to 1 per site per visit
D7540 Removal of reaction-producing foreign bodies - musculoskeletal system- Limited to 1 per site per visit
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone- Limited to 1 per site per visit
D7910 Suture of recent small wounds up to 5 cm- Limited to 1 per site per visit
D7921 Collect - Apply Autologous Product – Limited to 1 per consecutive 36 months
D7953 Bone replacement graft for ridge preservation - per site – Limited to 1 per site per lifetime. Not covered if done in conjunction with other bone graft replacement procedures.
D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure
D7963 Frenuloplasty
D7970 Excision of hyperplastic tissue - per arch- Limited to 1 site per consecutive 36 months
D7971 Excision of pericoronal gingiva- Limited to 1 site per consecutive 36 months
D7972 Reduction of fibrous tuberosity – Limited to 1 site per consecutive 36 months
D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar- Limited to once per appliance per lifetime
D7999 Unspecified oral surgery procedure, by report- Subject to clinical review and necessity.
Other Services
D9210 Local anesthesia not in conjunction with operative or surgical procedures- Not Covered in conjunction with operative or surgical procedure – Limited to 1 time per tooth per consecutive 60 months
D9219 Evaluation for moderate sedation, deep sedation or general anesthesia- Covered when Necessary in conjunction with covered dental services. If required for patients under 6 years of age or patients with behavioral problems or physical disabilities or if it is clinically necessary. Covered for patients over age of 6 if it is clinically necessary.
D9223 Deep sedation/general anesthesia - each subsequent 15 minute increment- Covered when Necessary in conjunction with covered dental services. If required for patients under 6 years of age or patients with behavioral problems or physical disabilities or if it is clinically necessary. Covered for patients over age of 6 if it is clinically necessary.
D9230 Analgesia anxiolysis, inhalation of nitrous oxide- Covered when Necessary in conjunction with covered dental services. If required for patients under 6 years of age or patients with behavioral problems or physical disabilities or if it is clinically necessary. Covered for patients over age of 6 if it is clinically necessary.
D9248 Non-intravenous conscious sedation- Covered when Necessary in conjunction with covered dental services. If required for patients under 6 years of age or patients with behavioral problems or physical disabilities or if it is clinically necessary. Covered for patients over age of 6 if it is clinically necessary.
D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment)- Not covered if done with exams or professional visit
D9612 Therapeutic parenteral drugs, two or more administrations, different medications- Limited to 1 per visit
D9630 Other drugs and/or medicaments, by report- Limited to 1 per site per 6 months
D9910 Application of desensitizing medicament- Limited to 1 per site per 6 months
D9911 Application of desensitizing resin for cervical and/or root surface, per tooth- Limited to 1 per site per 6 months
D9950 Occlusion analysis - mounted case- Limited to 1 time per consecutive 60 months
D9951 Occlusal adjustment – limited- Limited to 1 per site per 6 months
D9952 Occlusal adjustment – complete- Limited to 1 per site per 6 months
Services Not Covered
Refer to Section 7 for a list of general exclusions
Class C Major
Important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are necessary for the prevention, diagnosis, care, or treatment of a covered condition and meet generally accepted dental protocols.
The calendar year deductible is $0 if you use an in-network provider. If you elect to use an out-of-network provider, the Standard Option has deductible amounts of $100 for Self, $200 for Self Plus One, and $300 for Family for Class A, B, and C services; High Option has deductible amounts of $50 for Self, $100 for Self Plus One, and $150 for Family for Class B and C services.
The Annual Benefit Maximums within each option are combined between in and out-of-network services. The total Annual Benefit Maximum will never be greater than the in-network Maximum Annual Benefit. The Standard Option Annual Benefit Maximum is $1,500 per person for in-network services or $1,000 per person for out-of-network services for Class A, B, and C services. The High Option does not have Annual Benefit Maximums for in-network services or out-of-network services for Class A, B, and C services.
If more than one service or procedure can be used to treat the covered person’s dental condition, UnitedHealthcare Dental may decide to authorize coverage only for the less costly covered service or procedure when that service is an appropriate method of treatment and the service meets broadly accepted national standards of dental practice. This may apply but not limited to include: an amalgam or composite filling may be the alternate benefit of a crown or only, a partial denture may be an alternate benefit for implants. Should the member and the dentist choose the more expensive treatment, the member is responsible for the additional charges beyond the allowance for the alternate service, even if an in-network provider.
All services requiring more than one visit are payable once all visits are completed.
The following list is an all-inclusive list of covered services. UnitedHealthcare Dental will provide benefits for these services, subject to the exclusions and limitations shown in this section and Section 7.
Included with your plan benefits is comprehensive coverage for various methods of annual oral cancer screenings for all adults. In addition included in your plan is a Supplemental Oral Cancer Benefit. Any UnitedHealthcare Dental member who receives a diagnosis of Oral, Head and Neck Cancer, and who has an impact to their teeth and supporting structures, is eligible for a one-time single lump sum payment of $2,000 to cover expenses such as lost wages, child care, and more. This added financial benefit can be used at the member’s discretion as they navigate the various demands this diagnosis may bring. This is a fixed oral cancer benefit to aid with the unexpected dental care and personal disruptions often bringing an added financial burden.
Any dental service or treatment not listed as a covered service is not eligible for benefits.
You Pay:
High Option
In-Network: No deductible; you pay 50% of the plan allowance for covered services as defined by the plan.
Out-of-Network: After deductible, you pay 60% of the plan allowance for covered services as defined by the plan and any difference between our allowance and the billed amount.
Standard Option
In-Network: No deductible; you pay 65% of the plan allowance for covered services as defined by the plan subject to plan maximums.
Out-of-Network: After deductible, you pay 80% of the plan allowance for covered services as defined by the plan subject to plan maximums and any difference between our allowance and the billed amount.
Details
Major Restorative Services
D2410 Gold Foil – one surface – Multiple restorations on one surface will be treated as a single filling
D2420 Gold Foil – two surfaces – Multiple restorations on one surface will be treated as a single filling
D2430 Gold Foil – three surfaces – Multiple restorations on one surface will be treated as a single filling
D2510 Inlay - metallic - one surface - Limited to 1 time per tooth per consecutive 60 months.
D2520 Inlay - metallic - two surfaces - Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth. Not covered if done in conjunction with any other inlay, onlay and crown codes except post and core buildup codes.
D2530 Inlay - metallic - three surfaces – Limited to 1 per tooth per 60 consecutive months.
D2542 Onlay - metallic - two surfaces – Limited to 1 per tooth per consecutive 60 months
D2543 Onlay - metallic - three surfaces – Limited to 1 per tooth per consecutive 60 months
D2544 Onlay - metallic - four or more surfaces – Limited to 1 per tooth per consecutive 60 months
D2642 Onlay-porcelain - two surfaces – Limited to 1 per tooth per consecutive 60 months, including crowns, bridges, prosthetics
D2643 Onlay-porcelain - three surfaces – Limited to 1 per tooth per consecutive 60 months, including crowns, bridges, prosthetics
D2644 Onlay porcelain - four or more surfaces – Limited to 1 per tooth per consecutive 60 months, including crowns, bridges, prosthetics
D2650 Inlay-composite - one surface, lab proc – Limited to 1 per tooth per consecutive 60 months
D2651 Inlay-composite - two surfaces, lab proc – Limited to 1 per tooth per consecutive 60 months
D2652 Inlay-composite - three surfaces, lab proc – Limited to 1 per tooth per consecutive 60 months
D2662 Onlay-composite - two surfaces, lab proc – Limited to 1 per tooth per consecutive 60 months
D2663 Onlay-composite - three surfaces, lab proc – Limited to 1 per tooth per consecutive 60 months
D2664 Onlay-composite - four or more surfaces, lab proc – Limited to 1 per tooth per consecutive 60 months
D2710 Crown resin, lab proc – Limited to 1 per tooth per consecutive 60 months
D2712 Crown 3/4 resin, lab proc – Limited to 1 per tooth per consecutive 60 months
D2720 Crown resin/high noble metal – Limited to 1 per tooth per consecutive 60 months
D2721 Crown resin/pred base metal – Limited to 1 per tooth per consecutive 60 months
D2722 Crown resin/noble metal – Limited to 1 per tooth per consecutive 60 months
D2740 Crown - porcelain/ceramic – Limited to 1 per tooth per consecutive 60 months
D2750 Crown - porcelain fused to high noble metal – Limited to 1 per tooth per consecutive 60 months
D2751 Crown - porcelain fused to predominately base metal – Limited to 1 per tooth per consecutive 60 months
D2752 Crown - porcelain fused to noble metal – Limited to 1 per tooth per consecutive 60 months
D2753 Crown - porcelain fused to titanium and titanium alloys – Limited to 1 time per tooth per consecutive 60 months
D2780 Crown - 3/4 cast high noble metal - Limited to 1 per tooth per consecutive 60 months
D2781 Crown - 3/4 cast predominately base metal – Limited to 1 per tooth per consecutive 60 months
D2782 Crown - 3/4 cast noble metal – Limited to 1 per tooth per consecutive 60 months
D2783 Crown - 3/4 porcelain/ceramic – Limited to 1 per tooth per consecutive 60 months
D2790 Crown - full cast high noble metal – Limited to 1 per tooth per consecutive 60 months
D2791 Crown - full cast predominately base metal – Limited to 1 per tooth per consecutive 60 months
D2792 Crown - full cast noble metal – Limited to 1 per tooth per consecutive 60 months
D2794 Crown - titanium and titanium alloys - Limited to 1 per tooth per consecutive 60 months
D2932 Crown prefabricated resin - Limited to 1 per tooth per consecutive 60 months
D2933 Crown prefabricated stainless steel crown/resin window – Limited to 1 per tooth per consecutive 60 months
D2934 Prefabricated esthetic coated stainless steel crown, primary tooth – Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth. Prefabricated esthetic coated stainless steel crown-primary tooth are limited to primary anterior teeth
D2950 Core buildup, including any pins – Limited to 1 per tooth per consecutive 60 months when there is significant loss of tooth structure and deemed Necessary based on clinical review
D2952 Crown cast post/core – Covered only for teeth that have had root canal therapy. Limited to 1 per tooth per consecutive 60 months
D2953 Each additional indirectly fabricated post, same tooth – Covered only for teeth that have had root canal therapy. Limited to 1 per tooth per consecutive 60 months
D2954 Prefabricated post and core, in addition to crown – Covered only for teeth that have had root canal therapy. Limited to 1 per tooth per consecutive 60 months
D2957 Each additional prefabricated post, same tooth
D2960 Labial veneer (laminate) – chairside - Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth
D2961 Labial veneer (resin laminate) – laboratory - Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth
D2962 Labial veneer (porcelain laminate) – laboratory - Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth
D2975 Coping - Limited to 1 per tooth per consecutive 60 months
D2980 Crown repair, by report – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D2981 Inlay Repair - Limit 1 every 12 months- Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D2982 Onlay Repair – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D2983 Veneer Repair – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months
D2990 Resin infiltration/smooth surface- Limited to 1 per consecutive 36 months
Endodontic Services
D3310 Anterior root canal (excluding final restoration) Limited to 1 time per tooth per lifetime. Dentist cannot charge retreatment codes on tooth treated for the first 12 months.
D3320 Premolar root canal (excluding final restoration) Limited to 1 time per tooth per lifetime. Dentist cannot charge retreatment codes on tooth treated for the first 12 months.
D3330 Molar root canal (excluding final restoration) Limited to 1 time per tooth per lifetime. Dentist cannot charge retreatment codes on tooth treated for the first 12 months.
D3346 Retreatment of previous root canal therapy – anterior
D3347 Retreatment of previous root canal therapy – premolar
D3348 Retreatment of previous root canal therapy – molar
D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.) - Limited to 1 per tooth per lifetime
D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) - Limited to 1 per tooth per lifetime
D3353 Apexification/recalcification – final visit (includes completed root canal therapy, apical closure/calcific repair of perforations, root resorption, etc.) - Limited to 1 per tooth per lifetime
D3410 Apicoectomy/periradicular surgery – anterior - Limited to 1 per tooth per lifetime
D3421 Apicoectomy/periradicular surgery – premolar (first root) - Limited to 1 per tooth per lifetime
D3425 Apicoectomy/periradicular surgery – molar (first root) - Limited to 1 per tooth per lifetime
D3426 Apicoectomy/periradicular surgery (each additional root) - Limited to 1 per tooth per lifetime
D3450 Root amputation – per root - Limited to 1 per tooth per lifetime
D3920 Hemisection (including any root removal) – not including root canal therapy - Limited to 1 per tooth per lifetime
Periodontal Services
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces, per quadrant – Limited to 1 per quadrant or site per consecutive 36 months
D4211 Gingivectomy or gingivoplasty – one to three teeth, per quadrant – Limited to 1 per quadrant or site per consecutive 36 months
D4212 Gingivectomy or gingivoplasty - with restorative procedures, per tooth – Limited to 1 per quadrant or site per consecutive 36 months
D4240 Gingival flap procedure, including root planing, four or more contiguous teeth or bounded teeth spaces per quadrant – Limited to 1 per quadrant or site per consecutive 36 months
D4241 Gingival flap procedure, including root planing, one to three teeth per quadrant – Limited to 1 per quadrant or site consecutive 36 months
D4249 Clinical crown lengthening – hard tissue – Limited to 1 per quadrant or site per consecutive 36 months
D4260 Osseous surgery (including flap entry and closure), four or more contiguous teeth or bounded teeth spaces per quadrant – Limited to 1 per consecutive 36 months
D4261 Osseous surgery (including flap entry and closure), one to three contiguous teeth or bounded teeth spaces per quadrant – Limited to 1 per consecutive 36 months
D4263 Bone replacement graft – First site in quad – permanent teeth only - Limited to 1 per consecutive 36 months. For D4264 and D4268 see Class B services.
D4270 Pedicle soft tissue graft procedure – Limited to 1 per quadrant or site per consecutive 36 months
D4273 Autogenous connective tissue graft procedures first tooth (including donor and recipient site surgery) – Limited to 1 per quadrant or site per consecutive 36 months
D4274 Distal/proximal wedge – permanent teeth only - Limited to 1 per quadrant or site per consecutive 36 months
D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft - Limited to 1 per quadrant or site per consecutive 36 months
D4278 Free soft tissue graft procedure - additional teeth – Limited to 1 per quadrant or site per consecutive 36 months. For D4277 see Class B services.
D4283 Autogenous connective tissue graft procedures, additional tooth (including donor and recipient site surgery) – Limited to 1 per quadrant or site per consecutive 36 months
D4285 Non-autogenous connective tissue graft procedures, additional tooth (including donor and recipient site surgery) – Limited to 1 per quadrant or site per consecutive 36 months
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis - Limited to 1 per consecutive 36 months
Prosthodontic Services
D5110 Complete denture – maxillary – Limited to 1 per consecutive 60 months
D5120 Complete denture - mandibular – Limited to 1 per consecutive 60 months
D5130 Immediate denture – maxillary – Limited to 1 per consecutive 60 months
D5140 Immediate denture - mandibular – Limited to 1 per consecutive 60 months
D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limited to 1 per consecutive 60 months
D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limited to 1 per consecutive 60 months
D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) – Limited to 1 per consecutive 60 months
D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) – Limited to 1 per consecutive 60 months
D5221 Immediate maxillary partial denture, resin base – (including retentive/clasping materials, rests and teeth) – Limited to 1 per consecutive 60 months
D5222 Immediate mandibular partial denture, resin base – (including retentive/clasping materials, rests and teeth) – Limited to 1 per consecutive 60 months
D5223 Immediate maxillary partial denture, cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) -Limited to 1 per consecutive 60 months
D5224 Immediate mandibular partial denture, cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)- Limited to 1 per consecutive 60 months
D5225 Maxillary partial denture – flexible base – Limited to 1 per consecutive 60 months
D5226 Mandibular partial denture – flexible base – Limited to 1 per consecutive 60 months
D5282 Removable unilateral partial denture - one piece cast metal (including clasps/teeth), maxillary – Limited to 1 per consecutive 60 months
D5283 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), mandibular - Limited to 1 per consecutive 60 months
D5284 Removable unilateral partial denture – one piece flexible base (including clasps and teeth) – per quadrant – Limited to 1 per consecutive 60 months
D5286 Removable unilateral partial denture – one piece resin (including clasps and teeth) – per quadrant – Limited to 1 per consecutive 60 months
D5810 Interim complete denture (maxillary) - Limited to 1 per consecutive 60 months
D5811 – Interim complete denture (mandibular) - Limited to 1 per consecutive 60 months
D5820 – Interim partial denture (maxillary) - Limited to 1 per consecutive 60 months
D5821 – Interim partial denture (mandibular) - Limited to 1 per consecutive 60 months
D5863 Overdenture – complete maxillary - Limited to 1 per consecutive 60 months
D5864 Overdenture – partial maxillary - Limited to 1 per consecutive 60 months
D5865 Overdenture – complete mandibular - Limited to 1 per consecutive 60 months
D5866 Overdenture – partial mandibular - Limited to 1 per consecutive 60 months
D5876 Add metal substructure to acrylic full denture (per arch) - Limited to 1 per consecutive 60 months
D6010 Endosteal Implant – surgical placement – Limited to 1 per tooth per consecutive 60 months
D6012 Surgical Placement of Interim Implant Body – Limited to 1 per tooth per consecutive 60 months
D6013 Mini Implant – Limited to 1 per tooth per consecutive 60 months
D6040 Eposteal Implant – Limited to 1 per tooth per consecutive 60 months
D6050 Transosteal Implant, including hardware – Limited to 1 per tooth per consecutive 60 months
D6052 Semi-precision attachment abutment – Limited to 1 time per tooth per consecutive 60 months
D6053 Provisional pontic-further treatment or completion of diagnosis necessary prior to final impression - Limited to 1 time per tooth per consecutive 60 months
D6055 Connecting Bar – implant or abutment supported - Limited to 1 time per tooth per consecutive 60 months
D6056 Prefabricated Abutment - includes modification and placement – Limited to 1 time per tooth per consecutive 60 months
D6057 Custom fabricated abutment - includes modification and placement Limited to 1 time per tooth per consecutive 60 months
D6058 Abutment supported porcelain ceramic crown – Limited to 1 time per tooth per consecutive 60 months
D6059 Abutment supported porcelain fused to metal crown - high noble metal - Limited to 1 time per tooth per consecutive 60 months
D6060 Abutment supported porcelain fused to metal crown - predominately base metal - Limited to 1 time per tooth per consecutive 60 months
D6061 Abutment supported porcelain fused to metal crown - noble metal - Limited to 1 time per tooth per consecutive 60 months
D6062 Abutment supported cast metal crown - high noble metal - Limited to 1 time per tooth per consecutive 60 months
D6063 Abutment supported cast metal crown - predominately base metal – Limited to 1 time per tooth per consecutive 60 months
D6064 Abutment supported cast noble metal crown - noble metal – Limited to 1 time per tooth per consecutive 60 months
D6065 Implant supported porcelain/ceramic crown – Limited to 1 time per tooth per consecutive 60 months
D6066 Implant supported crown porcelain fused to high noble alloys – Limited to 1 time per tooth per consecutive 60 months
D6067 Implant supported crown - high noble alloys – Limited to 1 time per tooth per consecutive 60 months
D6068 Abutment supported retainer for porcelain/ceramic FPD – Limited to 1 time per tooth per consecutive 60 months
D6069 Abutment supported retainer for porcelain fused to metal FPD - high noble metal – Limited to 1 time per tooth per consecutive 60 months
D6070 Abutment supported retainer for porcelain fused to metal FPD - predominately base metal – Limited to 1 time per tooth per consecutive 60 months
D6071 Abutment supported retainer for porcelain fused to metal FPD - noble metal – Limited to 1 time per tooth per consecutive 60 months
D6072 Abutment supported retainer for cast metal FPD - high noble metal – Limited to 1 time per tooth per consecutive 60 months
D6073 Abutment supported retainer for cast metal FPD - predominately base metal - Limited to 1 time per tooth per consecutive 60 months
D6074 Abutment supported retainer for cast metal FPD - noble metal - Limited to 1 time per tooth per consecutive 60 months
D6075 Implant supported retainer for ceramic FPD – Limited to 1 time per tooth per consecutive 60 months
D6076 Implant supported retainer for FPD porcelain fused to high noble alloys - Limited to 1 time per tooth per consecutive 60 months
D6077 Implant supported retainer for metal FPD - high noble alloys – Limited to 1 time per tooth per consecutive 60 months
D6080 Implant Maintenance Procedures – Limited to 1 time per tooth per consecutive 60 months
D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure – Limited to 1 time per tooth per consecutive 60 months
D6082 Implant supported crown – porcelain fused to predominantly base alloys - Limited to 1 time per tooth per consecutive 60 months
D6083 Implant supported crown – porcelain fused to noble alloys - Limited to 1 time per tooth per consecutive 60 months
D6084 Implant supported crown – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6086 Implant supported crown – predominantly base alloys - Limited to 1 time per tooth per consecutive 60 months
D6087 Implant supported crown – noble alloys - Limited to 1 time per tooth per consecutive 60 months
D6088 Implant supported crown – titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6090 Repair Implant Prosthesis – Limited to 1 time per tooth per consecutive 60 months
D6091 Replacement of Semi-Precision or Precision Attachment – Limited to 1 time per tooth per consecutive 60 months
D6094 Abutment supported crown - titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6095 Repair Implant Abutment – Limited to 1 time per tooth per consecutive 60 months
D6096 Remove broken implant retaining screw – Limited to 1 time per consecutive 12 months
D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6098 Implant supported retainer – porcelain fused to predominantly base alloys - Limited to 1 time per tooth per consecutive 60 months
D6099 Implant supported retainer for FPD – porcelain fused to noble alloys - Limited to 1 time per tooth per consecutive 60 months
D6100 Implant Removal – Limited to 1 time per tooth per consecutive 60 months
D6101 Debridement of a peri-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure – Limited to 1 time per consecutive 60 months
D6102 Debridement and osseous contouring of a peri-implant defect; include surface cleaning of exposed implant surfaces and flap entry and closure – Limited to 1 time per consecutive 60 months
D6103 Bone graft for repair of peri-implant defect – not including flap entry and closure or, when indicated, placement of a barrier membrane or biologi materials to aid in osseous regeneration - Limited to 1 time per consecutive 36 months
D6104 Bone graft at time of implant placement - Limited to 1 time per consecutive 36 months
D6110 Implant supported removable denture for edentulous arch - Maxillary - Limited to 1 time per tooth per consecutive 60 months
D6111 Implant supported removable denture for edentulous arch - Mandibular - Limited to 1 time per tooth per consecutive 60 months
D6112 Implant supported removable denture for edentulous arch - Maxillary - Limited to 1 time per tooth per consecutive 60 months
D6113 Implant supported removable denture for edentulous arch - Mandibular - Limited to 1 time per tooth per consecutive 60 months
D6114 Implant supported removable denture for edentulous arch - Maxillary - Limited to 1 time per tooth per consecutive 60 months
D6115 Implant supported removable denture for edentulous arch - Mandibular - Limited to 1 time per tooth per consecutive 60 months
D6116 Implant supported removable denture for edentulous arch - Maxillary - Limited to 1 time per tooth per consecutive 60 months
D6117 Implant supported removable denture for edentulous arch - Mandibular - Limited to 1 time per tooth per consecutive 60 months
D6120 Implant supported retainer – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6121 Implant supported retainer for metal FPD – predominantly base alloys - Limited to 1 time per tooth per consecutive 60 months
D6122 Implant supported retainer for metal FPD – noble alloys - Limited to 1 time per tooth per consecutive 60 months
D6123 Implant supported retainer for metal FPD – titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6190 Implant Index – Limited to 1 time per tooth per consecutive 60 months
D6194 Abutment supported retainer crown for FPD - titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6205 Pontic – indirect resin based composite – Limited to 1 time per tooth per consecutive 60 months
D6210 Pontic - cast high noble metal - Limited to 1 time per tooth per consecutive 60 months
D6211 Pontic - cast predominately base metal - Limited to 1 time per tooth per consecutive 60 months
D6212 Pontic - cast noble metal - Limited to 1 time per tooth per consecutive 60 months
D6214 Pontic - titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6240 Pontic - porcelain fused to high noble metal - Limited to 1 time per tooth per consecutive 60 months
D6241 Pontic - porcelain fused to predominately base metal - Limited to 1 time per tooth per consecutive 60 months
D6242 Pontic - porcelain fused to noble metal - Limited to 1 time per tooth per consecutive 60 months
D6243 Pontic – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6245 Pontic - porcelain/ceramic - Limited to 1 time per tooth per consecutive 60 months
D6250 Pontic – resin with high noble metal – Limited to 1 time per tooth per consecutive 60 months
D6251 Pontic - resin with predominantly base metal – Limited to 1 time per tooth per consecutive 60 months
D6252 Pontic - resin with noble metal - Limited to 1 time per tooth per consecutive 60 months
D6545 Retainer - cast metal for resin bonded fixed prosthesis - Limited to 1 time per tooth per consecutive 60 months
D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis - Limited to 1 time per tooth per consecutive 60 months
D6549 Retainer - Resin for resin bonded fixed prosthesis - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6600 Inlay - porcelain/ceramic -2 surfaces - Limited to 1 time per tooth per consecutive 60 months
D6601 Inlay/onlay - porcelain/ceramic, three or more surfaces - Limited to 1 time per tooth per consecutive 60 months
D6602 Inlay-cast high noble metal, 2 surfaces – Limited to 1 time per tooth per consecutive 60 months
D6603 Inlay-cast high noble metal, 3 + surfaces – Limited to 1 time per tooth per consecutive 60 months
D6604 Inlay - cast predominantly base metal, two surfaces - Limited to 1 time per tooth per consecutive 60 months
D6605 Inlay - cast predominantly base metal, three or more surfaces - Limited to 1 time per tooth per consecutive 60 months
D6606 Inlay - cast noble metal, 2 surfaces – Limited to 1 time per tooth per consecutive 60 months
D6607 Inlay - cast noble metal, 3 + surfaces – Limited to 1 time per tooth per consecutive 60 months
D6608 Retainer Onlay - Porcelain/Ceramic, 2 or more surfaces - Limited to 1 time per tooth per consecutive 60 months
D6609 Retainer Onlay - Porcelain/Ceramic, 3 or more surfaces, including all other crowns, bridges, prosthetics - Limited to 1 time per tooth per consecutive 60 months
D6610 Onlay - cast high noble metal, 2 surfaces – Limited to 1 time per tooth per consecutive 60 months
D6611 Onlay - cast high noble metal, 3 + surfaces – Limited to 1 time per tooth per consecutive 60 months
D6612 Onlay - cast predominantly base metal, 2 + surfaces – Limited to 1 time per tooth per consecutive 60 months
D6613 Onlay - cast predominantly base metal, 3 + surfaces – Limited to 1 time per tooth per consecutive 60 months
D6614 Onlay - cast noble metal, 2 surfaces – Limited to 1 time per tooth per consecutive 60 months
D6615 Onlay - cast noble metal, 3 + surfaces – Limited to 1 time per tooth per consecutive 60 months
D6624 Inlay – cast titanium metal – Limited to 1 time per tooth per consecutive 60 months
D6634 Onlay - cast titanium metal – Limited to 1 time per tooth per consecutive 60 months
D6710 Crown - indirect resin based composite - Limited to 1 time per tooth per consecutive 60 months
D6720 Crown - Resin with high noble metal - Limited to 1 time per tooth per consecutive 60 months
D6721 Crown - resin with predominantly base metal - Limited to 1 time per tooth per consecutive 60 months
D6722 Crown - resin with noble metal – Limited to 1 time per tooth per consecutive 60 months
D6740 Crown - porcelain/ceramic – Limited to 1 time per tooth per consecutive 60 months
D6750 Crown - porcelain fused to high noble metal - Limited to 1 time per tooth per consecutive 60 months
D6751 Crown - porcelain fused to predominately base metal – Limited to 1 time per tooth per consecutive 60 months
D6752 Crown - porcelain fused to noble metal - Limited to 1 time per tooth per consecutive 60 months
D6753 Retainer crown – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6780 Crown - 3/4 cast high noble metal - Limited to 1 time per tooth per consecutive 60 months
D6781 Crown - 3/4 cast predominately base metal - Limited to 1 time per tooth per consecutive 60 months
D6782 Crown - 3/4 cast noble metal – Limited to 1 time per tooth per consecutive 60 months
D6783 Crown - 3/4 porcelain/ceramic – Limited to 1 time per tooth per consecutive 60 months
D6784 Retainer crown ¾ – titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D6790 Crown - full cast high noble metal - Limited to 1 time per tooth per consecutive 60 months
D6791 Crown - full cast predominately base metal - Limited to 1 time per tooth per consecutive 60 months
D6792 Crown - full cast noble metal - Limited to 1 time per tooth per consecutive 60 months
D6793 Provisional retainer crown - Limited to 1 time per tooth per consecutive 60 months
D6794 Crown - Retainer crown titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months
D9120 Fixed partial denture sectioning – Limited to 1 time per tooth per consecutive 60 months
D9941 Fabrication of athletic mouth guard
D9944 Occlusal guard – hard appliance, full arch – Limited to 1 per consecutive 36 months
D9945 Occlusal guard – soft appliance, full arch – Limited to 1 per consecutive 36 months
D9943 Adjustment of occlusal guard - Limit 1 every 24 months
D9946 Occlusal guard – hard appliance, partial arch – Limited to 1 per consecutive 36 months
D9999 Unspecified Adjunctive procedure, by report – Covered if Necessary
Other Services
D0160 Detailed and extensive oral evaluation - problem focused, by report - Limited to 2 times per calendar year
D9222 Deep sedation/general anesthesia – first 15 minutes – Covered when Necessary
D9223 Deep sedation/general anesthesia - each subsequent 15 minute increment Covered when Necessary
D9239 Intravenous moderate (conscious) sedation/anesthesia – first 15 minutes Covered when Necessary
D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment Covered when Necessary
D9610 Therapeutic drug injection, by report
D9930 Treatment of complications (post-surgical) unusual circumstances, by report
D9974 Internal bleaching - per tooth
Services Not Covered
Refer to Section 7 for a list of general exclusions
Class D Orthodontic
Important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are necessary for the prevention, diagnosis, care, or treatment of a covered condition and meet generally accepted dental protocols.
There is no waiting period and no deductible.
We pay 50% of the plan allowance up to the lifetime maximum. The lifetime maximum for orthodontic services depends on the option in which you enroll. If you are covered by High Option, the lifetime maximum is up to $4,000 per person. If you are enrolled in Standard Option the lifetime maximum is up to $2,000 per person.
Any dental service or treatment not listed as a covered service is not eligible for benefits.
You Pay:
High Option
In-Network: 50% of the plan allowance up to the $4,000 per person lifetime maximum. You are responsible for all charges that exceed the lifetime maximum.
Out-of-Network: 50% of the plan allowance up to the $4,000 per person lifetime maximum and any difference between our allowance and the billed amount.
Standard Option
In-Network: 50% of the plan allowance up to the $2,000 per person lifetime maximum. You are responsible for all charges that exceed the lifetime maximum.
Out-of-Network: 50% of the plan allowance up to the $2,000 per person lifetime maximum and any difference between our allowance and the billed amount.
Details
Orthodontic Services
D0340 – Cephalometric film – Limited to 1 per consecutive 12 months
D0351 – 3D photgraphic image – Limited to 1 per consecutive 12 months
D8010 Limited orthodontic treatment of the primary dentition
D8020 Limited orthodontic treatment of the transitional dentition
D8030 Limited orthodontic treatment of the adolescent dentition
D8040 Limited orthodontic treatment of the adult dentition
D8050 Interceptive orthodontic treatment of the primary dentition
D8060 Interceptive orthodontic treatment of the transitional dentition
D8070 Comprehensive orthodontic treatment of the transitional dentition
D8080 Comprehensive orthodontic treatment of the adolescent dentition
D8090 Comprehensive orthodontic treatment of the adult dentition
D8210 Removable appliance therapy Limited to 1 time per consecutive 60 months
D8220 Fixed appliance therapy - Limited to 1 time per consecutive 60 months
D8660 Pre-orthodontic treatment visit Limited to new patients or 2 times per consecutive 12 months
D8670 Periodic orthodontic treatment visit (as part of contract)
D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) Limited to 1 time per consecutive 60 months
D8690 Orthodontic treatment (alternative billing to a contract fee)
D8695 - Removal of fixed orthodontic appliances for reasons other than completion of treatment – Limited to 1 time per consecutive 60 months.
D8698 Re-cement or re-bond fixed retainer – maxillary
D8699 Re-cement or re-bond fixed retainer – mandibular
Services Not Covered
Refer to Section 7 for a list of general exclusions:
Repair of damaged orthodontic appliances
Replacement of lost or missing appliances
Services used exclusively to alter vertical dimension and/or restore or maintain the occlusion.
Section 6 International Services and Supplies
Term
Definition
International Claims Payment
If you receive dental services while overseas, you will pay the provider in-full at the time of service. You will then need to submit the claim to UnitedHealthcare Dental. Upon receipt of the claim we will translate the claim if necessary and process it. We use the rate of exchange in effect at the time we process the claim. Claims are paid in U.S. currency.
Finding an International Provider
You may use any dentist while overseas.
Filing International Claims
Submit the itemized paid receipt(s), along with the primary insured's unique identification number and patient's name and date of birth to:
SCS RMO-Lason Inc 4050 South 500 West, Ste 50 Salt Lake City, UT 84123-1358 Attn: 224 - Foreign Claims - DBP
International Rates
There is one international region. Please see the rate table for the actual premium amount.
Section 7 General Exclusions – Things We Do Not Cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless we determine it is necessary for the prevention, diagnosis, care, or treatment of a covered condition.
We do not cover the following:
Services and treatment not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, we will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law;
Services and treatment which are experimental or investigational;
Services and treatment which are for any illness or bodily injury which occurs in the course of employment if a benefit or compensation is available, in whole or in part, under the provision of any law or regulation or any government unit. This exclusion applies whether or not you claim the benefits or compensation;
Services and treatment received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, VA hospital or similar person or group;
Services and treatment performed prior to your effective date of coverage;
Services and treatment incurred after the termination date of your coverage unless otherwise indicated;
Services and treatment which are not dentally necessary or which do not meet generally accepted standards of dental practice.
Services and treatment resulting from your failure to comply with professionally prescribed treatment;
Any charges for failure to keep a scheduled appointment;
Any services that are considered strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;
Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMD);
Services or treatment provided as a result of intentionally self-inflicted injury or illness;
Services or treatment provided as a result of injuries suffered while committing or attempting to commit a felony, engaging in an illegal occupation, or participating in a riot, rebellion or insurrection;
Office infection control charges;
Charges for copies of your records, charts or x-rays, or any costs associated with forwarding/mailing copies of your records, charts or x-rays;
State or territorial taxes on dental services performed;
Those submitted by a dentist, which is for the same services performed on the same date for the same member by another dentist;
Those provided free of charge by any governmental unit, except where this exclusion is prohibited by law;
Those for which the member would have no obligation to pay in the absence of this or any similar coverage;
Those which are for specialized procedures and techniques;
Those performed by a dentist who is compensated by a facility for similar covered services performed for members;
Duplicate, provisional and temporary devices, appliances, and services;
Plaque control programs, oral hygiene instruction, and dietary instructions;
Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth;
Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan;
Treatment of services for injuries resulting from war or act of war, whether declared or undeclared, or from police or military service for any country or organization;
Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient);
Charges by the provider for completing dental forms;
Adjustment of a denture or bridgework which is made within 6 months after installation by the same Dentist who installed it;
Use of material or home health aids to prevent decay, such as toothpaste, fluoride gels, dental floss and teeth whiteners;
Cone Beam Imaging and Cone Beam MRI procedures;
Sealants for teeth other than permanent molars are not covered;
Precision attachments, personalization, precious metal bases and other specialized techniques;
Replacement of dentures that have been lost, stolen or misplaced;
Repair of damaged orthodontic appliances;
Replacement of lost or missing appliances;
Fabrication of athletic mouth guard;
Topical medicament center;
Bone grafts when done in connection with extractions, apicoetomies or non-covered/non-eligible implants;
Restoration foundation for an indirect restoration;
Veneers for cosmetic purposes;
Blood glucose level test - in-office using a glucose meter;
Add metal substructure to acrylic full denture (per arch);
Infiltration of sustained release therapeutic drug – single or multiple sites;
Duplicate/copy patient's records;
When two or more services are submitted and the services are considered part of the same service to one another the Plan will pay the most comprehensive service (the service that includes the other service) as determined by UnitedHealthcare Dental.
When two or more services are submitted on the same day and the services are considered mutually exclusive (when one service contradicts the need for the other service), the Plan will pay for the service that represents the final treatment as determined by this plan.
Incomplete Endodontic Therapy, inoperable, unrestorable or fractured tooth is not a covered service.
All out-of-network services listed in Section 5 are subject to the maximum allowable amount as defined by UnitedHealthcare Dental. The member is responsible for all remaining charges that exceed the allowable maximum.
Section 8 Claims Filing and Disputed Claims Processes
Term
Definition
How to File a Claim for Covered Services
To avoid delay in the payment of your dental claims, please have your dental provider submit your claims directly to your FEHB plan (Should you be enrolled), then to UnitedHealthcare Dental. Pretreatment estimates can be submitted directly to UnitedHealthcare Dental (exception: If accidental injury occurs, pretreatment estimates should be submitted to your FEHB plan).
If you need to send in a paper claim you may download a claim form from UnitedHealthcare Dental's website, www.myuhcdental.com/fedvip.
Mail completed claim form to:
UnitedHealthcare Dental Attention: Claims Department P.O. Box 30567 Salt Lake City, UT 84130-0567
Deadline for Filing Your Claim
You must submit your claim within 24 months from the date service was rendered.
Term
Definition
Disputed Claims Process
Step 1:
Ask us in writing to reconsider our initial decision. You must include any pertinent information omitted from the initial claim filing and send your additional proof to us within 180 days from the date of receipt of our decision.
Step 2:
You may mail your request for reconsideration to:
UnitedHealthcare Dental Attention: Dental Appeals and Grievance P.O. Box 30569 Salt Lake City, UT 84130-0569
Or go to www.myuhcdental.com/fedvip
We will review your request and provide you with a written or electronic explanation of benefit determination within 30 days of the receipt of your request.
Step 3:
If you disagree with the decision regarding your request for reconsideration, you may request a second review of the denial within 60 days from receipt of our reconsideration. You must submit your request to us in writing to the address shown above along with any additional information you or your dentist can provide to substantiate your claim so that we can reconsider our decision. Failure to do so will disqualify the appeal of your claim. We will provide a decision within 30 days of receipt of your request for second review.
Step 4:
If you do not agree with our final decision, under certain circumstances you may request an independent third party, mutually agreed upon by UnitedHealthcare Dental and OPM, review the decision. To qualify for this independent third party review, the reason for denial must be based on our determination that the rationale for the procedure did not meet our dental necessity criteria or our administration of the plans Alternate Benefit provision, for example, a bridge being given an alternate benefit of a partial denture.
The decision of the independent third party is binding and is the final review of your claim.
Follow this disputed claims process if you disagree with our decision on your claim or request for services. FEDVIP legislation does not provide a role for OPM to review disputed claims.
Follow this disputed claims process if you disagree with our decision on your claim or request for services. FEDVIP legislation does not provide a role for OPM to review disputed claims.
Section 9 Definitions of Terms We Use in This Brochure
Term
Definition
Alternative Benefit
If we determine a service less costly than the one performed by your dentist could have been performed by your dentist, we will pay benefits based upon the less costly services. See Section 3, How You Obtain Care.
Annual Benefit Maximum
The maximum annual benefit that you can receive per person.
Annuitants
Federal retirees (who retired on an immediate annuity) and survivors (of those who retired on an immediate annuity or died in service) receiving an annuity. This also includes those receiving compensation from the Department of Labor’s Office of Workers’ Compensation Programs, who are called compensationers. Annuitants are sometimes called retirees.
BENEFEDS
The enrollment and premium administration system for FEDVIP.
Benefits
Covered services or payment for covered services to which enrollees and covered family members are entitled to the extent provided by this brochure.
Calendar Year
From January 1, 2022 through December 31, 2022. Also referred to as the plan year.
Class A Services
Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants, and X-rays.
Class B Services
Intermediate services, which include restorative procedures such as fillings, prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture adjustments.
Class C Services
Major services, which include endodontic services such as root canals, periodontal services such as gingivectomy, major restorative services such as crowns, oral surgery, bridges, and prosthodontic services such as complete dentures.
Class D Services
Orthodontic services.
Date of Service
The calendar date on which you visit the dentist's office and services are rendered.
Enrollee
The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan.
FEDVIP
Federal Employees Dental and Vision Insurance Program.
Generally Accepted Dental Protocols
Dental Necessity means that a dental service or treatment is performed in accordance with generally accepted dental standards, as determined from multiple sources including but not limited to relevant clinical dental research from various research organizations including dental schools, current recognized dental school standard of care curriculums and organized dental groups including the American Dental Association, which is necessary to treat decay, disease or injury of teeth, or essential for the care of teeth and supporting tissues of the teeth.
In-Progress Treatment
Dental services that initiated in 2021 that will be completed in 2022.
Maximum Allowed Amount
The amount we use to determine our payment for services. If services are provided by an in-network dentist the maximum allowable amount is based on the discounted fee he or she accepts as payment in full for the procedure or procedures. If services are provided by an out-of- network dentist the maximum allowed amount is based on UnitedHealthcare Dental's determination of charges for the procedure or procedures.
Network Allowance
Network Allowance means the allowance per procedure that UnitedHealthcare Dental has negotiated with the provider and they have agreed to accept as payment in full for his/her services.
Plan
UnitedHealthcare Dental
Sponsor
Generally, a sponsor means the individual who is eligible for medical or dental benefits under 10 U.S.C. chapter 55 based on his or her direct affiliation with the uniformed services (including military members of the National Guard and Reserves).
TEI certifying family member
Under circumstances where a sponsor is not an enrollee, a TEI family member may accept responsibility to self-certify as an enrollee and enroll TEI family members
TRICARE-eligible individual (TEI) family member
TEI family members include a sponsor’s spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in a sponsor’s legal custody by a court. Children include legally adopted children, stepchildren, and pre- adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.
We/Us
UnitedHealthcare Dental
You
Enrollee or eligible family member.
Non-FEDVIP Benefits
Added Value:
UnitedHealthcare Hearing*
UnitedHealthcare Dental participants can purchase custom-programmed hearing aids with savings of up to 80% of industry pricing. These hearing aids use advanced technology to enhance speech understanding and comfort. Every hearing aid is backed by a money-back guarantee, one-year manufacturer warranty, free batteries and accessories that last most users up to six months, phone counseling and support, free programming adjustments, online videos on hearing aid use/cleaning/maintenance, and new user support sessions. Visit www.uhchearing.com or call 1-855-523-9355, Monday through Friday, 8:00 am to 8:00 pm CT. When accessing services, please use reference code HEAR FEDVIP. You will also be able to access their hearing aid discount through the Benefit Hub.
Laser Vision Correction*
Discounts on Laser Vision Correction - UnitedHealthcare Dental participants have access to QualSight LASIK. QualSight offers a network of credentialed ophthalmologists with more than 900 locations in 46 states. QualSight LASIK provides FEDVIP members with up to 35% off the national average price of laser vision correction. Visit uhc.qualsight.com or call 1-855-321-2020, Monday through Friday 7:00 am to 7:00 pm CT and Saturday - Sunday, 9:00 am to 3:00 pm CT.
*Programs available at no additional premium cost to you.
Summary of Benefits
Do not rely on this chart alone. This page summarizes your portion of the expenses we cover; please review the individual sections of this brochure, for more detail.
If you want to enroll or change your enrollment in this plan, please visit www.BENEFEDS.com or call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680.
The calendar year deductible is $0 if you use an in-network provider. If you elect to use an out-of-network provider, the Standard Option has deductible amounts of $100 for Self, $200 for Self Plus One, and $300 for Family for Class A, B, and C services; High Option has deductible amounts of $50 for Self, $100 for Self Plus One, and $150 for Family for Class B and C services.
Included with your plan benefits is comprehensive coverage for various methods of annual oral cancer screenings for all adults. In addition included in your plan is a Supplemental Oral Cancer Benefit. Any UnitedHealthcare Dental member who receives a diagnosis of Oral, Head and Neck Cancer, and who has an impact to their teeth and supporting structures, is eligible for a one-time single lump sum payment of $2,000 to cover expenses such as lost wages, child care, and more. This added financial benefit can be used at the member’s discretion as they navigate the various demands this diagnosis may bring. This is a fixed oral cancer benefit to aid with the unexpected dental care and personal disruptions often bringing an added financial burden.
The Enhanced Member Benefits offer additional services to our UnitedHealthcare Dental members who have been diagnosed and are managing one or more of eight medical conditions listed below. The additional dental services will be covered at 100%, require no referral, and will not count towards the member’s deductible or annual maximum. The Enhanced Member Benefits offer additional services to our UnitedHealthcare Dental members who have been diagnosed and are managing one or more of eight medical conditions listed below. The additional dental services will be covered at 100%, require no referral, and will not count towards the member’s deductible or annual maximum.
UnitedHealthcare Dental members with one or more of the following chronic conditions will be eligible for this benefit: Asthma, Coronary Artery Disease/Cardiovascular Disease, Chronic Obstructive Pulmonary Disease (COPD), Pregnancy, Cerebrovascular Disease, Diabetes, Kidney Disease, Rheumatoid Arthritis.
Eligible members will be able to sign up for Enhanced Member Benefits using a simple, one-step process available on the UnitedHealthcare Dental member website. Once the clinical exception form is completed, members are eligible to receive the enhanced services as their claims are received. No supplemental claim submission is required
Enhanced Service*: Additional prophylaxis (cleaning) per year, traditional or gingival. Allowable Maximum: Up to 4 cleanings annually, using any combination of codes D1110, D4346 and D4910 Enhanced Service*: Scaling and root planing; per quadrant. Allowable Maximum: Up to 1 annual treatment per quadrant. Enhanced Service*: Full mouth debridement. Allowable Maximum: One treatment per 24 months.
Enhanced Service*: Periodontal maintenance. Allowable Maximum: Up to 4 cleanings annually, using any combination of codes D1110, D4346 and D4910.
Enhanced Service*: Localized delivery of antimicrobial agents (not covered for pregnancy). Allowable Maximum: Up to 2 sites treated in one date of service, using code D4381, with a maximum of 24 sites treated per lifetime.
*These services are covered at 100% for eligible members, there is no cost when visiting an in-network dentist. Services do not count toward annual benefit maximums. Annual Deductible does not apply.
High Option Benefits :
In-Network (You Pay)
Out-of-Network (You Pay)
Class A (Basic) Services – preventive and diagnostic
0%
10%
Class B (Intermediate) Services – includes minor restorative services
30%
40%
Class C (Major) Services – includes major restorative, endodontic, and prosthodontic services
50%
60%
Class A, B, and C Services do not have an annual maximum benefit amount
Unlimited
Unlimited
Class D Services – orthodontic
up to $4,000 lifetime maximum per person combined for in-network or out-of-network
50%
50%
Standard Option Benefits :
In-Network (You Pay)
Out-of-Network (You Pay)
Class A (Basic) Services – preventive and diagnostic
0%
10%
Class B (Intermediate) Services – includes minor restorative services
45%
60%
Class C (Major) Services – includes major restorative, endodontic, and prosthodontic services
65%
80%
Class A, B, and C Services are subject to a combined $1,500 annual maximum benefit for the in-network benefits or $1,000 for the out-of-network benefits. The Annual Benefit Maximums within each option are combined between in and out-of-network services. The total Annual Benefit Maximum will never be greater than the in-network Maximum Annual Benefit.
$1,500
$1,000
Class D Services – orthodontic
$2,000 lifetime maximum per person combined for in-network or out-of-network
50%
50%
Notes
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Dental and Vision Insurance Program premium.
Protect Yourself From Fraud– Here are some things that you can do to prevent fraud:
Do not give your plan identification (ID) number over the telephone or to people you do not know, except to your providers, UnitedHealthcare Dental, BENEFEDS, or OPM.
Let only the appropriate providers review your clinical record or recommend services.
Avoid using providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
Carefully review your explanation of benefits (EOBs) statements.
Do not ask your provider to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-866-315-2321 or TTY 711 and explain the situation, you will be required to state your complaint in writing to us.
Do not maintain as a family member on your policy:
Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
Your child over age 22 (unless he/she is disabled and incapable of self- support). With respect to TRICARE-eligible individuals, children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.
If you have any questions about the eligibility of a dependent, please contact BENEFEDS.
Be sure to review Section 1, Eligibility, of this brochure prior to submitting your enrollment or obtaining benefits.
Fraud or intentional misrepresentation of material fact is prohibited under the plan. You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEDVIP benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the plan, or enroll in the plan when you are no longer eligible.
Rate Information
How to find your rate
In the first chart below, look up your state or zip code to determine your rating area.
In the second chart on the following page match your Rating Area to the enrollment type and plan option.
