Overview of Coverage
Overview of Coverage
A predetermination of benefits permits a review of a proposed treatment in advance and allows for resolution of any questions before, rather than after, the work has been done.
Additionally, both you and the dentist will know in advance the coverage and estimated benefit. A predetermination should be requested when the total charges will be $200 or more.
| Benefit Category | Plan Pays 1 |
|---|---|
| Class I - Diagnostic/Preventive Services (excluded from annual program maximum) | |
| Exams - two in any calendar year | 100% |
| Cleanings - two in any calendar year | |
| Bitewing X-rays - twice in any calendar year | |
| Fluoride Treatments (to age 19) | |
| Sealants - thru age 10 - 1st molars/age 15 - 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 | |
| General Anesthesia | |
| Periodontics | |
| Class III - Major Services | |
| Inlays, Onlays, Crowns | 60% |
| Prosthetics (Bridges, Dentures) | |
| Implant related Services (limited to subscribers age 18 and over) | |
| Implant prosthetic (crown) | 60% |
| Inclusive of $1,000 annual program maximum | |
| Orthodontics (All subscribers to any age; lifetime annual maximum) | |
| Diagnostic, Active, Retention Treatment | 60% |
| Orthodontic Lifetime Maximum | $1,500 |
| Maximums/Deductibles | |
| Annual Program Maximum (per covered member) | $1,000 |
| Program Deductible (per member/per family) | $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.
2 - There is no program deductible when services are performed by an In-Network provider. 
Unmarried Dependent Children covered to age 19/Unmarried Dependent Students covered to age 24.
This listing is a representative listing of covered services—please refer to your Certificate of Coverage and Implant Rider for a detailed description of benefits. Exclusions and limitations may apply.
