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Indiana - Individual Dental PPO Plans
 

How the Plan Works | Benefit Schedules | Eligibility and Enrollment


Individual and Family Dental PPO Plan Coverage
UNICARE Life & Health Insurance Company offers the Individual and Family Dental PPO Plan to help keep your teeth healthy and your smile bright. The UNICARE Individual and Family Dental PPO Plan gives you the option 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.

The plan was designed with two goals in mind. The first and foremost is to promote good dental hygiene and preventive care, important elements in a total health care package. The second goal is to provide you with the dental care you need in a convenient, cost-conscious manner, thus providing many dental services at reduced costs.

The plan features low-cost preventive and diagnostic care, basic dental care, and a benefit schedule that can help you offset the high cost of major dental care. Please read the following information for details about how the plan works, specific benefit information and certain exclusions and limitations that apply.

How the Individual and Family Dental Plan Works
A large number of dentists in Indiana have agreed to provide services at contracted rates to UNICARE plan members.

When you choose a contracting dentist, you will receive care at negotiated discounted ratesıwhat we term "The UNICARE Advantage." Should you choose a noncontracting dentist, the plan still provides benefits, but your out-of-pocket expense may be greater, as the negotiated fees donıt apply to noncontracting dentists. You are responsible for any charges in excess of the stated benefit for both contracting and noncontracting dentists.

Your current dentist may be a contracting dentist. Before you choose a dentist, be sure to check the Provider Finder on this site or call UNICARE Dental Services at 1-888-209-7852. It could save you money.

The plan lets you know up front in flat dollar amounts how much the plan pays for covered services. This means that you are able to calculate how much you will have to pay once you have determined your dentistıs fee for the specific procedure(s) listed. Contracting 

The following is an EXAMPLE of how negotiated fees may save you costs.  Negotiated fees may vary among preferred dentists.

Contracting Dentist   Noncontracting Dentist
If the billed charges are
$7
54
  If the billed charges are
$7
54
And UNICARE's negotiated rate is
$5
00
  UNICARE will pay the amount specified in the benefit schedule
$
225*
UNICARE will pay the amount specified in the benefit schedule
$2
25*
 
Therefore, you pay the difference between the negotiated amount and the scheduled benefit
$
275
  Therefore, you pay the difference between the billed amount and the scheduled benefit
$
529

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

Calendar Year Deductible: You are responsible for a yearly $50 per person deductible, with a maximum of three deductibles ($150) per family, before your benefits for covered services are available. The calendar year deductible is waived for preventive and diagnostic services when rendered by a contracting dentist.

Calendar Year Maximum Benefit: All dental benefits are limited to a $1,000 maximum payment by UNICARE Life & Health for expenses incurred by each enrolled member during a calendar year.

Waiting Periods: Coverage for preventive and diagnostic care begins upon approval of your application. Coverage for basic care begins after six (6) continuous months and for major care after twelve (12) continuous months of coverage.

Customer Service: UNICARE Life & Health Insurance Companyıs professional dedicated enrollment units are available to assist you and to answer any questions you may have about your plan. The toll-free number is listed on the dental plan identification card you will receive once your enrollment is approved.

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Benefit Schedules
Coverage is provided ONLY for the services stated in the following schedules. To use these schedules, check your dentistıs fee and then determine how much the plan pays. You can then 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 for both contracting and noncontracting dentists.

Preventive & Diagnostic Care

  • Begins upon approval of your application.
  • Calendar year deductible of $50 per person, with a maximum of three deductibles ($150) per family, is waived ONLY when preventive and diagnostic care services are rendered by a contracting dentist.
  • Two oral examinations and two dental cleanings per member, per year.
  • Total benefit for single and bitewing x-rays not to exceed benefit for full mouth x-raysı$39.
Procedure The Plan Pays Contracting The Plan Pays Non-Contracting
Initial Oral Exam 100% $13
Periodic Oral Exam, Limited to 2 per member, per year 100% $13
Bitewing X-rays - single film 100% $10
Bitewing X-rays - two films 100% $13
Single (periapical) X-rays - first film 100% $7
Single X-rays - additional films 100% $7
Bitewing X-rays - four films 100% $19
Full mouth X-rays, limited to one set every 3 years 100% $39
Routine cleaning, limited to 2 per adult per year 100% $30
Routine cleaning, limited to 2 per child per year 100% $21
Cleaning with fluoride, limited to 2 per child per year 100% $30
Topical fluoride only, limited to 2 per child per year 100% $12

Notes:

  • Adult  - Any person or dependent 19 years or older covered by this policy.
  • Child - Any person or dependent 18 years or younger covered by this policy.

Basic Dental Care

  • Coverage begins after the plan has been in effect for six continuous months.
  • Calendar year deductible of $50 per person, with a maximum of three deductibles ($150) per family, must be satisfied.
  • The benefit schedule is the same for both contracting and noncontracting dentists, but you may have a greater share of the costs if you choose a noncontracting dentist.
Procedure The Plan Pays
Filling - one surface, primary $30
Filling - one surface, permanent $33
Filling - two surfaces, primary $39
Filling - two surfaces, permanent $43
Filling - three surfaces, primary $46
Filling - three surfaces, permanent $50
Filling - four or more surfaces, primary $54
Filling - four or more surfaces, permanent $58
Extraction - single tooth (simple) $38
Extraction - each additional tooth (simple) $38
Surgical extraction $72
Removal of impacted tooth - soft tissue $95
Removal of impacted tooth - partial bony $120
Removal of impacted tooth - complete bony $144

Major Dental Care

  • Coverage begins after the plan has been in effect for twelve continuous months.
  • Calendar year deductible of $50 per person, with a maximum of three deductibles ($150) per family, must be satisfied.
  • The benefit schedule is the same for both contracting and noncontracting dentists, but you may have a greater share of the costs if you choose a noncontracting dentist.
Procedure The Plan Pays
Scaling/root planing per quadrant $43
Gingivectomy - per tooth $30
Gingivectomy - Per quadrant $107
Root canal - 1 canal $125
Root canal - 2 canals $150
Root canal - 3 canals $195
Crown (except stainless steel) $225
Stainless steel crown $50
Pontic $225
Complete denture (upper or lower) $300
Partial denture (upper or lower) $285
Denture reline (chairside) $65
Denture reline (lab) $88

This is a brief summary of the plan. Please refer to the Certificate of Coverage for more complete details including benefits, limitations and exclusions.

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Eligibility and Enrollment
To be eligible for enrollment, you must be

  • A resident of the State of Indiana who properly applies for coverage and is accepted by UNICARE Life & Health Insurance Company
  • A resident of the United States for at least six months
  • Age 64 1 /2 or younger
  • The applicantıs lawful spouse of the opposite sex, age 64 1 /2 or younger
  • The applicantıs unmarried child up to age 19
  • The applicantıs unmarried child who is a full-time student (12 units), age 19 through 22
  • Not enrolled under any other individual or group dental plan
  • Unmarried stepchildren who reside with the applicant up to age 19 or if a full-time student (12 units), age 19 through 22

Date Coverage Begins
The effective date of your coverage is printed on your identification card. Your coverage will stay in effect with our consent, on a three-month basis if you have chosen quarterly coverage, or on a monthly basis if you have chosen the monthly checking account deduction program.

Premium Rates
The rates listed are monthly rates. Monthly payment is available only through the monthly checking account deduction program. If you prefer to pay quarterly, multiply the monthly rate by three.

One adult $25.00
Two adults $50.00
Adult with 1 child $37.50
Adult with 2 children $50.50
Adult with 3+ children $69.50
Family (1 child) $62.50
Family (2 children) $75.50
Family (3+ children) $94.50
One child $12.50
Two children $25.50
Three+ children $44.50

Counties with strong network access:

Allen Lake
Delaware Marion
Hamilton Monroe
Johnson Porter

Counties without strong network access:
A fewer number of contracting dentists are available in other areas. UNICARE plan members are entitled to the benefits of the negotiated amounts if they choose one of those contracting dentists. Benefits are still available for noncontracting dentists, as specified by the plan. If you would like your dentist to become a contracting dentist, please have him or her contact us.

Terms of Coverage
Coverage under this plan remains in force as long as the required premiums are paid on time and as long as the insured remains eligible for coverage. In addition, when an insured becomes ineligible because of divorce or a change in dependent status, coverage ceases. (In the case of divorce and over-age dependents, UNICARE will offer a similar plan). UNICARE may refuse to renew or may change the premiums of this plan after 30 days written notice to the policyholder. However, UNICARE will not refuse to renew or change the premium schedule for this plan on an individual basis, but only for all policyholders in the same class and covered under the same plan as you.

Non-duplication of UNICARE Benefits
If, while covered under this plan, you are also covered by another UNICARE individual plan, you will be entitled only to the benefits of the plan with the greater benefits. UNICARE will refund any premiums received under the plan with the lesser benefits, covering the time period both policies were in effect. However, any claims payments made by UNICARE under the plan will be deducted from any such refund of premiums.

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