Comprehensive Plan

United Concordia
Comprehensive 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		 100%
of allowed amount		 0% of allowed amount
+
any charges in excess of allowed amount

No Deductible
Basic Services
  • Basic Restorative (amalgam for posterior teeth)
  • Simple Extractions
  • Endodontics
  • Non-Surgical Periodontics
  • Repair of denture and bridgework
  • General Anesthesia & I.V. Sedation
  • Complex Oral Surgery
  • Surgical Periodontics
80% 20%
Deductible Applies		 55%
of allowed amount		 45% of allowed amount
+
any charges in excess of allowed amount.

Deductible Applies
Major Services
  • Removable partial or complete dentures
  • Fixed bridges
  • Inlays, Onlays & Crowns (when teeth cannot be restored to normal form and function with Amalgam composite resin or plastic fillings)
50% 50%
Deductible Applies		 35%
of allowed amount		 65%
of allowed amount
+
any charges in excess of the allowed amount

Deductible Applies
Orthodontic Services
  • Diagnostic, Active, Retention, Treatment
50% 50%
No Deductible		 50%
of allowed amount		 50%
of allowed amount
+
any charges in excess of the allowed amount

Deductible Applies
Annual Deductible $50
($150 Family)		 $50
($150 Family)		 $50
($150 Family)		 $50
($150 Family)
Calendar Year Deductible $50 ($150 per family)
Calendar Year Maximum Per Person $1,500 $1,250
Lifetime Orthodontic Maximum Per person $1,500 $1,000
* In-network providers agree to accept United Concordia maximum allowable charge as payment in full.