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Active Health Summary Plan Description
As of July 1, 2022
En Español (PDF)

Article 8: Dental Plans Available to You

You may choose one of the following:

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

The Administrative Office offers three (3) dental plans from which to choose: a dental Preferred Provider Organization (PPO) plan and two (2) Dental Health Maintenance Organizations (DHMO) plans. The dental PPO plan is provided by United Concordia. The DHMO plans are DeltaCare USA 40R (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 (DeltaCare USA 40R 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.

8.1 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.

Dental Provider Name United Concordia DeltaCare USA United Concordia
Plan Type PPO DHMO DHMO
Member Customer Service (800) 332-0366 (800) 422-4234 (866) 357-3304
Website Address unitedconcordia.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
Annual deductible      
Per individual $0/$25 N/A N/A
Per family $0/$75 N/A N/A
Annual Maximum
Waived for diagnostic and preventive
     
Per individual $5,000 N/A N/A
Per family N/A N/A N/A
Diagnostic/Preventive
X-rays, exams, cleanings
0%/0%, plus balance billing $0 $0
Basic
Fillings, sealants, oral surgery, root canals
5%/20% plus balance billing $0
(for white fillings)
$0
(for white fillings)
Major
Crowns and casts, dentures, bridges and implants
25%/50% plus balance billing
Implants only: 25%/25% plus balance billing
$0
(no added metal fees)
(Implants not covered)
$0
($125 metal fee may apply for noble and/or high noble metals on crowns)
(Implants not covered)
Description MEMBER CO-PAYMENT
Network In-Network
Out-of-Network
In-Network Only In-Network Only
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 $950 - $1,400
Startup and retention charges not noted
$1,500 - $2,000, startup and retention charges not noted
Emergency Services
Emergency exam
0%/0% plus balance billing $0 $0