Basic Plan Summary

United Concordia
Basic Plan

  In-Network Out-of-Network
Plan Pays You Pay Plan Pays You Pay
Diagnostic & Preventative Services
  • Routine Oral Exams
  • Cleanings
  • X-Rays - complete mouth (once every 5 years) Bitewings (once every 6 months)
  • Sealants (through age 15) permanent first and second molars only.
  • Emergency treatment for relief of pain
  • Flouride treatment
100% 0%
No Deductible		 25%
of allowed amount		 75% of allowed amount
+
any charges in excess of allowed amount

Deductible Applies
Basic Services
  • Basic Restorative (amalgam for posterior teeth)
  • Simple Extractions
  • Endodontics
  • Non-Surgical Periodontics
  • Repair of denture and bridgework
80% 20%
Deductible Applies		 25%
of allowed amount		 75% of allowed amount
+
any charges in excess of allowed amount.

Deductible Applies
Major Services
  • Complex oral surgery
  • Surgical periodontics
  • Removable partial or complete dentures and fixed bridges
  • Inlays, Onlays & Crowns (when teeth cannot be restored to normal form and function with Amalgam composite resin or plastic fillings)
Not Covered
Orthodontic Services
  • Diagnostic, Active, Retention, Treatment
Not Covered
Contract Year Deductible
7/01/03-6/30/04 		$50 ($150 per family)
Contract Year Maximum Per Person
7/01/03-6/30/04 		$1,250 IN NETWORK $1,000 OUT OF NETWORK
Lifetime Orthodontic Maximum Per person Not Covered
* In-network providers agree to accept United Concordia maximum allowable charge as payment in full.