BWXT Y•12 - Dental Plans

UnitedHealthcare Dental and Vision Plan

When you enroll in the UnitedHealthcare Dental Plan, you are automatically enrolled in the Vision Plan.

To receive dental benefits, select and schedule an appointment with the dental provider of your choice. If the provider participates in the network, you will not be billed for any covered charges that are greater than the contracted in-network fee schedule.

To receive vision benefits, select and schedule an appointment with an in-network provider in order to receive maximum benefit payments. When you use an out-of-network provider, benefit payments are reduced and additional coverage limits may apply.

UnitedHealthcare Dental and Vision Plan

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

UnitedHealthcare Dental Plan – Summary of Benefits
Refer to the “Limitations” and “Exclusion” sections, on the following pages, for general limitations.
Services Covered	Amount of Coverage
Annual Deductible (applies to Basic and Major services)	$50 Individual $100 Family
Annual Maximum Benefit	$1,000 per member
Services Covered*	Amount of Coverage**
Preventive and Diagnostic Services:
Oral Examinations	Covered 100%, once every 6 months
Prophylaxis (cleanings)	Covered 100%, once every 6 months
Full Mouth X-rays	Covered 100%, once every 3 years
Bite-wing X-rays	Covered 100%, one set every 12 months
Fluoride	Covered 100% under age 16, once every 6 months
Sealants	Covered 100% under age 16, once per first or second permanent molar every consecutive 36 months
Basic Services:
Space Maintainers	Covered 80% under age 16, once per lifetime
Palliative Treatment (relief of pain)	Covered 80% after deductible Covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit
General Anesthesia	Covered 80% after deductible when medically necessary
Amalgam Restorations (fillings)	Covered 80% after deductible Multiple restorations on one surface will be treated as a single filling
Composite Restorations (fillings)	Covered 80% after deductible, for anterior teeth only Multiple restorations on one surface will be treated as a single filling.
Major Services – 12-month waiting period applies
Simple Extraction	Covered 50% after deductible
Surgical Extraction including Impacted Wisdom Teeth	Covered 50% after deductible
Root Canal Treatment	Covered 50% after deductible
Scaling and Root Planing	Covered 50% after deductible, once per quadrant every 24 months
Periodontal Surgery	Covered 50% after deductible, once every consecutive 36 months per surgical area
Periodontal Maintenance	Covered 50% after deductible, twice per consecutive 12 months following active and adjunctive periodontal therapy within the prior 24 months, exclusive of gross debridement
Crowns, Inlays and Onlays	Covered 50% after deductible, once every 5 years
Fixed Bridges	Covered 50% after deductible, once every 5 years Alternative benefits for a partial denture may be applied
Full or Partial Dentures	Covered 50% after deductible, once every consecutive 60 months from initial or supplement placement
Recement Bridges, Crowns and Inlays	Covered 50% after deductible, once every consecutive 60 months from initial or supplement placement
Relining and Rebasing Dentures	Covered 50% after deductible, once per year for relining done more than 6 months after initial insertion
Repairs to Full Dentures, Partial Dentures and Bridges	Covered 50% after deductible for repairs or adjustment performed more than 12 months after initial insertions

Waiting periods are waived if you were covered under the Company plan when you became effective for this plan.

* Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. If you and your dentist have agreed on a treatment which is more costly than the treatment on which the plan benefit is based, you will be responsible for the difference between the fee for service rendered and the fee covered by the plan. In addition, a pre-treatment estimate is recommended for any service estimated to cost over $200; please consult your dentist.

** If you visit an in-network provider, the percentage of benefits is based on the discounted fee negotiated with the provider. If you visit a non-network provider, the non-network percentage of benefits is based on the schedule of Reasonable and Customary Charges in the geographic area in which the expenses are incurred.

UnitedHealthcare Dental and Vision Plan

In addition to the limitations shown in the Summary of Benefits, the following general limitations apply:

Oral Examinations – Covered as a separate benefit only if no other service was performed during the visit other than prophylaxis and X-rays. Limited to once every 6 months.
Complete Series or Panorex Radiographs – Limited to one time per consecutive 36 months. Exception to this limit will be made for Panorex Radiographs if taken for diagnosis of third molars, cysts, or neoplasms.
Bite-wing Radiographs – Limited to 1 series of films per calendar year.
Extraoral Radiographs Limited to 2 films per calendar year.
Dental Prophylaxis – Limited to once every 6 months.
Diagnostic Casts – Limited to one time per consecutive 24 months.
Fluoride Treatments – Limited to covered persons under the age of 16 years, and limited to once every 6 months. Treatment should be done in conjunction with dental prophylaxis.
Sealants – Limited to covered persons under the age of 16 years, and once per first or second permanent molar every consecutive 36 months.
Space Maintainers – Limited to covered persons under the age of 16 years, once per lifetime. Benefit includes all adjustment within 6 months of installation.
Restorations – Multiple restorations on one surface will be treated as a single filling. Composite restorations limited to anterior teeth only.
Pin Retention – Limited to 2 pins per tooth; not covered in addition to Cast Restoration.
Inlays and Onlays – Limited to one time per 5 calendar years. Covered only when a filling cannot restore the tooth.
Crowns – Limited to one time per tooth per 5 calendar years. Covered only when a filling cannot restore the tooth.
Post and Cores – Covered only for teeth that have had root canal therapy.
Sedative Fillings – Covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit.
Scaling and Root Planing – Limited to 1 time per quadrant per consecutive 24 months.
Periodontal Maintenance – Limited to 2 times per consecutive 12 months following active and adjunctive periodontal therapy within the prior 24 months, exclusive of gross debridement.
Full Dentures – No additional allowances for overdentures or customized dentures.
Partial Dentures – No additional allowances for precision or semi-precision attachments.
Relining and Rebasing Dentures – Limited to relining or rebasing performed more than 6 months after the initial insertions. Limited to 1 time per calendar year.

UnitedHealthcare Dental and Vision Plan

The UnitedHealthcare dental plan does not cover certain expenses including, but not limited to, charges for:

Dental Services that are not necessary.
Hospitalization or other facility charges.
Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)
Reconstructive Surgery regardless of whether or not the surgery which is incidental to a dental disease, injury, or Congenital Anomaly when the primary purpose is to improve physiological functioning of the involved part of the body.
Any dental procedure not directly associated with dental disease.
Any procedure not performed in a dental setting.
Repairs to Full Dentures, Partial Dentures, Bridges – Limited to repairs or adjustments performed more than 12 months after the initial insertion.
Palliative Treatment – Covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit.
Occlusal Guards – Covered only if prescribed to control habitual grinding, and limited to one guard every consecutive 36 months.
Full Mouth Debridement – Limited to once every consecutive 36 months.
General Anesthesia – Covered only where medically necessary.
Osseous Grafts – With or without resorbable GTR membrane replacement, are limited to once every consecutive 36 months per quadrant or surgical site.
Periodontal Surgery – Hard tissue and soft tissue periodontal surgery are limited to once every consecutive 36 months, per surgical area. This includes gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, pedicle grafts, and free soft tissue grafts.
Replacement of Full Dentures, Partial Dentures, Bridges, or Crowns – Replacement of complete or partial dentures, both fixed and removable, or crowns, previously submitted for payment under this Plan is limited to once every consecutive 60 months from initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances.
Procedures that are considered to be experimental, investigational or unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics.
The fact that an experimental, investigational or unproven service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in coverage if the procedure is considered to be experimental, investigational or unproven in the treatment of that particular condition.
Services for injuries or conditions covered by Workers’ Compensation or employer liability laws, and services that are provided without cost to the covered person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.
Expenses for dental procedures begun prior to the covered person’s eligibility with the Plan.
Dental services otherwise covered under the policy, but rendered after the date individual coverage under the policy terminates, including dental services for dental conditions arising prior to the date individual coverage under the policy terminates.
Services rendered by a provider with the same legal residence as a covered person or who is a member of a covered person’s family, including spouse, brother, sister, parent or child.
Dental services provided in a foreign country, unless required as an Emergency.
Replacement of crowns, bridges, and fixed or removable prosthetic appliances inserted prior to plan coverage unless the patient has been eligible under the plan for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12-month period, the plan is responsible only for the procedures associated with the addition.
Replacement of missing natural teeth lost prior to the onset of plan coverage until the patient has been eligible for 12 continuous months.
Replacement of complete or partial dentures, crowns, or fixed bridgework if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement.
Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.
Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.
Procedures related to the reconstruction of a patient’s correct vertical dimension of occlusion (VDO).
Placement of dental implants, implant-supported abutments and prostheses. This includes pharmacological regimens and restorative materials not accepted by the American Dental Association (ADA) Council on Dental Therapeutics.
Placement of fixed bridgework solely for the purpose of achieving periodontal stability.
Billing for incision and drainage if the involved abscessed tooth is removed on the same date of service.
Treatment of malignant or benign neoplasms, cysts, or other pathology, except excisional removal. Treatment of congenital malformations of hard or soft tissue, including excision.
Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.
Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.
Acupuncture, acupressure and other forms of alternative treatment.
Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.
Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.

Customer Service is available toll-free at 1-800-436-7295 from 8:00 a.m. to 11:00 p.m., Monday through Friday, and from 9:00 a.m. to 5:30 p.m. on Saturdays.

If differences exist between this summary and the Certificate of Coverage, the Certificate 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 Vision Plan
This Plan is underwritten by UnitedHealthcare Insurance Company
Benefits at a Spectera Network Provider
Comprehensive Vision Exam — Once every 12 months	Covered 100% after $15 copay Vision examination provided by a network optometrist or opthamologist
Materials	$30 copay Materials copay applies to entire purchase of eyeglasses (lenses and frames) or contacts (in lieu of eyeglasses)
Pair of Lenses (for eyeglasses) — Once every 12 months (Standard single vision, lined bifocal, lined trifocal or lenticular)	Standard scratch-resistance coating, tints, UV and progressive lenses are covered in full, once every 12 months (after $30 materials copay) Lens Options such as polycarbonate lenses and anti-reflective coating may be available at a discount
Frames — Once every 24 months	Applies to virtually all of the frames on the market today, most of which are covered in full, without additional cost to the member, other than applicable copay. Receive a $50 wholesale frame allowance (approximate retail value of $120 to $150) at private practice providers, or a minimum $130 frame allowance at retail chain providers.
Contact Lenses (in lieu of eyeglasses) — Once every 12 months
Covered-in-full elective contact lenses	The fitting/evaluation fees, contacts (including disposables), and up to two follow-up visits are covered-in-full (after applicable copay) for the most popular brands on the market. If covered disposable contact lenses are chosen, up to 4 boxes (depending on prescription) are included when obtained from a network provider. It is important to note that Spectera’s covered-in-full contact lenses may vary by provider.
All other elective contact lenses	A $105 allowance is applied toward the fitting/evaluation fees and purchase of contact lenses outside of Spectera’s covered-in-full contacts (materials copay does not apply). Toric, gas permeable, and bifocal contacts are all examples of contacts that are outside of our covered-in-full selection.
Necessary contact lenses*	Covered-in-full (after applicable copay).
Refractive Eye Surgery	Spectera participants receive access to discounted refractive eye surgery from numerous provider locations throughout the United States. To find a participating laser eye surgeon in your area, visit our website at www.spectera.com.
Benefits at an Out-of-Network Provider
Vision Exam (Optometrist or Opthalmologist)	Covered up to $40
Lenses
Single Vision	Covered up to $40
Bifocal	Covered up to $60
Trifocal	Covered up to $80
Lenticular	Covered up to $80
Frames	Covered up to $45
Contact Lenses (in lieu of eyeglasses)
Elective	Covered up to $105
Necessary*	Covered up to $210
If you choose an out-of-network provider, you will need to send your itemized receipts, with the primary-insured’s unique identification number and the patient’s name and date of birth, to: Spectera Claims Department P. O. Box 26618 Baltimore, MD 21207-6618 Please note: Receipts for services and materials purchased on different dates must be submitted together at the same time to receive reimbursement.

* Necessary contact lenses are determined at the provider’s discretion for one or more of the following conditions: Following post cataract surgery without intraocular lens implant; To correct extreme vision problems that cannot be corrected with spectacle lenses; With certain conditions of anisometropia; With certain conditions of keratoconus.

If your provider considers your contacts necessary, you should ask your provider to contact Spectera concerning the reimbursement that Spectera will make before you purchase such contacts.

Important to Remember

Always identify yourself as a Spectera participant when making your appointment. This will assist your provider in obtaining a claim authorization number prior to your visit.
Benefits available every 12 or 24 months (depending on the benefit frequency), based on last date of service.
Your $105 contact lens allowance is applied to the fitting/evaluation fees as well as the purchase of contact lenses. For example, if the fitting/evaluation fee is $30, you will have $75 towards the purchase of contact lenses. The allowance may be separated at some retail chain locations between the examining physician and the optical store. Toric, gas permeable, and bifocal contacts are all examples of contacts that are outside of our covered-in-full selection.

Exclusions

The following services and materials are excluded from coverage under the policy:

Post cataract lenses
Non-prescription items
Medical or surgical treatment for eye disease, that requires the services of a physician
Workers’ Compensation services or materials
Services or materials that the patient, without cost, obtains from any governmental organization
Services or materials that are not specifically covered by the policy
Replacement or repair of lenses and/or frames that have been lost or broken
Cosmetic extras, except as stated in the Policy’s Table of Benefits

Please note: If there are differences in this document and the Group Policy, the Group Policy is the governing document.

Customer Service is available toll-free at 1-800-436-7295 from 8:00 a.m. to 11:00 p.m., Monday through Friday, and from 9:00 a.m. to 5:30 p.m. on Saturdays.

Please note: If there are differences in this document and the Group Policy, the Group Policy is the governing document.