Overview of Coverage - Dental
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.
|Class I - Diagnostic/Preventive Services|
|Exams - two in any calendar year||100% (deductible does not apply)||100% (after deductible)|
|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% (after deductible)||60% (after deductible)|
|Palliative Emergency Treatment|
|Repair of Broken Dentures|
|Class III - Major Services|
|Inlays, Onlays, Crowns||60% (after deductible)||50% (after deductible)|
|Prosthetics (Bridges, Dentures)|
|Repairs of Crowns, Inlays, Onlays|
|Repairs of Bridges|
|Orthodontics (All subscribers to any age; lifetime maximum)|
|Diagnostic, Active, Retention Treatment||60% (deductible does not apply)||60% (deductible does not apply)|
|Orthodontic Lifetime Maximum||$1,500||$1,500|
|Annual Program Maximum (per covered member)||$1,500||$1,500|
Faculty/Staff: Program Deductible (per member/per family)
$50/$150 (excludes Class I and Orthodontics)
$50/$150 (excludes Orthodontics)
|Technical Service: Program Deductible (per member/per family)||$50/$150 (excludes Class I, II and Orthodontics)||$50/$150 (excludes Orthodontics)|
Percentages are based on United Concordia Companies Maximum Allowable Charges (MAC). The Maximum Allowable Charge is an amount that UCCI has contracted with in-network providers to accept as payment in full, less any deductibles and co-insurances. Out-of-network providers will accept payment from UCCI for the Maximum Allowable Charge, but may bill you for the remaining amount not covered by the plan. You can maximize your benefits by obtaining services through a participating United Concordia Provider (Advantage Network, or Nittany Dental Network provider in Centre County).
For more details on plan exclusions and limits, please review the Dental Summary Plan Document.