Dental Benefits Summary for Prestige Preschool Academy

EEM-0160-1116

UnitedConcordia.com • 1-800-332-0366

Effective Date: 12/01/2017 Network: Alliance

Benefit Category1 CONCORDIA PREFERRED PLAN

In-Network2 Non-Network2 Class I – Diagnostic/Preventive Services

Exams

100% 100%

Bitewing X-rays All Other X-rays Cleanings & Fluoride Treatments Sealants Space Maintainers Palliative Treatment

Class II – Basic Services Basic Restorative (Fillings)

90% 80%

Simple Extractions Repairs of Crowns, Inlays, Onlays, Bridges & Dentures Endodontics Nonsurgical Periodontics Surgical Periodontics Complex Oral Surgery General Anesthesia

Class III – Major Services Inlays, Onlays, Crowns

60% 50% Prosthetics (Bridges, Dentures)

Included Plan Features

Smile for Health®--Wellness3 Provides periodontal care for people with certain chronic medical conditions: diabetes, heart disease, lupus, oral cancer, organ transplant, rheumatoid arthritis and stroke

Covers 1 additional periodontal maintenance per year and all are covered at 100%

Scaling and root planing are covered at 100% 4 periodontal surgery procedures are covered at 100%

Maximums & Deductibles (applies to the combination of services received from network and non-network dentists)

Annual Program Deductible (per person/per family) $50/$150

Excludes Class I Annual Program Maximum (per person) $1,500

Reimbursement Alliance 90th UCR 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 (also known as balance billing). United Concordia Dental’s standard exclusions and limitations apply. 3. Members (subscribers or covered dependents) with certain medical conditions must sign up for this program through My Dental Benefits on UnitedConcordia.com.

Q: Is my dentist in United Concordia’s network?A: To search for your dentist, visit UnitedConcordia.com. Click on Find a Dentist and then select your network (see

the enclosed benefits summary) and search preferences.

Q: Why should I visit a network dentist?A: You can save time and money by using a network dentist. Our network dentists agree to file claims for you, and

to accept our allowances as full payment for covered services. And, most of our dentists accept our allowances

for non-covered services or services above your annual maximum. That means you can save money by visiting

a network dentist, because our allowances are typically lower than the dentist’s standard charges. United

Concordia’s network dentists undergo rigorous review, so you can be sure you’re receiving quality care.

Q: Can I still see a non-network dentist?A: Yes, you can receive care from any licensed dentist. However, if you visit a non-network dentist your benefits may

differ and your out-of-pocket expenses could be higher than if you visit a network dentist. If your dentist is not a

part of our network, you can nominate him or her for participation. To nominate your dentist, visit the Members

section of UnitedConcordia.com, select Forms, and click Nominate Your Dentist.

Q: What can my dentist bill me for?A: It depends whether you visit a network or non-network dentist. United Concordia network dentists can only

charge you for applicable deductibles and coinsurance amounts. Non-network dentists can charge you for

applicable deductibles and coinsurance amounts, and the difference between their standard charges and United

Concordia’s allowances.

Q: What information is available online?A: In the Members section of UnitedConcordia.com, you can access forms, frequently asked questions, a glossary

of dental terms, and a dental health center containing articles, brochures, videos and kids’ pages. Once your

plan is effective, you can find your personal benefits information in our online tool, My Dental Benefits. After

registering, you can review details of your coverage, eligibility, network, claim status and procedure history; and

print an ID card.

Q: What if I have other questions about my dental plan?A: Questions about dental treatment should always be discussed with your dentist. For information about your

benefits, visit UnitedConcordia.com or call Customer Service at 1-800-332-0366.

Frequently Asked Questions About Your PPO Dental Plan

EEM-0052-0114

You’re at the dentist and you’ve been told the tooth that’s been bothering you will need some extensive dental work. How much will it cost? How much will your dental plan cover? Are there any alternative treatment options available?

Get the answers to these questions, and more, by submitting a predetermination before you receive treatment.

What is a predetermination?

A predetermination lets you know what procedures will or won’t be covered prior to receiving services. It calculates the total amount you owe and what your plan will cover based on your coinsurance amounts. It also notifies you of alternate treatment options covered by your dental plan. A predetermination is not a guarantee of payment—it is an estimate of what you can expect to owe.

How should I submit a predetermination?

Your dentist can submit predeterminations electronically or by mail. Electronically submitted predeterminations are processed instantly, unless additional supporting documentation is required. Mailed predeterminations are typically processed within 14–30 days. The results are then summarized and mailed to both you and your dentist.

How does it work?

We use predetermination of benefits to confirm member eligibility and to review the treatment plan to determine the extent of coverage. This process lets both you and the provider know that the service being performed is covered. It also informs you of your financial liability at the time the predetermination is processed.

In cases where alternate methods of treatment are available, we approve and/or make payment based on our allowance for the less expensive procedure, provided it meets accepted standards of dental treatment. We base your financial liability on information that is current when we process the predetermination. However, your financial liability may change when services are rendered as a result of meeting the deductible or exhausting the maximum.

When should I ask for a predetermination?

We encourage you to request a predetermination whenever the amount of a proposed treatment is more than $500.

How Much Will It Cost?The Benefits of Predeterminations

MEM-0372-1116

United Concordia’s large, nationwide dentist network, combined with our knowledge of local markets, means you can find affordable, quality care with great service no matter where you live.

What Is a Network Dentist?

Network dentists agree to accept United Concordia’s discounted fees as payment in full for covered services. Non-network dentists can charge you more. This means you’ll lower your out-of-pocket expense using a network dentist.

You can still receive care from any licensed dentist. But your benefits may differ and your out-of-pocket costs could be higher with a non-network dentist. Using a network dentist maximizes your dental benefits because they:

Save money—A network dentist saves you the difference between our negotiated fees and the dentist’s regular charges. And, you stretch your benefit dollars by getting more services before reaching your annual maximum.

Savings Example1

Save time—Network dentists file your claims for you, saving you time and the hassle of paperwork.

Save worry—Every network dentist goes through a rigorous review, so you know you’re getting high-quality care.

Save More with a Network Dentist

Using an Advantage Plus 2.0 network dentist maximizes your benefits

Member’s Annual Dental Care

Example Dentist Charge

Network Dentist Visit—Member Responsibility 2

Non-network Dentist Visit—

Member Responsibility

Member’s Savings for Visiting a

Network Dentist

2 Cleanings $151 $0 $63 $632 Exams $85 $0 $45 $451 Set x-rays $117 $0 $59 $592 Composite fillings $227 $22 $149 $1271 Crown $931 $324 $611 $287

TOTAL $1,512 $346 $928 $5821. Savings estimates based on internal data for zip code 17110, as of 6/15; savings will vary by dentist, service and geographic region. 2. All services performed by an Advantage Plus 2.0 network dentist.

*Based on United Concordia Dental internal research and reports, 06/15.

This advertisement is not an offer of coverage or proposal of insurance. The Group Policy or Contract and Certificate of Insurance (“Plan Documents”) include a complete listing of covered services, limitations, exclusions, cancellation and renewal provisions. In the event of conflict, the Plan Documents will govern. PPO products underwritten by: United Concordia Insurance Company, United Concordia Dental Corporation of Alabama, and United Concordia Life and Health Insurance Company. United Concordia Insurance Company is not licensed in AL, DE, DC, IL, KY, MD, MO, NJ, NY, NC and PA. Not all products are available in all jurisdictions. United Concordia policies cover dental benefits only. For a complete listing of the products and services available in your area, the specific UCCI company licensed to provide those products, and exclusions, limitations, renewal, cancellation and cost information, contact a United Concordia account representative or visit UnitedConcordia.com. United Concordia Insurance Company, California certificate of authority number 3739-0, is domiciled in Arizona at its statutory address, 2198 East Camelback Road, Suite 260, Phoenix, AZ 85016. Available Concordia products are underwritten by United Concordia Insurance Company in OK and written on OK policy forms OK9802 (11/07) and OK9802L (11/07). The administrative office of UCCI and/or its licensed corporate affiliates is located at 4401 Deer Path Road, Harrisburg, PA 17110.

MEM-0274-0715 • Advantage Plus 2.0

Finding YOUR Dentist

It’s not just about finding a dentist; it’s about finding YOUR dentist. While our vast network includes 107,000 dentists,* we also understand your local market. We research the facilities and costs in your area, and carefully screen and qualify each dentist to help you get the best dental care.

So, wherever you live or work, you’ll probably find two or more of our network dentists within 10 miles.* And if you move, it’s easy to find a new one.

How to Find a Dentist

It’s simple to search, compare and get directions to an Advantage Plus 2.0 network dentist with the Find a Dentist tool on UnitedConcordia.com. Once you have clicked the “Find a Dentist” button on the home page, be sure to select Advantage Plus 2.0 in the “My Network Is” drop down.

You can search by specialty, county, ZIP code, street address, dentist or practice name. If your dentist is not in our network, and you’d like him or her to participate, go to the Members section of UnitedConcordia.com, select Forms, and click Nominate Your Dentist.

You Can Find Quality Care No Matter Where You Live

Dental plans are administered by United Concordia Companies, Inc. and underwritten by United Concordia Life and Health Insurance Company, United Concordia Dental Corporation of Alabama, United Concordia Insurance Company of New York, United Concordia Insurance Company, United Concordia Dental Plans, Inc., United Concordia Dental Plans of California, Inc., United Concordia Dental Plans of Kentucky, Inc., United Concordia Dental Plans of the Midwest, Inc., United Concordia Dental Plans of Pennsylvania, Inc., and United Concordia Dental Plans of Texas, Inc. For information about which companies are licensed in your state, visit the “Disclaimers” link at www.UnitedConcordia.com. Administrative and claims offices are located at 4401 Deer Path Road, Harrisburg, PA 17110.

Your time is valuable—and you’d rather not spend it managing dental insurance. That’s why United Concordia combines online and personal service to make dental insurance easy.

Manage Your Benefits and Oral Wellness

Online and in person,we’re there for you

… on Your Smart PhoneDownload our FREE apps at the App Store or Google Play. Just search for “United Concordia.”

Member App Chomper Chums™ App for Kids • Findadentistnearyou • Usethetwo-minutebrushingtimer • Learnaboutoralhealthandwellness • Developproperbrushinghabits • Accessyourbenefitsinformation • Encouragehealthyeating • GetavirtualIDcard • Interactwithfunanimalcharacters

… on Your ComputerVisit UnitedConcordia.com to access these and other helpful tools.

Online Services • Updateyourprofile • ManageyourpolicyonlinewithMy Dental Benefits • Findadentist • Connectonsocialmedia

… over the PhoneCall1-800-332-0366tospeaktodentalprofessionalsandgetbenefitsinformation.

Award-Winning Customer Service • Tenured,US-basedrepresentativeswithspecializedknowledge • Littletonowait • 24/7interactivevoiceresponsesystem • 97%ofcallsresolvedonfirstattempt

No matter how you prefer to manage your dental benefits, we have quick and easy options to meet your needs.

Scan now to download:

Member App

Chomper Chums™ App

MEM-0343-0314