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DENTAL PROGRAM
DENTAL BENEFITS
(Dental benefits are provided through a stand-alone dental insurance policy underwritten by
 United Concordia Life and Health Insurance Company.  See Dental Exclusions and Limitations
 section for exclusions, limitations, and other policy provisions)
In-Network Out-of-Network
 - Contract Year Maximum per Covered Person $1,500 $1,500
 - Contract Year Deductible per Covered $25/$75 $25/$75
    Person/Family - Class I exempt
Class I Dental Plan Payment
(no waiting period or deductible)
 - Exams 100% 100%
 - All X-Rays
 - Cleanings
 - Fluoride Treatments
 - Sealants
 - Palliative Treatment
Class II Dental Plan Payment
(no waiting period, deductible applies)
 - Space Maintainers 90% 90%
 - Basic Restorative
 - Non-surgical Periodontics
 - Repairs of Crowns, Inlays, Onlays, Bridges and Dentures
 - Simple Extractions
Class III Dental Plan Payment
(six-month waiting period, deductible applies)
 - Endodontics 50% 50%
 - Surgical Periodontics
 - Complex Oral Surgery
 - General Anesthesia
 - Inlays, Onlays, Crowns
 - Prosthetics
Orthodontics Not Covered Not Covered
*  Plan payment percentages are based on United Concordia's Maximum Allowable charge. 
    Network dentists accept their contracted Maximum Allowable Charge as payment in full for
    covered services.
This is a brief summary of benefits under the Dental Program.  Complete terms and conditions
of coverage and benefits are set forth in the Master Policy issued to Student Osteopathic
Medical Association. The plan is underwritten by United Concordia Life And Health Insurance
Company.


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