|Coinsurance||20% - 50%|
|Deductible||$50 per person (maximum three deductibles per family per calendar year)|
|Annual Maximum Benefit||$1,000 per covered person|
|Teeth Cleanings||No charge (twice per calendar year; no waiting period)|
|Restorative Dentistry/Fillings||20% Coinsurance after deductible|
|Oral Surgery||50% Coinsurance after deductible|
|Extractions||20% Coinsurance after deductible|
|X-Rays||No charge (once per calendar year; no waiting period)|
|Crowns||50% Coinsurance after deductible|
|Root Canals||50% Coinsurance after deductible|
|Periodontics||50% Coinsurance after deductible|
|Dentures||50% Coinsurance after deductible (once every 5 years; 12 months waiting period)|
|Topical Fluoride||No charge (twice per calendar year for covered person under age 16; no waiting period)|
|Bridges||50% Coinsurance after deductible (first installation to replace one or more lost functioning natural teeth; 12 months waiting period)|
|Endodontics||50% Coinsurance after deductible|
|A.M. Best Rating||A as of 03/31/2015|
|Electronic Signature for Application Available||Yes|
|Details and documents about this plan|
|View Plan Brochure Exclusions and Limitations|
Important notices and disclaimers
- The benefits matrix is a summary for informational purposes only. Review the evidence of coverage and insurance policy (plan contract) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
- The benefits listed may be contingent on your use of physicians, hospitals, dentists and services within the specific insurance company's provider network.
- The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
- The quotes or rates shown above are estimates only. Your premium is subject to change based on your medical history (pursuant to state law of residence), the underwriting practices of the insurance company, the optional benefits you selected, if any, and other relevant factors, such as changes in rates which take effect before your requested effective date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
Carrier specific notices, disclaimers and fees
- UnitedHealthOne - Golden Rule Insurance Company is the underwriter of health plans marketed under the UnitedHealthOne brand. Dental benefits are administered by Dental Benefit Providers, Inc. Vision benefits are administered by Spectera, Inc.
- UnitedHealthOne - Download and review the product brochure for benefits, exclusions, limitations, eligibility and renewal terms.
- UnitedHealthOne - Please Note: Benefits may be reduced for covered expenses for care received from a provider outside your network.