Page 10 - Premier EE Guide 12-17 - Texas Final

DENTAL INSURANCE

United Concordia | PPO Dental Plan
With the United Concordia Preferred Provider Organization (PPO) dental plan, you may visit a PPO dentist and benefit from the
negotiated rate or visit a non‐network dentist. When you utilize a PPO dentist, your out-of-pocket expenses will be less. You may
also obtain services using a non-network dentist; however, you will be responsible for the difference between the covered amount
and the actual charges and you may be responsible for filing claims.

United Concordia
Plan Name PPO
Network Network Non-Network
Dental Benefits
Calendar Year Maximum/Person $1,500 $1,500

Deductible (Annual)
- Individual $50 $50
- Family $150 $150
Preventive No Charge No Charge
Exams, X-Rays, Cleanings 90th*
Basic Services Deductible, 20% Deductible, 50%
Fillings, Oral Surgery, 90th*
Endodontics, Periodontics
Major Services Deductible, 50% Deductible, 50%
Crowns, Prosthetics 90th*
Orthodontia
- Covered Members Children & Adults
- Copay N/A
- Coinsurance 50%
- Lifetime Benefit Maximum $1,000

*Non-network reimbursement is calculated at the 90th percentile - see page 10 for additional information.

Finding In-Network Dental Providers
Go to www.unitedconcordia.com or call (800) 332-0366 for PPO.
• PPO: Refer to the “Elite Plus” network when prompted.

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