Texas - Dental Fee for Service Plan Coverage

UNICARE Life & Health Insurance Company has created the Individual Dental Fee for Service Plan to help keep your teeth healthy and your smile bright.  The UNICARE Individual Dental Fee for Service Plan offers you the choice of going to any dentist you choose.  Hundreds of dedicated professionals have contracted with UNICARE Life & Health Insurance Company to provide a wide range of dental services such as routine check-ups, cleanings, fillings, crowns and dental surgery.  When you choose a contracting dentist, you will receive care at negotiated, discounted rates.

The UNICARE Individual Dental Fee for Service Plan carries a yearly $50 deductible per person (maximum of three deductibles per family).  All dental benefits are limited to a maximum payment of $1,000 for expenses incurred by each enrolled member during a calendar year.  Should you choose a noncontracting dentist, the plan still provides benefits, but your out-of-pocket expenses may be greater, as the negotiated fees do not apply to noncontracting dentists.  You will be responsible for any charges in excess of the stated benefit.  Your current dentist already may be a contracting dentist.  Be sure to check the UNICARE dental directory before you choose a dentist.  It could save you money.

Counties with strong network access:

Bexar, Brazoria, Brazos, Collin, Colorado, Cormal, Dallas, Denton, El Paso, Fort Bend, Galveston, Harris, Jefferson, Montgomery Tarrant, Travis, Victoria, Washington, Webb and Williamson

Counties without strong network access:

A fewer number of contracted dentists are available in other areas.  UNICARE plan members are entitled to the benefits of the negotiated amounts if they choose one of those contracted dentists.  Benefits are still available for noncontracting dentists, as specified by the plan.  If you would like your dentist to become a contracted dentist, please have him or her contact us.

Dental Benefit Schedules

Coverage is provided ONLY for the services stated in the following schedules.  To use these schedules, determine your dentist's fee then look up how much the plan pays.  Then you can easily calculate what you will pay for a specific service after your deductible has been met.  The plan pays either the specified amount, or the actual amount charged by your dentist, whichever is lower.  You are responsible for any charges in excess of the stated benefit.

 

Contracting Dentist		Noncontracting Dentist
If the billed charges are $705		If the billed charges are $705
And UNICARE's negotiated rate is $455		UNICARE will pay the amount specified in the benefit schedule $170*
UNICARE will pay the amount specified in the benefit schedule $170*
Therefore, you pay the difference between the negotiated amount and the scheduled benefit $285		Therefore, you pay the difference between the billed amount and the scheduled benefit $535

* This assumes any deductible has been met and you have not reached your annual maximum.

Preventive & Diagnostic Care

• Begins upon approval of your application
• Two oral examinations and two dental cleanings per member, per year

Procedure	The Plan Pays
Initial Oral Exam	$13
Periodic Oral Exam, Limited to 2 per member, per year	$13
Emergency oral exam	$13
Bitewing X-rays - single film	$6
Bitewing X-rays - two films	$11
Single (periapical) X-rays - first film	$7
Single X-rays - additional films	$7
Bitewing X-rays - four films	$16
Full mouth X-rays, limited to one set every 3 years	$31
Routine cleaning, limited to 2 per adult per year	$28
Routine cleaning, limited to 2 per child per year	$21
Cleaning with fluoride, limited to 2 per child per year	$28
Topical fluoride only, limited to 2 per child per year	$9

Notes:

Total benefit for single and bitewing x-rays not to exceed cost of full mouth - $31 at noncontracting dentists.

Adult  - Any person or dependent 19 years or older covered by this plan.

Child - Any person or dependent 18 years or younger covered by this plan.

Basic Dental Care

Coverage begins after the plan has been in effect for six continuous months.

Procedure	The Plan Pays
Filling - one surface, primary	$24
Filling - one surface, permanent	$28
Filling - two surfaces, primary	$34
Filling - two surfaces, permanent	$38
Filling - three surfaces, primary	$42
Filling - three surfaces, permanent	$45
Filling - four or more surfaces, primary	$50
Filling - four or more surfaces, permanent	$55
Extraction - single tooth (simple)	$31
Extraction - each additional tooth (simple)	$31
Surgical extraction	$55
Removal of impacted tooth - soft tissue	$75
Removal of impacted tooth - partial bony	$95
Removal of impacted tooth - complete bony	$115

Major Dental Care

Coverage begins after the plan has been in effect for twelve continuous months.

Procedure	The Plan Pays
Scaling/root planing per quadrant	$37
Gingivectomy - per tooth	$27
Gingivectomy - Per quadrant	$100
Root canal - 1 canal	$110
Root canal - 2 canals	$135
Root canal - 3 canals	$170
Crown (except stainless steel)	$170
Stainless steel crown	$38
Pontic	$170
Complete denture (upper or lower)	$205
Partial denture (upper or lower)	$205
Denture reline (chairside)	$44
Denture reline (lab)	$60

UNICARE Individual Dental Fee for Service Plan Monthly Rates

One adult	$19.50
Two adults	$39.50
Adult with 1 child	$30.00
Adult with 2 children	$40.50
Adult with 3+ children	$56.00
Family (1 child)	$49.50
Family (2 children)	$60.00
Family (3+ children)	$75.50
One child	$10.50
Two children	$20.50
Three+ children	$36.00

Dental Plan Limitations & Exclusions

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