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Graduate Assistant and Graduate Fellow Dental Program

Dental Program Schedule
Benefit Category Plan Pays1
Class I Diagnostic/Preventive Services
(excluded from annual program maximum)
Routine Exams two in any contract year 100%
Bitewing X-rays twice in any contract year
Cleanings two in any contract year
Fluoride Treatments (to age 19)
Sealants - to age 16 1st and 2nd molars
Class II Basic Services
Full mouth X-rays-once in any 36 consecutive months 80%
Palliative Emergency Treatment
Space Maintainers
Basic Restorative
Endodontics
Repair of Broken Dentures
Simple Extractions
Oral Surgery 2
General Anesthesia
Periodontics
Class III Major Services
Inlays, Onlays, Crowns 60%
Prosthetics (Bridges, Dentures)
Orthodontics
Diagnostic, Active, Retention Treatment Not Covered
Maximums/Deductibles
Annual Program Maximum (per covered member) $1,000
Annual Program Deductible (per member/per family) 3 $25.00/$50.00

1 Percentages are based on United Concordia Companies Maximum Allowable Charges (MAC). The Maximum Allowable Charge is an amount that UCCI has contracted with providers to accept as payment in full, less any deductibles and co-insurances. You can maximize your benefits by obtaining services through a participating United Concordia Provider (Advantage Network, or Nittany Dental Network provider in Centre County.

2 Some Surgical Services may also be covered under your medical plan. Please refer to your Medical benefits

3 There is no program deductible when services are performed by an In-Network provider.

This is a summary of your dental benefits. United Concordia Companies, Inc. policies and procedures apply.

For Customer Service Please Call 1-800-423-8217

Website: www.unitedconcordia.com/dental-insurance

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