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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%
Diagnostic, Active, Retention Treatment Not Covered
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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