Fraternal Order of Police
Fort Lauderdale Lodge # 31
HEALTH TRUST

735 NE 3rd Avenue
Fort Lauderdale, Florida 33304
FOP Health Trust (954) 527-9218
 

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Fort Lauderdale FOP Lodge 31

UnitedHealthcare Dental Options PPO
Covered Dental Services (Custom-with Orthodontics)

6/1/2006  - Fraternal Order Of Police Lodge 31 Health Trust

Dental plan code—p2695/72695

						Orthodontics
		In-Network		Out-of-Network	In-Network		Out-of-Network
Individual Annual Deductible		$50		$50	$0		$0
Family Annual Deductible		$150		$150	$0		$0
Maximum  (combined for both In-Network and Out-of-Network services)		$1,200 per person per calendar year		$1,000   per person per calendar year	$2,500   per person per lifetime		$1,500  per person per lifetime

 

Annual deductible applies to preventive and diagnostic services	No
Annual deductible applies to orthodontic services	No
For new enrollees, a 12-month waiting period applies to major services, orthodontics	No
Orthodontic eligibility requirement	Children Only to age 19

 

Covered Services		In-Network Plan Pays*	Out-of-Network Plan Pays**	Benefit Guidelines
	PREVENTIVE AND DIAGNOSTIC DENTAL SERVICES
Periodic Oral Examinations		100%	80%	Covered as a separate benefit only if no other service was done during the visit other than x-rays. Limited to one every 6 months.
Bitewing X-rays		100%	80%	Limited to 1 series of films per calendar year.
Complete Series or Panorex X-rays		100%	80%	Limited to 1 time per 36 months.
Dental Prophylaxis (Cleanings)		100%	80%	Limited to once every 6 months.
Fluoride Treatments		100%	80%	For covered persons under the age of 16 years, up to one per 6 month period. Treatment should be done in conjunction with dental prophylaxis.
Sealants		100%	80%	For covered persons under the age of 16 years, once per first or second permanent molar every 5 years.
	BASIC DENTAL SERVICES (Minor Restorative, Endodontics, Periodontics and Oral Surgery)
Amalgam Restorations (Fillings)		80%	60%	Multiple restorations on one surface will be treated as a single filing.
Composite Resin Restorations (Fillings)		80%	60%	Multiple restorations on one surface will be treated as a single filing.
Space Maintainers		80%	60%	For covered persons under the age of 16 years, once per lifetime. Benefit includes all adjustment within 6 months of installation.
Root Canal Treatment		80%	60%
Root Planing		80%	60%	Limited to 1 time per quadrant per 24 months.
Periodontal Surgery		80%	60%	Once every 36 months per site.
Simple Extraction		80%	60%
Surgical Extraction including Impacted Wisdom Teeth		80%	60%
General Anesthesia		80%	60%	When clinically necessary.
Palliative Treatment (Relief of Pain)		80%	60%	Covered as a separate benefit only if no other services except exam and X-rays were performed during the visit.
	MAJOR DENTAL SERVICES
Crowns		60%	40%	Limited to one time per tooth every 5 calendar years. Covered only when a filling cannot restore the tooth.
Fixed Bridges		60%	40%	Limited to one time per tooth every 5 calendar years. Covered only when a filling cannot restore the tooth. (Alternate benefits for a partial denture may be applied.)
Full Dentures		60%	40%	Once every 60 months. No additional allowances for over-dentures or customized dentures.
Inlays and Onlays		60%	40%	Limited to one time per 5 calendar years. Covered only when silver fillings cannot restore the tooth.
Partial Dentures		60%	40%	Once every 60 months. No additional allowances for precision or semi precision attachments.
Recement Bridges, Crowns, Inlays		60%	40%	Once every 6 months per restoration.
Relining Dentures		60%	40%	Limited to relining done more than 6 months after the initial insertions. Limited to 1 time per calendar year.
Repairs to Full Dentures, Partial Dentures, Bridges		60%	40%	Limited to repairs or adjustments done within 12 months after the initial insertion.
	ORTHODONTIC SERVICES
Diagnose or correct misalignment of the teeth or bite including Phase I and Phase II		60%	40%	Preauthorization required.
Bolded  items = change

*The in-network percentage of benefits is based on the discounted fee negotiated with the provider.                           **The out-of-network percentage of benefits is based on the usual and customary rates prevailing in the geographic area in which the expenses are incurred.                                   

The material contained in the above table is for informational purposes only and is not an offer of coverage.  Please note that the above table provides only a brief, general description of coverage and does not constitute a contract.  For a complete listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your Certificate of Coverage or contact your benefits administrator.  If differences exist between this Summary of Benefits and your Certificate of Coverage/benefits administrator, the certificate/benefits administrator will govern.  All terms and conditions of coverage are subject to applicable state and federal laws.  State mandates regarding benefit levels and age limitations may supersede plan design features.

UnitedHealthcare Dental Options PPO Plan is either underwritten or provided by: United Healthcare Insurance Company, Hartford, Connecticut; United Healthcare Insurance Company of New York, Hauppauge, New York; or United HealthCare Services, Inc.