Benefit Reference Guide - The School District of Palm Beach County

Dental
PPO Plans (P5215 and P5105)
BENEFIT Option 3 - PPO Plan P5215 Option 4 - PPO Plan P5105
In-Network Out of Network In-Network Out of Network
Deductible (maximum 3 per family)
(Calendar Year is January 1 - December 31)
Class I
Class II, III, IV
None
$50 per year,
individual
None
$50 per year,
individual
None
$50 per year,
individual
None
$50 per year,
individual
CALENDAR year Maximum $1,000 $1,000 $1,000 $1,000
Lifetime Orthodontic Maximum $2,000 $2,000 Not Covered Not Covered
Waiting period
Class I and II
Class III
Class IV
None
12 Months
12 Months
None
12 Months
12 Months
None
12 Months
N/A
None
12 Months
N/A
BENEFIT In-Network Out of Network* In-Network Out of Network*
Class I - Preventive & Diagnostic
Oral Evaluation (Diagnostic)
X-Rays (Diagnostic)
Lab and Other Diagnostic Tests
Prophylaxis (Preventative)
Fluoride Treatment (Preventative)
Sealants
Space Maintainers
100%
100%
100%
100%
100%
100%
100%
90%
90%
90%
90%
90%
90%
90%
100%
100%
100%
100%
100%
100%
100%
80%
80%
80%
80%
80%
80%
80%
class ii - basic services
Restoration (Amalgams and Resin Based Only)
General Services (Emergency Treatment and
Anesthesia)
Simple Extractions
Oral Surgery (includes surgical extractions)
Periodontics
Endodontics
80%
80%
80%
80%
80%
80%
70%
70%
70%
70%
70%
70%
50%
50%
50%
50%
50%
50%
40%
40%
40%
40%
40%
40%
Class III - major services
Inlays/Onlays/Crowns and Bridges
Dentures and other Removable Prosthetics
Fixed Prosthetics
50%
50%
50%
40%
40%
40%
50%
50%
50%
40%
40%
40%
Class IV - Orthodontic Services
Orthodontia (Child up to age 19) 50% 50% Not Covered Not Covered
*Out of network percentage is based upon allowable charges.
Please refer to your Certificate of Coverage booklet for a complete
list of benefits, frequencies, limitations and exclusions for all Plans.
The UnitedHealthcare Dental PPO Plans are administered
by Dental Benefit Providers, Inc. and underwritten by
UnitedHealthcare Insurance Company.
The Solstice Dental Plans are offered by Dental Benefit Providers,
Inc. and underwritten by Solstice Benefits, Inc., a licensed Prepaid
Limited Health Service Organization, under F.S. 636.
Did you read about...
• Dental plan options?
• Plan comparisons?
• Orthodontics?
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