Active Health Summary Plan Description
As of September 1, 2017
En Español (PDF)

Article 9: Dental Plans Available to You

You may choose one of the following:

  • United Concordia Plan (PPO)
  • CIGNA Dental Plan (DHMO)
  • DeltaCare USA Dental Plan (DHMO)
  • United Concordia Dental Plan (DHMO)

The Administrative Office offers four (4) dental plans from which to choose: a dental Preferred Provider Organization (PPO) plan and three (3) Dental Health Maintenance Organizations (DHMO) plans. The dental PPO plan is provided by United Concordia. The DHMO plans are CIGNA, DeltaCare USA (also known as Delta Dental), and United Concordia. We suggest that you carefully review all of the Plans, and discuss these different Plan options with your family members. A brief overview of the United Concordia PPO Plan and the DHMO plans (CIGNA, DeltaCare USA and United Concordia) appears on the following page. Please refer to your Evidence of Coverage document for a complete description of your dental benefits, including the exclusions and limitations.

To maximize benefits under the PPO plan, you should use dentists which are part of the United Concordia PPO network.

When you use United Concordia PPO participating dentists, you receive greater benefits than if you go to a dentist who is not a United Concordia PPO provider. The difference in benefits between using a participating United Concordia PPO provider can be substantial, which affects your out-of-pocket costs.

9.1 Comparison of Dental Benefits Available to You

This summary of the DHMOs' benefits, exclusions, limitations, and other provisions affecting dental benefits is not intended to take the place of the respective DHMO's 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 DHMO's Certificate of Insurance document or Schedule of Benefits, the DHMO's Certificate of Insurance document or Schedule of Benefits shall govern.

This section modified by Amendment 1. View old language.

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; Annual Maximum applies to combination of in-network and non-network providers
       
Per individual $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
(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)
Orthodontics
Typical cost of completing a 24-month orthodontic treatment plan for permanent teeth for children, up to 19th birthday
50%/50% plus balance billing, up to max payment of $1,400 $50 - 2,328 $800 - $1,150 $1,500 - $2,000, startup and retention charges not noted
Emergency Services
Emergency exam
0%/0% plus balance billing $0-$68 $5 $0
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 $2,500/$2,000 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
(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)
Orthodontics
Typical cost of completing a 24-month orthodontic treatment plan for permanent teeth for children, up to 19th birthday
50%/50% plus balance billing, up to max payment of $1,400 $50 - 2,328 $800 - $1,150 $1,500 - $2,000, startup and retention charges not noted
Emergency Services
Emergency exam
0%/0% plus balance billing $0-$68 $5 $0