Benefit Category 2 - JHSPH



| Network: *ADVANTAGE PLUS PPO Network – |

|PREVENTIVE PPO PLAN (“■” AMENDED Providers ONLY) |

|Benefit Category1 |CONCORDIA DISCOUNT PPO PLAN |

| |In-Network2 |Non-Network2 |

| | | |

|Class I – Diagnostic/Preventive Services |

|Exams |100% |100%* |

|Bitewing X-rays | | |

|Cleanings & Fluoride Treatments | | |

|Sealants | | |

|Class II – Basic Services |

|All Other X-rays |Discounted Fee |Member pays dentist’s full |

| | |charge |

|Basic Restorative (Fillings) | | |

|Simple Extractions | | |

|Space Maintainers | | |

|Repairs | | |

|Palliative Treatment | | |

|Class III – Major Services |

|Endodontics |Discounted Fee |Member pays dentist’s full |

| | |charge |

|Nonsurgical & Surgical Periodontics | | |

|Complex Oral Surgery | | |

|General Anesthesia | | |

|Inlays, Onlays, Crowns | | |

|Prosthetics (Bridges, Dentures) | | |

|Orthodontics |

|Diagnostic, Active, Retention Treatment |Discounted Fee |Member pays dentist’s full |

| | |charge |

|Cosmetics, Implants, Veneers & Bleaching |

|Cosmetics, Implants, Veneers & Bleaching |Discounted Fee |Member pays dentist’s full |

| | |charge |

|Maximums & Deductibles (cumulative of network and non-network) |

|Annual Program Deductible (per person/per family) |None |

|Annual Program Maximum (per person) |None |

|Lifetime Orthodontic Maximum (per person) |None |

|Reimbursement |Advantage Plus  |MAC* |

Representative listing of covered services – certificate of coverage provides a detailed description of benefits.

1. Unmarried dependent children covered to age 19. Unmarried dependent students covered to age 23.

2. Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. Non-network dentists may bill the member for any difference between our allowance and their fee. United Concordia Dental’s standard exclusions and limitations apply.

✓ Discounts are only available from participating Advantage Plus “Amended (■)” providers.

✓ Discounted services are not insurance.

✓ Discounts may vary by dentist, service and geographic area.

✓ Participating providers can be found on-line at w, or our “unitedconcordia dental” smart-phone app, using the Find a Dentist tool.

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