Federal Employees Non-FEHB CALIFORNIA 2015 • SIGNATURE VALUE • DENTAL 142

More Choices. More Coverage. More Savings.

Signature Dental is a cost-effective dental plan that offers you and your family coverage for a broad range of dental services designed to keep your smile healthy.

If you are enrolled in UnitedHealthcare’s medical plan, you are automatically enrolled in a dental indemnity plan and eyewear vision plan. Now you have the opportunity to purchase enhanced dental benefits for greater coverage. Plus, if you are not enrolled in UnitedHealthcare’s medical plan, it’s not too late to receive dental coverage with the Signature Value dental plan.

Just follow the directions and complete the application on the last page of this brochure. With UnitedHealthcare Dental’s, dental plan, you have the peace of mind knowing that you and your family are well covered.

Enjoy extensive dental benefits

•Receivepreventiveservices,fromexamstocrowns,atlowornocost. •Benefitfromgenerousorthodontiadiscounts. •Enjoylowerout-of-pocketcostsforservices.

It’s easy to enroll

BenefitfromgeneroussavingswithUnitedHealthcare’sDental142enhancedcoverageplan.You can see how much you’ll save per service in the table below.

We give you something to smile about!

Savings for the Whole FamilyEvery family member in your household may participate in the UnitedHealthcare Dental SignatureValue program, including your spouse and unmarried dependent children up to age 25. Plus, each family member can choose a different provider from our large network. And there isnoannualmaximum,nomatterhowoftenyourfamilyusestheprogram.

AllcopaymentslistedintheSummaryofBenefitsarepaidbythememberdirectlytotheir assigned General Dentist’s office. Copayments for treatment referred by your assigned GeneralDentist to a participating specialist may vary.

Brace Yourself: Receive Orthodontia DiscountsStraight teeth are important, not only for a great-looking smile, but for the lifelong health of your teeth, gums and mouth. That’s why UnitedHealthcare Dental 142 includes a value-priced orthodontic program. Plus, orthodontics is available for both adults and children. Most orthodontists accept payment plans, so you just pay a specially negotiated fee, startup, retention and final records fees.

u N i T e D H e A LT H c A r e D e N TA L S i G N AT u r e V A L u e ( H M O ) D e N TA L 1 4 2

Take advantage of greater out-of-pocket savings when you join this dental plan. You’llreceive care from a fully credentialed dental provider who is a member of our network. Even better, an orthodontia benefit is included. For provider selection and other member information, visit http://www.uhcfeds.com/home (Network: CA DHMO-Legacy PacifiCare).

Procedure Your cost With Dental 142 Your cost Without Dental 142

Exam $0 $38 X-rays, complete series $0 $94 Routineteethcleaning $0 $65 Filling – 2 surfaces $10 $114 Porcelain with metal crown $250 $817 Denture, upper $195 $1,140 Benefits are not coordinated with the dental plan included with the UnitedHealthcare medical plan.

united Healthcare Dental SignatureValue® (HMO) Dental 142 plan

cALiFOrNiA - Federal employee Non-FeHb Plans 2015

Federal Employee Non-FEHB Plan Benefits Comparison

DENTAL LIMITATIONS • Full denture and partial denture replacement: only when dentures cannot be

made serviceable.• Cleanings:onceeverysixmonths.• Full mouth X-rays: once every two years.• Pedodontic referrals (through age 18 as necessary): referral covered to 51% of

specialist’s fees.• Administration of I.V. sedation or general anesthesia: limited to covered oral

surgical procedures involving one or more impacted teeth (soft tissue, partial bony or complete bony impaction).

DENTAL EXCLUSIONS• Dispensingofdrugs(prescription or over-the-counter).• Teethextractedfororthodonticpurposes.• TreatmentofTemporomandibularJointSyndrome(TMJ).• Oralsurgeryrequiringthesettingoffracturesordislocations.• Treatmentofmalignancies,cysts,orneoplasms.• Cosmeticdentistry.• Lostorstolendenturesororthodonticappliances.

A Summary of Benefits and CopaymentsPREVENTIVE SERVICES

Preventive Services Member Pays

— Office visit $5.00

D0210 X-rays, full mouth No Charge

D0220 X-rays, single film No Charge

D0230 X-rays, each additional film No Charge

D110/D1120 Teeth cleaning - adult or child No Charge

D1201 Topical fluoride (including cleaning) - child No Charge

D1351 Sealant - per tooth (under age 18) $10.00

D0470 Diagnostic casts (non-orthodontic) $15.00

D9110 Emergency treatment (palliative) $5.00

D9440 Office visit (after hours) $20.00

ROUTINE SERVICE

Restorative Dentistry

— Amalgam restorations (cavities involving primary and permanent teeth

D2140 One tooth surface - permanent or primary $7.00

D2150 One tooth surface - permanent or primary $10.00

D2160 Three tooth surfaces - permanent or primary $15.00

D2951 Pin retention, in addition to final restoration - per tooth $15.00

D2960 Sedative filling $5.00

Oral Surgery

— Extractions

D7111 Deciduous tooth $8.00

D7140 Erupted tooth $10.00

D7220 Removal of impacted tooth – soft tissue $50.00

D7230 Removal of impacted tooth – partially bony $60.00

D7240 Removal of impacted tooth – completely bony $90.00

D7210 Surgical removal of an erupted tooth $30.00

D7285 Biopsy of oral tissue (hard) $20.00

D7286 Biopsy of oral tissue (soft) $10.00

D7310 Alveoplasty, in conjunction with extractions – per quadran $70.00

D7320 Alveoplasty, not in conjunction with extractions – per quadrant $80.00

D9220 One tooth surface - permanent or primary $125.00

D9221 One tooth surface - permanent or primary $60.00

D9240 One tooth surface - permanent or primary $140.00

Endodontics

D3110 Pulp capping (direct) $5.00

D3120 Pulp capping (indirect) $12.00

D3220 Therapeutic pulpotomy $12.00

— Root canals (per tooth)

D3320 Anterior (excluding final restoration) $100.00

D3320 Bicuspid (excluding final restoration) $120.00

D3330 Molar (excluding final restoration) $180.00

ROUTINE SERVICES

Periodontics Member Pays

D4210 Gingevectomy – per quadrant 4 or more teeth $120.00

D4211 Gingevectomy – 1-3 teeth $20.00

D4260 Osseous Surgery $290.00

D4910 Perio recal including prophy $15.00

D9952 Occlusion adjustment (complete) No Charge

MAJOR SERVICES

Crowns

D2930 Stainless steel crown – primary tooth $25.00

D2932 Resin crown (not for molars) $25.00

D2781 3/4 metal crown* $175.00

D2791 Full metal crown* $175.00

D2740 Porcelain crown (not for molars) $175.00

D2751 Porcelain with metal crown (not for molars)* $175.00

D2751 Porcelain with metal crown (for molars)* $250.00

D2952 Cast post & core, in addition to corwn* $75.00

D2954 Prefabricated post & core, in addition to crown $45.00

— Pontics

D6211 Pontic, cast metal (base) $175.00

D6242 Pontic, porcelain with metal* $175.00

D2910 Inlay recementation $10.00

D2920 Crown recementation $10.00

D6930 Bridge recementation $12.00

Prosthetics

— Dentures and partials

D5110-D5120 Complete denture, upper or lower $8.00

D5211-D5212 Partial denture, upper or lower with resin base $10.00

D5410-D5422 Adjustment $50.00

D5510-D5640 Repair $60.00

D5650-D5660 Add tooth or clasp $90.00

D5730-D5741 Reline (chairside) $30.00

D5750-D5761 Reline (lab processed) $20.00

D1510-D1515 Fixed space maintainer (band type) $10.00

D1520-D1525 Removable acrylic space maintainer $70.00

Dentist may charge $20.00 for broken appointments if not notified at least 24 hours in advance.* Plus actual lab cost of precious metal.

ORTHODONTICS

The orthodontic benefit covers: consultation, all necessary appliances, banding, and monthly office visits for 24 months.

— Both upper and lower arch $1,895.00

— Upper or lower arch only $947.50

— Startup $250.00

— Retention — child (to age 18) $250.00

— Retention — adult (age 18 or older) $300.00

— Final records $150.00

Refer to the Evidence of Coverage and Disclosure Form booklet for complete details of benefits, exclusions, limitations, and plan description. You can obtain a copy by calling 1-800-22-TEETH (1-800-228-3384) or visiting the http://www.uhcfeds.com/home website to view or download a copy.The Dental premium includes expenses related to state & federal taxes, fees and assessments. It may also include additional new taxes, fees and assesments from the Affordable Care Act.

Orthodontic treatment must be provided by a UnitedHealthcare Dental Panel Orthodontist. A referral must be submitted by your assigned dental provider group to UnitedHealthcare Dental.

california law prohibits an HiV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. For All Participants: If your membership or that of a dependent terminates for any reason, it is the subscriber or the subscriber’s family’s responsibility to notify United-Healthcare Dental in writing by the 20th of the month to be effective the same month. You can fax, mail or email changes:

This form cannot be processed if information is incomplete and will be returned.

If you have selected the “Monthly Auto Pay” method of payment, please also:

Complete and sign Pre-Authorized Payment Application below.

Include one voided check.

Required:

Signature

Social Security Number

Date of birth

Address

Plan selection

Payment selection

For UnitedHealthcare Dental 142 plan: Provider Number

If you have selected the “Annual Payment” method of payment, please also:

Include check for the annual premium, made payable to: UnitedHealthcare Dental.

Customer Service is available 7 a.m. to 6 p.m. Pacific Time at 1-800-228-3384.

eNrOLLMeNT cHecKLiST Please use this checklist to make sure your application is complete.

TerMS AND cONDiTiONS Please read these terms and conditions, then sign at “X” on the previous page.

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Pre-AuTHOriZeD PAYMeNT APPLicATiON

complete this section only if you want your monthly premium automatically deducted from your checking account.

OUR PRE-AUTHORIZED PAYMENT PLANIt’s the forget-proof method of paying your premium – almost as easy as payroll deduction. Just authorize us to debit your personal checking account each month. We’ll do the rest. There will be no more paper work for you and no more checks to write. No worries about monthly late-payment charges. And you’ll save on postage and envelopes. It’s easy, reliable, and automatic.

AUTHORIZED AGREEMENT FOR PRE-ARRANGED PAYMENTS (DEBITS) I (we) hereby authorize UNITEDHEALTHCARE DENTAL to initiate debit entries to my (our) checking account indicated for the subscriber listed below, and the bank named below, herein called BANK, to debit the same to such account.

Subscriber Name (print clearly) ________________________________________________________________________________________________________

Account No. (please enclose one voided check) __________________________________________

Bank Name ______________________________________________________________________________Bank Phone ______________________________

Street Address _____________________________________________________________________________________________________________________

City _____________________________________________________________________________________ State _________ Zip _______________________

This authority is to remain in full force and effect until BANK has received written notification from me (or either of us) of its termination in such time and in such manner as to afford BANK a reasonable opportunity to act on it. A customer has the right to have the amount of an erroneous debit immediately credited to his account by BANK up to 15 days following issuance of statement of account or 45 days after the charge, whichever comes first.

Name on Bank Account (print clearly) __________________________________________________________________________________________________

Signature of Bank Account Holder __________________________________________________________ Date ____________________________________

2015 calendar for Auto Debit

Jan 25th Apr 24th Jul 25th Oct 25th

Feb 22nd May 25th Aug 25th Nov 24th

Mar 25th Jun 24th Sep 24th Dec 25th

The auto debit process is 7 calendar days prior to the last day of the month except when that day is Saturday; then it will be Sunday. Please have your funds available for withdrawal on this day.

Fax: 714-784-3730

Email: IndividualDHMODental@uhc.com

Mail: ATTN: M/S CA120-0351 UnitedHealthcare Dental P.O. Box 6044 Cypress, CA 90630

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SubScriber (You) Please complete all sections. This form cannot be processed if information is incomplete.

DePeNDeNTS List all dependents you wish to be covered. For additional dependents, please attach additional sheets.

Benefits for the UnitedHealthcare Dental® Signature Value DHMO plans are offered and provided by Dental Benefit Providers of California, Inc.

* UnitedHealthcare Dental SignatureValue (HMO) Dental 142 plan is not available in all counties. All dental care must be provided by a network dentist; please check the dentist listing for available dentists. Benefits for the UnitedHealthcare Dental® Signature Value DHMO plans are offered and provided by Dental Benefit Providers of California, Inc.

I understand and agree to the terms and conditions on the following page.

SubscriberSignature _______________________________________________ Date ____________

iNSTrucTiONS• Please PRINT neatly and complete all sections. • Please choose a Provider (Dentist).• Signature: Read the Terms and Conditions on the following page and sign in the box at the “X” on the bottom of this page. This form must be signed for coverage

to be effective. Your payment and completed form must be received by the 20th of the month for coverage to be effective the 1st of the following month.

enrollment for Federal employees - california 2015- V142 Plan

Pre-Authorized Monthly Payment (complete Pre-Authorized Payment Application on next page and include voided check)

Annual Payment (include check payable to UnitedHealthcare Dental for your annual premium)

Last Name First Name MI

Mailing Address Apt#

City State Zip

Home Phone # Work Phone #

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For Federal Employees Only - Employer: Agency:

Provider Number Dentist’s Name/City

-required for Dental 142

Existing Patient?

Yes No

Customer Service 800-22-TEETH (800-228-3384) | Fax Number: (714) 784-3730Email changes: IndividualDHMODental@uhc.com

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Provider Number Dentist’s Name/City

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Relationship:SpouseDaughter

Son required for Dental 142

SpouseDaughter

Son required for Dental 142

SpouseDaughter

Son required for Dental 142

SpouseDaughter

Son required for Dental 142

Existing Patient?

Yes No

Yes No

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Yes No

Last Name First Name MI

Date of Birth Sex Social Security NumberRelationship:

Existing Patient?

Last Name First Name MI

Date of Birth Sex Social Security NumberRelationship:

Existing Patient?

Last Name First Name MI

Date of Birth Sex Social Security NumberRelationship:

Existing Patient?

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PAYMeNT SeLecTiON

UnitedHealthcare Dental, CA120-0351, P.O. Box 6044, Cypress, CA 90630

Cell Phone # Email Address

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united Healthcare Dental SignatureValue® (HMO) Dental 142 plan

Complete the Member Enrollment form.

Select which payment option you wish –

Monthly Auto Pay or Annual Payment.

Follow the directions on the form.

For your added convenience, we've added the option of payment by credit card. Just give us a call and authorize a one-time or recurring payment.

Direct Dental inquiries to: UnitedHealthcare Dental’s Customer Service Department at 1–800-228-3384. For provider selection and other member information, visit: http://www.uhcfeds.com/home (Network: CA DHMO-Legacy PacifiCare)

Federal Employee Non-FEHB Dental Premiums

Enjoy comprehensive dental coverage at a price that fits into your family’s budget. Discover what your low premium would be for the dental plan in the table below.

cALiFOrNiA - Federal employee Non-FeHb Plans 2015

u N iTe D H eALTHcAr e D e NTAL S iG NATu r eVALu e D e NTAL 142 Fe D e rAL b uY u P PLAN

Monthly Auto Pay Annual Payment

Self $17.13 $205.56Self + 1 Dependent $33.09 $397.08Family $48.77 $585.24

Benefits for the UnitedHealthcare Dental® Signature Value DHMO plans are offered and provided by Dental Benefit Providers of California, Inc.

400-4345 9/14 © 2014 United HealthCare Services, Inc.

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