United HealthCare Dental Program
Available to AFT members as a part of the Limited Supplemental Medical Plan
Basic Plan Benefits Coverage
Annual Maximum Benefit $1,000 per covered member
Annual Deductible $25 per covered member
Sample Schedule*
Service Description Maximum Covered Charge
Diagnostic, Preventive and Restorative
Periodic Oral Evaluation $17
X-Rays (Bitewings) - Four Films or Intraoral - Complete Series
(including bitewings) $17 - $40
Fillings - Based on tooth location, materials and # of surfaces $35 - $85
Endodontics and Periodontics
Root Canal - Anterior, Bicuspid and molar (Permanent Tooth)
(Excluding Final Restoration) $125 - $140
Periodontal Maintenance; Periodontal Scaling and Root Planing, Four or More Teeth Per Quadrant $33 - $72
Oral Surgery
Extraction, Erupted Tooth Or Exposed Root (Elevation and/or Forceps Removal) $39
Removal of Impacted Tooth $45 - $85
Incision and Drainage of Abscess - Intraoral Soft Tissue $45
Adjunctive General Services
Emergency Exam and Visit - Pain Relief Treatment During Regularly Scheduled Office Hours $38
Deep Sedation/General Anesthesia - First 30 Minutes $52
Using the plan:
Enjoy comprehensive care from any dentist or specialist you choose
At the time of your visit, pay for care and obtain a receipt
To file a claim, submit a copy of your receipt (containing the Subscriber # provided
on your ID card along with a diagnosis from the dentist) to
United HealthCare Dental
Attn: Claims Unit
You will receive prompt payment in accordance with your policy
To enroll in this program, please call 888/423-8700
*This is a sample schedule of covered charges. Please consult your policy for full details.
Photographs and illustrations, as well as text, cannot be used without permission from the AFT.