| SOMA
COLLEGE HEALTH INSURANCE PROGRAM |
| 2008
- 2009 SCHOOL YEAR |
| DENTAL
PROGRAM |
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| 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) |
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In-Network |
Out-of-Network |
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Contract Year Maximum per Covered Person |
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$1,500 |
$1,500 |
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Contract Year Deductible per Covered |
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$25/$75 |
$25/$75 |
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Person/Family - Class I
exempt |
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| Class
I Dental Plan Payment |
| (no
waiting period or deductible) |
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Exams |
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100% |
100% |
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All X-Rays |
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Cleanings |
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Fluoride Treatments |
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Sealants |
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Palliative Treatment |
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| Class
II Dental Plan Payment |
| (no
waiting period, deductible applies) |
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Space Maintainers |
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90% |
90% |
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Basic Restorative |
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Non-surgical Periodontics |
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Repairs of Crowns, Inlays, Onlays, Bridges and Dentures |
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Simple Extractions |
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III Dental Plan Payment |
| (six-month
waiting period, deductible applies) |
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Endodontics |
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50% |
50% |
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Surgical Periodontics |
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Complex Oral Surgery |
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General Anesthesia |
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Inlays, Onlays, Crowns |
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Prosthetics |
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| Orthodontics |
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Not
Covered |
Not
Covered |
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| *
Plan payment percentages are based on United Concordia's
Maximum Allowable charge. |
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Network dentists accept their contracted Maximum Allowable
Charge as payment in full for |
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covered services. |
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| 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. |
