- News
- Active Health
- Retiree Health
- DB Pension
- Defined Benefit Plan
- Benefit Tabs™
- SPD
- Plan Document
- FAQs
- Forms
- Life Events
- Links
- DC Pension
- Defined Contribution Plan
- SPD
- Plan Document
- Forms
- Life Events
- Links
- SUB Plan
- Supplemental Unemployment Benefit Plan
(IBEW Local 11 and LA NECA only) - Benefit Tabs™
- SPD
- FAQs
- Forms
- Life Events
- Supplemental Unemployment Benefit Plan
- Contact
New Participant Portal
You can enroll for the new Participant Portal experience. Click here for instructions on how to access the new Participant Portal.
Register for New Participant PortalRetiree 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 |