UHC Solstice DHMO - Standard
UnitedHealthcare Solstice Dental Health Maintenance Organization, or DHMO, is a network of Provider Groups who have agreed to offer specific services at negotiated rates to participating members.
This benefit is not offered to employees represented by Fraternal Order of Police (FOP)
Benefits Summary
Plan Documents & Resources
Exclusions & Limitations
Provider Contact Info
DHMO Dental Member Services
1 (800) 955-4137
www.myuhc.com/member
| M-F | 8am - 11pm |
UnitedHealthcare Solstice DHMO Plans
You do not need to select a dental facility at the time of enrollment; you elect your dentist at the time of service by selecting a participating provider and verifying their participation in the plan prior to the dental visit. Additionally, these plans provide you with certain services with set reimbursements when accessing care from non-participating providers.
The member pays a copayment at participating providers; however, most diagnostic and preventive care is covered at no cost. Additionally, there are no deductibles, and no claim forms are needed. The plans also provide reimbursement for services provided by an out-of-network provider for preventive and diagnostic services. Additionally the plan offers a 25% discount on all procedure codes not listed in the Services and Copayment.
The patient/Member is ultimately responsible for verifications to the accuracy and appropriateness of all fees applicable to any dental benefit provided by a network provider. We urge all of our Members to verify all fees for proposed treatment via the “Schedule of Benefits” and/or with UnitedHealthcare Solstice DHMO Member Services Department prior to treatment.
Summary of Benefits
| Exam | You Pay |
| Office Visit | $0.00 |
| Periodic Oral Evaluation | $0.00 |
| Limited Oral Evaluation – Problem focused | $0.00 |
| Comprehensive Oral Evaluation | $0.00 |
| X-Rays | You Pay |
| Intraoral – Complete Series, including bitewings | $0.00 |
| Intraoral – Periapical first film | $0.00 |
| Intraoral – Periapical each additional film | $0.00 |
| Bitewings – two films | $0.00 |
| Bitewings – four films | $0.00 |
| Panoramic | $0.00 |
| Preventive Services | You Pay |
| Prophylaxis – adult cleaning | $0.00 |
| Prophylaxis – child cleaning | $0.00 |
| Fluoride – child | $0.00 |
| Sealant – per tooth | $0.00 |
| Silver Fillings | You Pay |
| Amalgam, 1 Surface, primary or permanent | $20.00 |
| Amalgam, 2 Surface, primary or permanent | $25.00 |
| White Fillings, Front Teeth | You Pay |
| Anterior Composite, 1 surface | $35.00 |
| Anterior Composite, 2 surface | $40.00 |
| Onlays and Crowns | You Pay |
| Crown, All Porcelain |
$320.00 Additional cost for material and lab fees apply as follows: 1. Crown laboratory fees up to $155 |
| Core Build Up | $60.00 |
| Periodontal Care (For Gums) | You Pay |
| Periodontal Therapy, 4+ teeth/quadrant | $60.00 |
| Periodontal Maintenance | $60.00 |
| Extractions | You Pay |
| Extraction, erupted tooth or exposed root | $20.00 |
| Surgical removal of erupted teeth | $50.00 |
| Orthodontia Care | You Pay |
| Comprehensive Orthodontic treatment – adolescent(up to 24 months – including fixed/removable appliances) to age 19 | $2,095.00 |
| Comprehensive Orthodontic treatment – adult(up to 24 months – including fixed/removable appliances) | $2,095.00 |
| Pre-orthodontic treatment visit (consult/records/exam) | $35.00 |
| Orthodontic Retention (removal of appliances, construction and placement of retainer(s)) | $300.00 |
| Unspecified Orthodontic Procedure – By Report | $250.00 |
If differences exist between this Summary of Benefits and your Certificate of Coverage/benefits administrator, the certificate/benefits administrator will govern.
Plan Documents & Resources
Limitations and Exclusions
Limitations of Benefits
- Any oral evaluation (excluding problem) is limited to One (1) time per consecutive six (6) months; comprehensive exams can only be covered one (1) time per 36 months, if and only if patient is considered to be new or an established patient. All subsequent oral evaluations will be at a 25% reduction off the dentist’s usual and customary fee without a frequency limitation.
- All bitewing X-rays are limited to one set in any twelve (12) consecutive month period.
- The dental prophylaxis or periodontal maintenance procedure is limited to one (1) time in any consecutive six (6) month period. Any additional procedures will follow D1110 and D4910 Member copayments as listed in the Schedule of Benefits.
- Fluoride treatment is limited to one (1) in any twelve (12) consecutive month period.
- Sealants are limited to one (1) time per tooth in any three (3) consecutive year period. This is only allowed for unrestored permanent molar teeth for children under the age of 16.
- Space maintainers and all adjustments are limited to children under the age of 16.
- Harmful habit appliances are limited to one (1) time per person under the age of 16.
- General anesthesia or IV sedation is available when listed on the Schedule of Benefits, medically necessary, and previously approved by Solstice.
- New dentures include one (1) reline within the first six (6) months
- Replacement of crowns, implants, and fixed bridges or dentures is limited to one (1) time every consecutive five (5) years.
- When crown, implant and/or bridgework exceed six (6) consecutive units, there will be an additional charge of $30.00 per unit.
- Copayments marked by ‘*’ do not include the cost of material and laboratory fees. Additional cost to patient is as follows:
- High noble metal (precious) up to $145.00
- Titanium metal up to $120 (covered with proof of allergy to other metals)
- Noble metal (semi-precious) up to $120.00
- Predominantly base metal (non-precious) up to $55.00
- Crown laboratory fees up to $155.00
- Laboratory fees on dentures up to $225.00
- Porcelain laboratory fees for D2610-D2644, D2929, D2961, D2962, D6600, D6601, D6608, and D6609 up to $65.00 Denture repair laboratory fees up to $50.00
- All ceramic and/or porcelain crown material fees up to $155.00
- Copayments marked by “†” are not eligible at a specialist.
- Either D0210 or D0330 are reimbursable one (1) time every five (5) consecutive years.
- Copies of X-rays can be obtained for $2 per periapical image up to a maximum of $30. Panoramic X-ray can be obtained for a $15 fee.
- D0274, D0277 or D0210 are payable only when other inclusive image have not been taken (paid) within the last six (6) months.
- All denture adjustment fees are for dentures which were not fabricated at the present office; All denture adjustment for new dentures made within 12 months are at no fee to the member.
- Emergency treatment is available for palliative treatment for the abatement of pain up to $100.00 per occurrence.
- A broken appointment fee up to $20 may be charged by the dental office if 24 hour prior notice is not given.
- Surgical removal of wisdom tooth covered when pathology (disease) exists. Surgical removal of wisdom teeth/3rd molar when pathology does not exist will be covered at 25% off of the general dentists’ or specialists’ usual and customary fees. Orthodontic related surgeries (except D7280) needed to relieve crowding or to facilitate eruption are available at a 25% reduction off of the doctor’s usual and customary fees.
- Member may choose Invisalign in place of traditional Orthodontic treatment, and would pay the sum of the listed member Orthodontic copay plus the difference in cost for the enhanced treatment.
- Occlusal Guard(s) is limited to one (1) time in any consecutive thirty-six (36) months for the purposes of habitual grinding/Bruxism.
- D0364-D0395 is limited to one (1) time per sixty (60) months, covered only in a dental setting and not in a radiographic imaging center.
Exclusions of Benefits
- Services performed by a dentist or dental specialist, not contracted with Solstice without prior approval.
- Any dental services or appliances which are determined to be not reasonable and/or necessary for maintaining or improving the Member’s dental health or experimental in nature, as determined by the participating Solstice dentist.
- Orthographic surgery or procedures and appliances for the treatment of myofunctional, myoskeletal or temporomandibular joint disorders unless otherwise specified as an orthodontic benefit on the Schedule of Benefits.
- Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions, or medications.
- Treatment of malignancies, cysts, or neoplasms, without proof of medical necessity and prior Solstice approval.
- Dental procedures initiated prior to the Member’s eligibility under this benefit plan or started after the Member’s termination from the plan.
- Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the Member, including but not limited to, physical or emotional resistance, in ability to visit the dental office, or allergy to commonly utilized local anesthetics.
- D9972 Excludes bleaching material for home use.