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Dental PlansA dental planfor individualsand familiesA DHMO plan that gives yousimpler benefits for ahealthier smile SignatureValue Dental Plan V160 California
We give you something to smile aboutYour health benefits just aren’t completewithout dental coverageWhether you need coverage for yourself or for a growing family, you’ll appreciateUnitedHealthcare Dental Plan V160 plan that provides a wide range of benefits.Routine exams are covered at no charge. And the plan covers a range of preventive,routine and major services at a fraction of what you would pay without coverage.There’s even an orthodontic plan with special pricing. Now, that’s worth smiling about!The UnitedHealthcare Dental Plan V160 plan is simple to use. There are no claimforms and no deductibles. Your annual premiums cover common dental proceduresto keep your smile healthy. (See the Benefit & Copayment Highlights inside.)The dentist just for youWhen you join UnitedHealthcare Dental (“UnitedHealthcare Dental Plan V160 or ThePlan”), you’ll select a contracted dentist from our directory to oversee your dentalcare. All dentists are rigorously screened before they’re added to our network. Withour large DHMO California network, you’re sure to find a dentist you’re comfortablewith at a location that’s convenient for you.Find your primary care dentistEach family member can have their own primary care dentist. Before you enroll,search the network to find the dentist that is right for you.Online1. Go to myuhc.com2. Select Find a Dentist3. Select California4. Select the “CA DHMO-Legacy PacifiCare” networkCall Open Enrollment Hotline at 1-888-679-8925.Brace yourself: orthodontia is included tooStraight teeth are important, not only for a great-looking smile, but also for the lifelonghealth of your teeth, gums and mouth. That’s why UnitedHealthcare Dental V160includes a value-priced orthodontic program. You pay a specially negotiated fee (mostorthodontists accept payment plans), plus startup, retention and final records fees.Your Plan primary care office submits a referral form. Then, the Plan sends youan Explanation of Benefits which includes the name and location of a contractedorthodontist who can provide the orthodontic treatment.2
It’s easy to enroll1 Fill out the attached enrollment form and, if choosing the ACH method ofpayment, be sure to fill out the Pre-Authorization payment application.2 Indicate which dental office you’ve chosen. Choose the dental office from ourDentist Directory by visiting myuhc.com or by calling 1-888-679-8925.3 Include a check for your enrollment fee and annual premium payable toUnitedHealthcare Dental. Make sure we receive your enrollment form andpayment by the 20th of the month to ensure coverage begins the first of thefollowing month.Send enrollment form and payment to:ATTN: M/S CA 124-0152UnitedHealthcare DentalP.O. Box 6020Cypress, CA 90630-0020Make paymentseven easierSelect our monthly auto pay, whichallows us to automatically debityour personal checking accounteach month. This payment optionauthorization can be found on theenrollment form inside.3
2021 Dental V160 rates by regionYou may select to pay on a monthly basis or save by making an annual payment.1RegionAlameda, Contra Costa, El Dorado, Fresno,Kern, Los Angeles, Napa, Orange, Placer,Riverside, Sacramento, San Bernardino, SanDiego, San Francisco, San Joaquin, SanMateo, Santa Clara, Santa Cruz, Venturacounties:2Butte, Marin, Solano, Sonoma,Stanislaus counties:3Monterey, San Louis Obispo, SantaBarbara, Tulare counties:Monthly PaySubscriber 21.30 51.91 46.50Subscriber 1 33.72 82.14 73.58Family 47.57 115.90 103.82Or save when you select the Annual Payment OptionAnnual Payment OptionSubscriber 246.71 601.07 538.43Subscriber 1 390.44 951.24 852.11Family 550.88 1,342.12 1,202.27For all other areas, please call 1-888-679-8925.Quality dental care.Broad coverage.Cost-effective premiumsand copayments.So, are you smiling yet?4
Preventive ServicesMember Pays:Major ServicesCrowns and PonticsMember Pays:Office visitNo ChargeX-rays, full mouthNo ChargeStainless steel, primary toothSingle filmNo ChargeResin crown† 85.00Each additional filmNo ChargeFull metal crown* 145.00Teeth cleaningNo Charge3/4 metal crown* 140.00Topical fluoride (under age 18)No ChargePorcelain crown† 130.00Porcelain with metal crown*† 165.00 30.00Sealants (per tooth; under age 18)Not CoveredDiagnostic casts (non-orthodontic) 10.00Cast post and core, in addition to crown* 65.00Emergency treatment (palliative) 10.00Pontic, cast metal (base) 145.00Office visit (after-hours) 20.00Pontic, porcelain with metal* 165.00Inlay recementation 12.00Crown recementation 12.00Bridge recementation 18.00Routine ServicesRestorative DentistryAmalgam restorations (cavities involving permanent teeth)ProstheticsOne tooth surface 15.00Two tooth surfaces 20.00Denture adjustment 12.00Three tooth surfaces 26.00Replace tooth, per tooth 23.00Resin restorations, per tooth (anterior) 25.00Denture repair 28.00As above, involving incisal edge 28.00Denture reline (office) 35.00Denture reline, lab-processed 65.00Resin restorations, per tooth (posterior)Pin retention in addition to final restoration, pertoothSedative base 66.00- 102.00 5.00Interim partial denture 60.00 7.00Partial denture, upper or lower (including anyconventional clasps, rests, and teeth)* 225.00Partial denture (cast metal base with resinsaddle), upper or lower (including anyconventional clasps, rests, and teeth)* 255.00Complete denture, upper or lower 250.00Add tooth or clasp to existing partial 31.00Fixed space maintainer 55.00Oral SurgeryExtraction (uncomplicated)Each additional tooth (same visit)Soft tissue impaction 16.00 10.00 50.00Partially bony impactionNot CoveredCompletely bony impactionNot CoveredBiopsy of oral tissue (soft) 10.00Biopsy of oral tissue (hard) 16.00Surgical removal of an erupted tooth 40.00Alveoloplasty (not in conjunction with extractions),per quadrant 80.00Alveoloplasty in addition to tooth extraction,per quadrant 90.00Class I (teeth straightening) 1,895.00Class II (correction of overbite) 1,895.00Drain abscess/intraoral 30.00Class III (correction of underbite) 1,895.00Drain abscess/extraoral 30.00Frenectomy 50.00Specific copayment levels also have been set for startup and retentionservices. The orthodontic benefit covers: consultation, retention, banding,and monthly office visits for 24 months.Pulp capping (direct) 10.00Pulp capping (indirect) 24.00Orthodontic treatment must be provided by a UnitedHealthcare DentalPanel Orthodontist. A referral must be submitted by the assigned generaldentist, and an orthodontist will be assigned by UnitedHealthcare Dental.EndodonticsTherapeutic pulpotomy 22.00Root canals - Anterior 100.00Root canals - Bicuspid 130.00Root canals - Molar 175.00Prefabricated post 50.00Cast post and core 65.00PeriodonticsGingival curettage, per quadrant 40.00Gingivectomy, per quadrant 115.00Muco-gingival surgery, per quadrantGingivectomy, per toothPeriodontal maintenance (once every 6 months)Occlusion adjustmentRemovable acrylic space maintainerClasps, each additional, for space maintainer 55.00No Charge*Plus actual lab cost of gold.† Not for molars.Dentist may charge 20.00 for broken appointments if not notified at least 24 hours in advance.OrthodonticsRefer to the Evidence of Coverage and Disclosure Form booklet and theOrthodontic Information Sheet for complete details of benefits, exclusions,limitations, and plan description. There is no specialty referral for theUnitedHealthcare Dental V160 plan. Copayments are applicable atparticipating general dentist offices only.The Dental premium includes expenses related to state and federal taxes,fees and assessments. It also may include additional new taxes, fees andassessments from the Affordable Care Act.Not Covered 20.00 20.00No Charge5
Individual member enrollment 2021Instructions for completing enrollment form. Check all appropriate boxes and print all information clearly. (Please retain the brochure information until you receive your ID card.) Subscriber: Fill out section completely. Remember to indicate the Provider Number/Dentist/City you have selected. Dependents: All dependents you wish to be covered should be listed in this section with their selected Provider (Dentist). Method of Payment: Please indicate your preferred method of payment, Monthly Auto Pay, Monthly Pay by Check, Credit Card or Annual Payment.Should you choose the Monthly Auto Pay option, complete and sign the Pre-Authorized Payment Application on the adjacent page. UnitedHealthcareDental will then automatically deduct the monthly premium from your checking account. Or, if you select the pay by check option, please include acheck made payable to UnitedHealthcare Dental for the annual or monthly premium and one-time enrollment and processing fee of 15.00. Terms and Conditions: Read the Terms and Conditions on the adjacent page and sign in the box at the “X” on the bottom of this sheet. This formmust be signed for coverage to be effective. Your payment and completed enrollment form must be received by the 20th of the month for coverageto be effective the 1st of the following month.Effective DateSubscriber (you)Please complete all sections. This form cannot be processed if information is incomplete.Last NameSexMFirst NameFDate of Birth//Mailing AddressSSNMiddle Initial/CityProvider NumberStateDependents (your spouse and/or children)MFDate of BirthProvider NumberSexMFDate of BirthSexMFDate of BirthSexMF//Last NameSSN//Middle Initial/Have you received treatment fromYesNothis dental office?First Name/SSN/Middle Initial/Have you received treatment fromthis dental office?YesNoLast NameFirst Name/SSN/Middle Initial/Have you received treatment fromYesNothis dental office?Dentist Name/CityThis section must be completed by the individual who will be responsible for paying for the plan.First NameAddressBe sure to read the terms andconditions on the following page,and sign at the “X” by this symbol:6Have you received treatment fromYesNothis dental office?Dentist Name/CityDate of BirthMiddle InitialFirst Name/)/Last NameProvider NumberPayor (if not you)/Last NameProvider NumberRelationship (spouse, daughter, son)4SSNDentist Name/CityRelationship (spouse, daughter, son)3First Name/Provider NumberWork ()Dentist Name/CityRelationship (spouse, daughter, son)2ZIP CodeRemember to select a provider. Be sure to read the terms.Last Name/)Have you received treatment fromYesNothis dental office?Cell (Relationship (spouse, daughter, son)SexHome (Dentist Name/CityEmail1/Middle InitialCityEmail AddressStateMail To:ATTN: M/S CA 124-0152UnitedHealthcare DentalP.O. Box 6020Cypress, CA 90630-0020ZIP CodeTelephone:1-888-679-8925Fax: 1-844-608-0601
Terms and ConditionsPlease complete all sections. This form cannot be processed if information is incomplete.I agree and understand that any and all disputes, including claims relating to the delivery of services under the plan and claims of medical/dentalmalpractice (that is as to whether any dental services rendered under the health plan were unnecessary or unauthorized or were improperly, negligentlyor incompetently rendered), except for claims subject to ERISA, between myself and my dependents enrolled in the plan (including any heirs or assigns)and UnitedHealthcare Dental or any of its parents, subsidiaries or affiliates shall be determined by submission to binding arbitration. However, in the eventthe amount in controversy in the dispute including any claims of damage is not greater than 5,000.00, such disputes are not subject to binding arbitrationhereunder. Disputes in which more than 5,000.00 is in controversy will not be resolved by a lawsuit or resort to court process, except as applicablelaw may provide for judicial review of arbitration proceedings. By enrolling in UnitedHealthcare Dental, both member (including any heirs or assigns)and UnitedHealthcare Dental entities agree to waive the constitutional right to a jury trial and instead voluntarily agree to the use of binding arbitrationas described in the Evidence of Coverage. Request for disenrollment or changes in coverage must be received in writing by the 20th of the month to beeffective same month. You can fax, mail or email changes:Fax: 1-844-608-0601Email: individualdhmodental@uhc.comMethod of paymentMail: ATTN: M/S CA 124-0152UnitedHealthcare DentalP.O. Box 6020Cypress, CA 90630-0020Please complete all sections. This form cannot be processed if information is incomplete.Monthly Auto Pay.Complete the attached Pre-Authorized Payment Application andinclude a voided check. A one-time non-refundable enrollmentand processing fee of 15.00 will be debited from your checkingaccount along with your first month’s premium.Annual Payment.Include a check payable to UnitedHealthcare Dentalfor your annual premium, including a one-time nonrefundable enrollment and processing fee of 15.00.or save whenyou select theAnnual PaymentOption.Monthly Pay by Check.Include a check payable to UnitedHealthcare Dental for yourmonthly premium, including a one-time non-refundable enrollmentand processing fee of 15.00.UnitedHealthcare Dental Signature Value (HMO) DentalV160 plan is not available in all counties. All dental caremust be provided by a network dentist; please checkthe dentist listing for available dentists. Benefits for theUnitedHealthcare Dental Signature Value DHMO plansare offered and provided by Dental Benefit Providers ofCalifornia, Inc.Pay by Credit Card (over the Phone).Please circle one (one-time, recurring, annual). Includes a onetime non-refundable enrollment and processing fee of 15.00.Please complete all sections. This form cannot be processed if information is incomplete.xSubscriber Signature (This form must be signed by the Subscriber for coverage to be effective.)DatePre -Authorized Payment ApplicationComplete this section only if you want your monthly premium automatically deducted from yourchecking account and provide a voided check.Our Pre-Authorized Payment PlanIt’s the forget-proof method of paying your premium — almost as easy as payroll deduction. Justauthorize us to debit your personal checking account each month. We’ll do the rest. There will beno more paperwork for you and no more checks to write. No worries about monthly late-paymentcharges. And you’ll save on postage and envelopes. It’s easy, reliable and automatic.Automatic Payment(s)I (we) hereby authorize UnitedHealthcareto initiate debit entries to the accountindicated below. I also authorize thenamed financial institution to debit thesame to such account. I agree thisauthorization will remain in effect untilyou actually receive written notificationof its termination from me.Type of account: Checking2021 Calendar for Auto DebitJan 25Apr 25Jul 25Oct 25Feb 22May 25Aug 25Nov 24Mar 25Jun 24Sep 24Dec 26The auto debit process is 7 calendar days prior to thelast day of the month except when that day is Saturday;then it will be Sunday. Please have your funds availablefor withdrawal on this day.Financial Institution’s NameAddressCity, State, ZIPThis auto debit process is 7 calendar days prior to the last dayof the month except when that day is Saturday; then it will beSunday. Please have your funds available for withdrawal onthis day. SavingsxNine-digit Routing NumberAuthorized Account SignatureAccount NumberAgency/Broker Use OnlyAgencyBrokerNameID NumberAddressCityEmail AddressPhoneStateZIP Code
1-888-679-8925 uhc.com Network name: CA DHMO-Legacy PacifiCareATTN: M/S CA 124-0152, UnitedHealthcare Dental, P.O. Box 6020, Cypress, CA 90630-0020Learn moreNondiscrimination Notice and Access to Communication ServicesWe do not exclude, deny benefits to, or otherwise discriminate against any Member onthe ground of race, color, national origin, ancestry, religion, sex, marital status, gender,gender identity, sexual orientation, age, or disability for participation in, or receipt ofthe covered services under, any of its Plans, whether carried out by UnitedHealthcaredirectly or any other entity with which UnitedHealthcare arranges to carry out coveredservices under any of its Plans.Free services are available to help you communicate with us such as letters in otherlanguages and in other formats like large print. You can also ask for an interpreter at nocharge. For assistance, please call the toll-free number listed on your plan ID card.If you think you weren’t treated fairly because of your race, color, national origin,ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, ordisability, you can send a complaint to:Online:UHC Civil Rights@uhc.comiil\lH!ilflR ://!JoJ rnt1Wl lJH1Jfflf1litfiJllltlrHrrnlH1l 1/!JiiJJ.,:l §JlllllmH.exilll!U l'll llB?tiR §w liffill" '§W'oo'l1UR Da):J.,;l//!JB g §Jlllt ti'hmi ' i!i!lHJ/f!j .l'l -t'll'oo/i/i91J ilfi tii' [ li.i't ' :t.JiR §9UU tHH (TTY) 711 si.1/!J\'lii Je:li tU!J ii/H!HT DMHC !UH OOO1-888-466-2219 :l.illi.F- . "'L.,i.L.; , , ,. u, ,, '-.,.fall wL.c. ,I,., ,; !""fa "' J ,.,Jr ,to.,\ wws.J1, J ,i,.llJ ,.,.,.Jl ¼ ;. ufo L.; u.J1 !1 r,!.J uk I Jl.,.:.:i'il 1.r-J. , i L.- J .f'r'.J UJ uW i.l"! µ1 .:.it. ,1-ll I .)ji:i,'YI cs"' DMHCJJ\.-'1I el&, ,,oct.ll u- e, ;.!w;,,hl lo) .TTY 711 ,'-, ,.JI u :,.:.;tJ.,l i s,- ,!Ie-a ,.ll "' "'.1-888-466-2219'-!Urt'lilr ltQ'lU'-IU'l, St'1.t'-lilJ ffeSilp'l,'2.unj wltwlpnlt t, np :;lhq hwuwlthl]l \]11.thlt hhU1liJwl)ipwtj mltplthplt m bwnwJmpJmltlthp]!:'-lwpnq hp 11\JlWUWLFWUWtj np pwpqtfwuw ljwtf pwpqtfwl.tmpJWU w1.ttj 6:wp bwnWJDLpJml.tl.thp:2.1.twpunjnp t, np tfp 2wpp lhqml.thpntj 1.twli umljw \]11.tp w1.ttj 6:wp qpwtjnp tnhqhljmpJml.t: :;)hplhqtj ntj oql.tmpJmli utnwl.twlm hwtfwp, jul.tqpmtf hup qwl.tqwhwphl :;)hp wnnq2U111jWhwljwl.tbpwqj,p' :;)hp 6:wltw nqwljwlt pwpU1p hhtnlimtf u2tJ.wb hhnw]unup hwtfwpntj , TTY 711:2.llltJ.hUllll oqumpJlllU ljlllppp)i qhUjpmtf, qU1uqU1hU1php DMHC-)1 Oql.tmpJllll.t hhnllljunuwqbJi1-888-466-2219 hwtfwpntj :llfitf1Sfl5212H filfulltjl'lH1G8i:l1J12fii§ fam : fii si:ltfiJi11m211:11unt11 tjl'lHlG9!!ruljl'lUl'lltJJ tJlfiliimrun11u Hl1tu l'iril'il 1i\ 1J121 rum2fil1tfilr iiH1Gsi:l1J12tl1mfilll;!tuti'221cntu l'ifml!;j1W1 1 BmmuNt1n mmrua11HiJDl runii1m211:1 1:1l2ulli) ID 1Ufill.Jl'l TTY 71111iifii2t1nmrmr '2tllldtil9Jl'i 1UT11BJ!!fftl8 tu DMHC mmrua 1-888-466-22191:U4J JJ.JA .JJ tf-- .:.itc. l . "- .:.i:;.L.Y.LJJ-1: I.J"'- !-Y4u-Al.i.:.r!"faul.J.:i. ljiu-A . l: 1 ;.-!, I.J . .d ul.J.:i. .J J ,i.:,.1.51. : .:.I W"½ (.r-1.lt.l ; .J .S.S -:'.1!4y .sly . .i.!o4 J.,.;,, ,. 04j Y. "½ i.::.i.:.L.Y. U.J .:.I W\.r. I - 4Y. .AS.'½ j.1 .TTY 711 - IJ"t.,:; o.l.!. , Wu-:!L.Ww ;lS y.Si.S\ o).,,.:,,'½ 1.,y.,Uy,4 lil:J ,LJl:iJ.P-LJ4j.'l.J!-.u,,W 1-888-466-2219 aw. , DMHC ,;W.la ,.s.s .l. l; ,,,), jl,l'-' ;.,;, ,;W.I ,lfrllT- : 3lttm.m ,);- I'@*tt1Jnqq;)- * 11'1 m* W i l l ! ; , f f 61 ' :ITT"lT3IT F.mlri, :11)- 61 3TT"lT * qra ,);- fi;tv, 'fl lT fil 'l,fg,);- tl'ro; fm w ai"aR, TTY 711 'R 'liTof 'RI 3lT'm" JITTlqi" ,!s'i- .ffim'l'lic!T t n1 ;,ff DMHCtrr filOnline: laint forms are available at :Toll-free 1-800-368-1019,1-800-537-7697 (TDD)Mail:U.S. Dept. of Health and Human Services200 Independence Avenue, SW Room 509FHHH BuildingWashington, DC 20201Civil Rights CoordinatorUnitedHealthcare Civil Rights GrievanceP.O. Box 30608Salt Lake City, UT 84130INFORMACIÓN IMPORTANTE SOBRE IDIOMAS:Es probable que usted disponga de los derechos y servicios a continuación. Puede pedir unintérprete o servicios de traducción sin cargo. Es posible que tenga disponible documentaciónimpresa en algunos idiomas sin cargo. Para recibir ayuda en su idioma, llame a su plan desalud al número
without dental coverage Whether you need coverage for yourself or for a growing family, you’ll appreciate UnitedHealthcare Dental Plan V160 plan that provides a wide range of benefits. Routine exams are covered at no charge. And the plan covers a range of preventive, routine and major servi
