Benefit Reference Guide - The School District of Palm Beach County

Dental
Specialty Services for Managed Care Plan
(S500PB and S700)
• The fees within this overview of services apply when such
services are performed by a participating general dentist, unless
otherwise authorized by UnitedHealthcare Dental.*
• If services are not listed within the Schedule of Benefits and are
performed by a participating general dentist, fees will be charged
at the dentist’s usual and customary fee less 25%.
• The participating general dentist you select may not perform all
outlined procedures. The co-payments shown apply to general
dentists who perform these procedures. Therefore, you are
encouraged to secure availability of the scheduled services with
your participating general dentist.
• Should the services of a specialist (Oral Surgeon, Endodontist,
Orthodontist, Periodontist, Prosthodontist or Pedodontist) be
necessary, you may receive this care in one of two ways: (1)
You may go directly to a participating specialist with no referral
and receive a 25% reduction off the provider’s usual and
customary fee; or (2) You may obtain prior written authorization
by UnitedHealthcare Dental* and receive specialty treatment by
an approved participating specialist at the listed co-payments.
Please refer to the Specialty Care Referral Policy in your member
ID packet.
* UnitedHealthcare Dental plans are administered by Dental Benefit Providers, Inc.
Managed Care Plans (S500PB and S700)
Features:
About fillings
The aforementioned UnitedHealthcare Dental managed care
programs provide coverage for the following fillings benefits:
Amalgam (silver fillings) (S500PB and S700)
• No co-payments - Covered 100%
• Verify that your treating dentist provides amalgam fillings. If your
dentist does not offer amalgam fillings, you will receive a resin
(white filling) and you will be responsible for the following copayments:
Composite Resin (white fillings)
S500PB
• Anterior Teeth – Co-payment will apply from $25 - $105
• Posterior Teeth – Co-payment will apply from $55 - $105
S700
• Anterior Teeth – Co-payment will apply from $30 - $115
• Posterior Teeth – Co-payment will apply from $65 - $115
Please discuss your treatment plan with your dentist prior to the
initiation of treatment. If the dentist you selected does not cover the
treatment you desire, please check with another dentist within our
network. With this plan, you have the ability to select any dentist
within the network at any time.
Option I-S500PB Option 2-S700 Option 3-P5215*** Option 4-P5105***
Typical Annual Cost What You Pay What You Pay What You Pay** What You Pay**
In-Network Only In-Network In-Network/Out-of-Network In-Network/
Out-of-Network
Office Visit No charge No charge 0% / 10% 0% / 20%
Oral Examination (every 6 months) No charge No charge 0% / 10% 0% / 20%
Tooth Extraction (simple) $10 $20 20% / 30% 50% / 60%
Silver Fillings No charge No charge 20% / 30% 50% / 60%
Prophylaxis (cleaning - every 6 months) No charge No charge 0% / 10% 0% / 20%
Crown* $240* $245* 50% / 60% 50% / 60%
Molar Root canal $225 $245 20% / 30% 50% / 60%
Bridge - porcelain, base metal, per tooth* $240* $245* 50% / 60% 50% / 60%
* See Exclusion and Limitations
** Member is responsible for the difference between the allowed amount and what the provider charges.
*** Deductible applies except for Preventative and Diagnostic Services.
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