Retiree Health Summary Plan Description
As of February 1, 2018
En Español (PDF)

8.2 Comparison of Dental Benefits

This summary of the benefits, exclusions, limitations, and other provisions affecting dental benefits is not intended to take the place of the respective Evidence of Coverage document or Schedule of Benefits. Please refer to your Evidence of Coverage and Disclosure Document for a complete description of your dental benefits, including the exclusions and limitations. In the event of any conflict between the information summarized in this section and the Certificate of Insurance document or Schedule of Benefits, the Certificate of Insurance document or Schedule of Benefits shall govern.

Dental Provider Name United Concordia Cigna DeltaCare United Concordia
Plan Type PPO DHMO DHMO DHMO
Member Customer Service (800) 332-0366 (800) CIGNA-24 (800) 422-4234 (866) 357-3304
Website Address unitedconcordia.com cigna.com deltadentalins.com unitedconcordia.com
Claims Filing Address
Applies to PPO plan only

P.O. Box 69421, Harrisburg, PA. 17106-9421

Description

MEMBER CO-PAYMENT

Network In-Network/
Out-of-Network
In-Network Only In-Network Only In-Network Only
Annual deductible        
Per individual $0/$25 N/A N/A N/A
Per family $0/$75 N/A N/A N/A
Annual Maximum
Waived for diagnostic and preventive
       
Per individual $5,000/$5,000 N/A N/A N/A
Per family N/A N/A N/A N/A
Diagnostic/Preventive
X-rays, exams, cleanings
0%/0%, plus balance billing $0 $0 $0
Basic
Fillings, sealants, oral surgery, root canals
5%/20% plus balance billing $0 - $430 $0 - $220 $0 - $140
(for white fillings)
Major
Crowns and casts, dentures, bridges and implants
25%/50% plus balance billing
Implants only: 25%/25% plus balance billing
$12 - $725 $0 - $195, implants not covered $0 (for metal crowns and bridges) In-Network Dentists can charge an additional $125 for the use of precious (high noble) or semi precious (noble) metal. Implants are not covered.
Emergency Services
Emergency exam
0%/0% plus balance billing $0-$68 $5 $0