To save the most money, use Interplan/DentiNex Dental PPO providers. Retirees, please see notes at the bottom of this page.
| Provider Network | In-Network | Out-of-Network |
|---|---|
| Interplan / DentiNex® Dental PPO – a network of participating dentists, specialists and orthodontists who have agreed to charge lower fees for their services. | Use Any Provider |
| Network Service Area | |
| California | |
| Who Provides Care | |
| You can select any dentist of your choice. To receive the Plan’s highest level of benefits and pay the lowest out-of-pocket costs, use a DentiNex® Dental PPO network dentist. | |
| Calendar-Year Deductible | |
| $50 per person / $150 per family for Basic Services (Class II) and also for Major Services (Class III). | |
| Calendar-Year Maximum Benefit | |
| $2,000 per person. | |
| Benefits for Most Covered Services | |
Plan pays a percentage of eligible expenses:
|
|
| In-network eligible expenses are based upon the Interplan / DentiNex® Dental PPO negotiated rates. | Out-of-network eligible expenses are based upon the maximum Plan allowance for usual, customary and reasonable charges. |
| Orthodontia | |
| Plan pays 60% of eligible expenses after calendar-year deductible of $25. Plan Lifetime Maximum benefit: $2,000 per person. | |
| Predetermination of Benefits | |
| If charges for a course of treatment will exceed $500, it is recommended that your dentist submit a treatment plan to United Administrative Services (Plan Administrator) for review ahead of time. The dentist and you will receive an estimate of the Plan’s benefits, which you should review together. | |
Retirees and their spouses eligible under the Retiree Health Plan are also eligible for Retiree Dental Benefits through the Self-Funded Plan. If you or your spouse incur Covered Dental Charges, this Plan will pay at the In-Network benefit level for covered services rendered by preferred provider dentists. Covered dental services incurred at a Non-PPO Dentist will be paid at the Out-of-Network benefit level based on Usual, Customary and Reasonable Charges.
Information regarding preferred provider dentists and Usual, Customary and Reasonable Charges are provided in the "Dental Benefits" section of this Plan booklet.
The In-Network benefit level for Retiree Dental Benefits is one hundred percent (100%) of the Contract Rate for Class I services and, sixty percent (60%) of the Contract Rate for Class /I and Class III services. Class II and Class 1/1 Services are subject to a TWENTY-FIVE DOLLAR ($25) per person per year deductible.
The Out-of-Network benefit level for Retiree Dental Benefits is one hundred percent (100%) of Usual, Customary and Reasonable Charges for Class I Services and, sixty percent (60%) of Usual,Gustomary and Reasonable Charges for Class /I and Class III Services. Class II and Class /II Services are subject to a TWENTY-FIVE DOLLAR ($25) per person per year deductible.
Benefits are payable up to a Maximum of FIFTEEN HUNDRED DOLLARS ($1,500) per person each calendar year.
"Covered Dental Services" shall be deemed to have incurred on the date the dental service is performed. Covered dental services are organized into three (3) "classes": Class I Diagnostic/Preventive Care, Class II Basic Services and Class /II Major Services. The services covered under each Class are listed in the "Dental Benefits" section of this Plan booklet. There is one major change: Class /I Services will be covered at 60% of the Usual, Customary and Reasonable Charges under the Retiree Plan. In addition a $25.00 deductible applies.
The Retiree Plan does not provide Class IV Orthodontia Services.
Exclusions and Limitations to the Retiree Dental Plan are listed in the "Dental Benefits" section of the Plan Booklet.