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 | 100% |
| Cleanings – two in any contract year | 100% |
| Fluoride Treatments (to age 19) | 100% |
| Sealants - to age 16 – 1st and 2nd molars | 100% |
| Class II – Basic Services | |
| Full mouth X-rays-once in any 36 consecutive months | 80% |
| Palliative Emergency Treatment | 80% |
| Space Maintainers | 80% |
| Basic Restorative | 80% |
| Endodontics | 80% |
| Repair of Broken Dentures | 80% |
| Simple Extractions | 80% |
| Oral Surgery 2 | 80% |
| General Anesthesia | 80% |
| Periodontics | 80% |
| Class III – Major Services | |
| Inlays, Onlays, Crowns | 60% |
| Prosthetics (Bridges, Dentures) | 60% |
| 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.
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