|
|
Dental
For Plan Year Beginning September 1, 2011
|
Depending on where you live, you may have a choice of dental insurance:
- UT SELECT Dental, the self-funded dental plan administered by Delta Dental, or
- Assurant DMO, a fully insured dental HMO plan administered by Assurant Employee Benefits
The following chart shows which portion of the dental charges you are expected to pay and the service areas for each dental plan option.
Dental Plan Comparison Chart
| Dental Service |
UT SELECT Dental1 |
ASSURANT Heritage Plus Plan |
| Service Area |
Available Nationwide |
Austin, Dallas/Ft. Worth, El Paso, Galveston, Houston, San Antonio |
| Maximum Annual Benefit |
$1,250 |
None |
| Annual Deductible |
$25 per Person2 |
None |
| Oral Exam, X-rays, Cleaning |
$0 |
$0-5 |
| Fluoride Treatment |
$0, up to age 19 |
$0 up to age 14 |
| Sealants |
$0, up to age 14 |
$10, per tooth |
| Space Maintainers |
$0, up to age 14 |
$60-105 |
| Fillings |
20% |
$10-110 |
| Extractions |
20% |
$15-135 |
| Root Canals |
20% |
$90-175 |
| Periodontics3 |
20% |
$27-140 |
| Crowns, Jackets and Cast Restorations |
50% |
$275 (lab fees may also apply) |
| Bridges and Dentures |
50% |
$275-400 (lab fees may also apply) |
| Orthodontics |
50%, $1,250 Lifetime benefit per person |
25% discount off Network Dentist Retail Fee, no lifetime maximum |
| Out-of-Network Benefits |
Yes |
Limited to Emergencies |
1Reimbursement is based on a percentage of the allowable amount
2Excludes oral exams, x-rays, cleanings, fluoride treatments, sealants, space maintainers and specialist consultations
3Scaling, root planing and treatment of gum disease
|
|
