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Plan Type PPO
Coinsurance 20% - 50%
Deductible $50 per person (maximum three deductibles per family per calendar year)
Annual Maximum Benefit $1,000 per covered person
Office Visit
Find Dentists
No charge
Primary Benefits
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)
Sealant No charge
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
Additional Information
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.
  • Drug Savings amounts shown are only estimates — your costs and savings can differ. Check your plan information for accuracy. See details.

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.