Questions? Contact HR One Connect at 1.888.471.3362 (1.888.HR1.EDMC).
In connection with oral surgery, extractions or other covered dental services
Oral Examinations
Non-surgical Periodontics
Topical Fluoride
Treatments
X-rays
Space Maintainers
Sealants
80% after deductible
80% after deductible
50% after deductible
50% after deductible
80% after deductible
80% after deductib
80% after deductible
80% after deductible
80% after deductible
80% after deductib
80% after deductible
80% after deductib
80% after deductible
80% after deductible
80% after deductible
80% after deductib
80% after deductible
80% after deductible
80% after deductible
80% after deductib
50% after deductible
50% after deductib
50%
50%
80% after deductible
Not Covered
Not Covered
Not Covered
Not Covered
80% after deductible
80% after deductible
80% after deductib
50% after deductible
50% after deductible
80% after deductible
80% after deductib
50% after deductible
50% after deductible
50% after deductible
50% after deductib
50% after deductible
50% after deductible
50% after deductible
50% after deductib
Fillings
(including posterior resin)
Simple Extractions
Complex Oral Surgery
(impacted teeth)
Crown, Denture and
Bridge Repair/
Re-cementing
Endodontics
General Anesthesia
100%
Two per calendar year
Two per calendar year
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
One treatment per calendar year for
dependent children up to age 19
One treatment per calendar year for
dependent children up to age 19
Full Mouth X-rays: One every 3 years
Bitewing X-rays: One set per calendar year for adults
Two sets per calendar year for children
Full Mouth X-rays: One every 3 years
Bitewing X-rays: One set per calendar year for adul
Two sets per calendar year for children
One application every 3 years for each molar
for dependent children up to age 14
One application every 3 years for each molar
for dependent children up to age 14
Periodontics (surgical)
Major Restorative Services
Bridges and Dentures
Crowns/Inlays/Onlays
Initial placement to replace one or more natural tee
lost while covered by the Plan. Dentures/bridgewo
replaced once every 5 years.
Oral Surgery
Orthodontia
Dependent children up to age 19
Dependent children up to age 19
Employees, dependent spouses/ domestic partners
and dependent children
Basic Restorative Services
* The listed network percentages represent the portion of United Concordia’s maximum allowable charges (MAC) for which the plan will be resp
providers agree to accept United Concordia’s MAC for covered services as payment in full and also agree to file claims for you. If you or your co
receive services from an out-of-network provider, United Concordia will apply the percentages shown to United Concordia’s MAC for covered s
will be responsible for the difference, up to the provider’s charge. Plan exclusions and limitations apply.
**Part of the Smile for Health Benefit.