Unlimited Unlimited. Lifetime Maximum Unlimited, except for fertility services Unlimited, except for fertility services AACPS • Division of Human Resources • HR/Benefits • DPS/JH 2095/2a (Rev. 10/17) Dental and Vision Options Dental and Vision Options Active Employees and Retirees Dental Options CareFirst Traditional CareFirst PPO Concordia Plus DHMO MD1560* Oral Examination 100% of AB 100% of AB 80% of AB $5 copay Routine Cleaning 100% of AB 100% of AB 80% of AB 100% Sealants (limited to permanent molars – until end of year in which a member turns 19) 100% of AB 100% of AB 80% of AB 100% Bitewing X-ray 100% of AB 100% of AB 80% of AB 100% Palliative Treatment 100% of AB 100% of AB 80% of AB 95% Other X-rays as required 100% of AB 100% of AB 80% of AB 100% Space Maintainers 100% of AB 100% of AB 80% of AB 95% Fillings 100% of AB 80% of AB 60% of AB** 100% Simple Extractions 100% of AB 80% of AB 60% of AB** 75%-85% Pulpotomy 100% of AB 80% of AB 60% of AB** 75%-80% Direct Pulp Caps 100% of AB 80% of AB 60% of AB** 75%-80% Root Canals 100% of AB 80% of AB 60% of AB** 75%-80% Apicoectomy 80% of AB** 80% of AB 60% of AB** 75%-80% Oral Surgical Services 80% of AB** 80% of AB 60% of AB** 75%-85% Surgical Extractions 80% of AB** 80% of AB 60% of AB** 75%-85% Oral Surgery 80% of AB** 80% of AB 60% of AB** 75%-85% General Anesthesia 80% of AB** 80% of AB 60% of AB** See note 1 Periodontics 50% of AB** 80% of AB 60% of AB** 50%-65% Crown 80% of AB** 80% of AB 60% of AB** 60%-80% Prosthetic Appliances (including implants) 50% of AB 80% of AB 60% of AB** 60%-80% Implants not covered Orthodontics Children and Adults 50% of AB 50% of AB 35% of AB See note 3 Annual Deductible $25 Ind./$50 Family None $50 Ind./$150 Family None Annual Benefit Maximum $1,500 $1,500 None/See note 2 Ortho Lifetime Maximum $1,500 $1,500 See note 3 (AB Allowed Benefit) Under the Concordia Plus DHMO (MD1560*) Plan, out-of-network services are reimbursed up to a maximum amount, based on the fee schedule provided by United Concordia. Note 1—General Anesthesia is considered integral to other procedures under this plan and is not covered separately. Note 2—No annual maximum for in-network services. United Concordia will reimburse up to a maximum of $1,000 per family member per contract year for out-of-network services. Note 3—After $2,900 member copayment satisfied, benefits applicable to in-network services; provider should submit pre-treatment estimate. United Concordia will not reimburse covered members for any ortho...
Unlimited Unlimited. Number of available UNIs 4 standard 4 standard 4 standard 1 with a second UNI available on request 2 1000/100 Base-T + 2 SFP Sockets standard L2CP support No No No Limited Limited Diversity On request with limited availability On request with limited availability On request with limited availability Available to Priority Users in selected areas Available to Priority Users in selected areas
Unlimited Unlimited. Lifetime Maximum Unlimited, except for fertility services Unlimited, except for fertility services AACPS • Division of Human Resources • HR/Benefits • DPS/JH 2095/2a (Rev. 9/16)
Unlimited Unlimited. Number of available UNIs 4 standard 4 standard 4 standard 4 standard 1 with a second UNI available on request NID: 2 1000/100 Base-T + 2 SFP Sockets standard Glass: 1 with a second UNI available on request L2CP support No No No No Limited Limited Diversity Lead-in diversity only available on request with limited availability Lead-in diversity only available on request with limited availability Lead-in diversity only available on request with limited availability Lead-in diversity only available on request with limited availability Available to Priority Users in selected areas Available to Priority Users in selected areas The Bandwidth options for each Bitstream Service are detailed in appropriate Bitstream Service Description. Clause 3.7.8 above lists options for Small Business Fibre and further options can be developed using the Product Development Process.
Unlimited Unlimited. Annual Deductible Individual Family None None None None Reimbursement Levels Based on contracted amount Based on Reasonable & Customary Allowances
Unlimited Unlimited. Number of available UNIs 4 standard 4 standard 4 standard 1 with a second UNI available on request NID: 2 1000/100 Base- T + 2 SFP Sockets standard Glass: 1 with a second UNI available on request L2CP support No No No Limited Limited Diversity On request with limited availability On request with limited availability On request with limited availability Available to Priority Users in selected areas Available to Priority Users in selected areas
Unlimited Unlimited. 0704 90 10 White cabbages and red cabbages 6 Unlimited Unlimited
Unlimited Unlimited. Access via Internet to Library of Doble Committee Transactions, including technical questionnaires and apparatus surveys.
Unlimited Unlimited. Access via Internet to the Doble Portal for technical resources, historical archive of AskDoble Email Forum questions, apparatus guides, tutorials, service advisories. UNLIMITED UNLIMITED Attendance via web conference to Doble Monthly Webinar series on apparatus testing and diagnostics. UNLIMITED UNLIMITED On‐demand, 24/7 access to Library of recorded Monthly Webinars via Doble Portal. Copies of webinar presentations available upon request. UNLIMITED UNLIMITED Participation in the activities of the Doble Technical Committees at the International Conference of Doble Clients held annually in March/April and September/October. UNLIMITED UNLIMITED Participation in the activities of the Regional Technical Committees. UNLIMITED UNLIMITED Membership on the special Doble Oil Committee. 1 PERSON ADDITIONAL FEE Receipt of Doble Annual Oil Survey and Transformer Oil Purchase Specifications (TOPS). 1 COPY ADDITIONAL FEE
Unlimited Unlimited. Notes: The family deductible and family out-of-pocket maximum for the plan shall be embedded. ● Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance. However, the deductible does not apply to Emergency Room Services @ Hospital where a percentage (%) coinsurance applies to other covered services. ● Network and Non-network deductibles, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other. ● Physicians Home and office visit copayment also applies if the office visit is billed with allergy injections. ● PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, geriatrics or any other Network provider as allowed by the plan. ● SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice. ● Certain diabetic and asthmatic supplies have no deductible/copayment/coinsurance up to the maximum allowable amount at network pharmacies except diabetic test strips.
