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AFT Dental Insurance

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

PO Box 30567

Salt Lake City, UT84130

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.

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