Page 17 - Tender Greens EE Guide 01-20

United Concordia | PPO Plan
This plan offers you the freedom and flexibility to use the dentist of your choice. However, you will maximize your benefits and
reduce your out-of-pocket costs if you choose a dentist who participates in the United Concordia Elite Plus network. When
you utilize a network dentist, your out-of-pocket expenses will be less, therefore you will usually pay the lowest amount for
services when you visit a PPO dentist. If you obtain services using a non-network dentist, you will be responsible for the
difference between the covered amount and the actual charges and you may be responsible for filing claims. The chart
below provides a high-level overview of your dental plan.

United Concordia
Plan Name PPO
Network Name Elite Plus Non-Network
Note:
Dental Benefits We strongly recommend you
ask your dentist for a
Calendar Year Maximum Benefit $2,000
predetermination if total
Annual Deductible charges are expected to
- Individual $50 exceed $300.
- Family $150
Predetermination enables
Preventive Services No Charge 20%* you and your dentist to know
- Oral Evaluations, Cleanings, in advance what the
Fluoride Treatment, Sealants, payment will be for any
X-Rays service that may be in
Basic Services Deductible, 20% Deductible, 40%* question.
- New Fillings, Space Maintainers,
Extractions, Biopsy, Endodontics,
Periodontics, Minor Gum Disease
Treatment
Major Services Deductible, 50% Deductible, 50%*
- Dentures and Bridges, Stainless
Steel Crowns, Dental Implants,
General Anesthesia and IV Sedation
(when medically required)
Orthodontia
- Child 50% / $1,500 Lifetime Benefit Maximum
- Adult 50% / $1,500 Lifetime Benefit Maximum
*Dentists who are out-of-network have not agreed to pricing, and may bill you for the
difference between what United Concordia pays them and what the dentist usually
charges (based on 90th UCR).

Finding a Dental Provider
Go to www.unitedconcordia.com or call
(800) 332-0366, and refer to the Elite Plus
Network

Team Member Benefits 17
Team Member Benefits 17