Dental Insurance

Your Plan Choices

REGULAR DENTAL OPTION

• Benefits are determined using the 90th percentile rates for procedures.
• You may use any dentist you choose.
• You may choose a dentist in the available preferred network with benefits based on the maximum allowable charge (MAC). This may result in lower out of pocket costs.
• A non network dentist is entitled to collect from you the difference between the amount of benefits payable by United Concordia and the dentist charge for that service.

PREFERRED PROVIDER OPTION (PPO)

• Benefits are based on the MAC determined by United Concordia and accepted by the PPO dentist.
• Enrollment in the PPO is with the PPO Program, not with a particular dentist. PPO dentists can discontinue their arrangement with the Program at any time.
• If you require the services of a specialist, ask your dentist to refer you to a PPO specialist.
• If you use the services of a non-PPO dentist: The dentist is entitled to charge you the difference between the amount of benefits payable by United Concordia and the dentist's charge. This means you could pay more out-of-pocket expense for using a non-PPO dentist, because the payment will reflect the lower PPO scheduled fee.

PREPAID OPTION

• The Prepaid option through CIGNA Dental Care is an easy to use plan offering choice, quality, and savings with a focus on preventive care. Choose a general dentist from the CIGNA Dental network. Covered family members can each choose their own dentists, near home, work, or school.
• You will receive a Patient Charge Schedule listing all covered services and the corresponding patient charge for each service. For many services, there is no charge at all. Other plan features include: No deductibles to meet. No annual dollar maximums. No claim forms to file and no waiting periods for coverage.
• If you choose this option, you must select and use a CIGNA Dental Care Participating General Dentist to receive the benefits the option offers. Each family member you enroll may select a personal Participating General Dentist. If your dentist recommends specialty treatment, he/she will refer you to a participating CIGNA Dental Care Specialist, whether seeing a general dentist or specialist.You will still only be responsible for the fees listed on your Patient Charge Schedule.
• To find a participating CIGNA Dental Care network dentist call 1-800-642-5810 or log onto www.cigna.com.
• If a procedure is not listed on your Patient Charge Schedule, it is not covered. A full explanation of plan exclusions and limitations is included in your Patient Charge Schedule.

DID YOU KNOW...
Your dental benefits are not taxed, and most dental expenses that are not paid by dental coverage - such as deductibles and copayments - can be submitted to your health care spending account, providing a tax savings of 26% - 45% on these expenses.

LATE ENTRANT PROVISIONS FOR REGULAR AND PPO
Late Entrant Limitations result in delayed benefits. This means you won't receive some
benefits until you have participated in the dental plan for a specified period of time.

Late Entrant Limitations Will Apply To:

• current employees who are enrolling in either the Regular or PPO Options for the first time; or
• employees who fail to pay premiums when they are on an unpaid leave.
• current employees who choose not to continue coverage and re-enroll at a later date.

Late Entrant Limitations Will Not Apply:

• if you enroll in the Prepaid Option as a new or current employee
• when you transfer between the dental options (if not currently under Late Entrant);
• if you enroll in the PPO or Regular Option plan when you are first eligible as a new employee; or
• to employees who fail to pay premiums when they are on unpaid Family Medical Leave or Military Leave (if not currently under Late Entrant)

New employees are not subject to the Late Entrant Limitations - as long as they enroll when first eligible. If you are a new employee and are interested in the Regular or PPO Options, sign up now to avoid these limitations in the future. Under the Regular and PPO Options, new employees have a six-month waiting period for Major and Orthodontic (dependents under age 19) services.

CERTAIN RESTRICTIONS, along with age and frequency limitations, apply to all dental options. For more information on the Regular and PPO Options, call United Concordia toll free 1-866-215-2356. For more information on the Prepaid option, call CIGNA at 1-800-642-5810.

Some Important Information About the Prepaid Option

• Once enrolled, you will receive a complete Patient Charge Schedule listing all covered services and associated fees along with your CIGNA Dental Care ID Card. Procedures not listed on the Patient Charge Schedule are not covered.
• You do not need your ID card to receive care. CIGNA Dental will send each dentist a monthly listing of all members who have enrolled with their office. You may request a Patient Charge Schedule by calling CIGNA Dental Member Services at 1-800-642-5810 or online at www.cigna.com, then go to mycigna.com. This Patient Charge Schedule will provide a complete list of covered benefits and co-payments.
• If you choose the Prepaid Option, you must select and use a CIGNA Dental Care Participating Dentist. Otherwise, you will not be eligible for benefits.
• Each enrolled family member may select a different Participating General Dentist.
• To select a CIGNA Dental Care dentist for the first time, fill out and send in the Dentist Selection Form included in your enrollment materials. If you enroll in the CIGNA Dental Care plan but do not choose a dentist, one will be chosen for you based on your zip code. You have the option to change network dentists as often as you like by calling 1-800-642-5810, or by logging onto www.cigna.com. Your change will be effective the first day of the following month.
• Under the prepaid option, only amalgon (silver) fillings are covered.

DENTAL OPTIONS COMPARISON CHART

REGULAR

PPO

PREPAID

TYPE I - PREVENTIVE

100% of the 90th percentile***

100% MAC**

100% Reduced, fixed, preset charges for all covered services. See your patient Charge Schedule for Specific Charges

TYPE II - BASIC

80% of the 90th percentile***

90% MAC**

100% Reduced, fixed, preset charges for all covered services. See your patient Charge Schedule for Specific Charges

TYPE III - MAJOR

50% of the 90th percentile***

50% MAC**

60%* Reduced, fixed, preset charges for all covered services. See your patient Charge Schedule for Specific Charges

ORTHODONTIA

50% of the 90th percentile *** for dependents under 19

50% MAC** for dependents under 19

50% for employee (and eligable dependents*) Reduced, fixed, preset charges for all covered services. See your patient Charge Schedule for Specific Charges

ANNUAL DEDUCTIBLE

$50 per person; $150 for family (applies to Type II and Type III Major services only) each plan year

NONE

MAXIMUM BENEFITS

$1,000 per person each plan year; $1,500 lifetime benefit for Orthodontia

NO MAXIMUM

WAITING PERIOD FOR BENEFITS

New employees or newly enrolled dependents - after six months of continuous coverage for Type III Major services and Orthodontia

NO WAITING PERIOD

LATE ENTRANT LIMITATIONS FOR BENEFITS

Current employees enrolling for coverage for the first time after 12 months continuous coverage for Type II Basic services; after 24 months continuous coverage for Type III Major services and Orthodontia

NO LIMITATION

* Your share of the cost for these services will actually be a flat dollar copayment. * See Schedule of Benefits for details.

 

TYPE I - PREVENTIVE

TYPE II - BASIC

TYPE III - MAJOR

ORTHODONTIA

-- Oral exams -- Prophylaxis -- Space maintainers     for dependents     under 14 -- X-rays

-- Filings -- Root canals -- Extractions -- Scaling and root     planing -- Repairs to dentures,     bridges, and     crowns -- Sealants, children     under 16

-- Crowns -- Dentures -- Bridgework -- Surgical periodontal

-- Cephalometric     x-rays -- Treatment study -- Bands, appliances

** United Concordia reimburses all fee-for-service and PPO dentist according to the maximum allowable charge (MAC) schedules. The MAC is determined using charge data submitted to United Concordia from more than 100,000 participating providers.
United Concordia policies & procedures and exclusions limitations apply.
This chart is a representative listing of services covered under the program.

***You may use a PPO provider even if you enrolled in the Regular Dental Option. This may result in lower out-of-pocket costs.

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