Page 8 - TCR Benefit Guide 2017 - Non-CA - sent 9.12.17
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Benefits
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 Flex Plan
Network Name Alliance DPPO Network Non-Network*
Dental Benefits
Calendar Year Maximum $1,500
Deductible (Annual) Waived for Preventive Services
- Individual $50
- Family $150
Preventive (Plan Pays) 100% 100%
Exams, X-Rays, Cleanings
Basic Services (Plan Pays) Ded, 80% Ded, 80%
Fillings, Oral Surgery,
Major Services (Plan Pays) Ded, 50% Ded, 50%
Crowns, Prosthetics
Orthodontia
- Covered Members Children & Adults
- Copay N/A
- Coinsurance 50%
- Lifetime Benefit Maximum $1,500
*Based on 90th percentile
Finding a Dental Provider
Go to www.unitedconcordia.com or call (866) 357-3304 for DHMO or (800) 332-0366 for DPPO.
• DHMO participants should refer to the “DHMO Concordia Plus General Dentist” network
• DPPO participants should refer to the “Alliance” network
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