| Benefit Categories |
Concordia PLUS Managed Care Plan |
Concordia FLEX I Plan |
Concordia FLEX II Plan |
| Diagnostic & Preventive *** |
Schedule Provided ** |
Coinsurance Percentage of Allowances * |
Coinsurance Percentage of Allowances * |
| Exams |
100% |
100% |
100% |
| X-Rays |
100% |
100% |
100% |
| Cleanings |
100% |
100% |
100% |
| Fluoride Treatments |
100% |
100% |
100% |
| Palliative Treatments |
100% |
100% |
100% |
| Basic Services |
| Restorative |
100% |
50% |
80% |
| Anterior & Bicuspid Endodontics |
100% |
50% |
80% |
| Non-surgical Periodontics |
100% |
50% |
80% |
| Simple Extractions |
100% |
50% |
80% |
| Major Services |
| Crowns |
60% |
50% |
50% |
| Fixed Prosthetics |
60% |
50% |
50% |
| Removable Prosthetics |
60% |
50% |
50% |
| Specialty Services |
| Molar Endodontics |
60% |
50% |
50% |
| Surgical Periodontics |
60% |
50% |
50% |
| Complex Oral Surgery |
60% |
50% |
50% |
| Orthodontics - dependents to age 19 |
| Diagnostic, Active and Retention Treatment |
Approximately 40%-50%
(treatment must be initiated under the ConcordiaPlus program and
completed in the service area of Western PA. Please refer to Schedule of
Benefits provided for actual co-pay amounts.) |
Not Covered |
50%
(Orthodontic treatment in progress is covered under ConcordiaFLEX II
program and can be completed by a licensed dentist anywhere.) |
| Maximums and Deductibles ** |
Plan program maximum
(July 1 - June 30) |
None |
$500 Per covered person |
$1,000 Per covered person |
| Lifetime Orthodontic maximum |
None |
Not Applicable |
$1,500 Per covered dependent |
| Deductible per plan year |
None |
$50 for individual
$100 for individual/spouse or child
$150 maximum for family
Applies to ALL services |
$50 for individual
$100 for individual/spouse or child
$150 maximum for family
Diagnostic & Preventive Orthodontics EXEMPT |
| |
| * This percentage is based upon United Concordia's Maximum
Allowable Charge (MAC). Participating providers will accept United
Concordia's allowance as payment in full (less any coinsurance amounts that are
the members responsibility). The network of participating providing
providers for this program is Concordia Advantage |
| |
| ** Please refer to the Schedules of Benefits provided to determine
the approximate co-pay for covered services. This chart is only a
representative sampling of co-pay amounts. Before you begin any treatment
plan, it is important to discuss actual co-pay amounts with the provider of
service. The network of participating providers for this program is
ConcordiaPlus. |
| |
| *** $5.00 office visit co-pay applies to Diagnostic and
Preventative Services under the ConcordiaPlus plan. This co-pay only
applies for services provided at the University of Pittsburgh Dental School
(Provider Number 154327) or University Dental Health Services, Inc (Provider
Number 608061). |
