Page 9 - 2023 Down East Wood Ducks - Benefits Guide.docx_Neat

DENTAL COVERAGE

It’s important to have regular dental exams and cleanings so problems are detected before they become painful—and
expensive. Keeping your teeth and gums clean and healthy will help prevent most tooth decay and periodontal disease
and is an important part of maintaining your medical health.

The Down East Wood Ducks’ dental plan is through United Concordia. You do not need to elect medical to enroll in dental
coverage.

Your dental plan provides coverage for routine exams and cleanings and pays for a portion of other services, as shown
in the displayed table chart.

United Concordia Dental’s standard exclusions and limitations apply.

Benefit In-Network Out of Network
Annual Deductible $50 Individual $50 Individual
$150 Family $150 Family

Annual Maximum
(Per Person) $1,500 $1,500
Class I: Diagnostic and Preventive Includes Exams, 100% 100%
Cleanings and Fluoride Treatments (No Deductible) (No Deductible)

Class II: Basic Services
Includes Fillings, Periodontics, Endodontics, Complex 80% after Deductible 80% after Deductible
Oral Surgery
Class III: Major Services 50% after Deductible 50% after Deductible
Includes Inlays, Onlays, Crowns, and Prosthetics
Orthodontia 50% after Deductible 50% after Deductible
(Dependent Children up to Age 19) $1,500 Lifetime Maximum $1,500 Lifetime Maximum

To check for participating providers, go to:www.unitedconcordia.com

Employee Cost Per Month
United Concordia Dental Plan
Monthly Bi-Weekly
Employee Only $6.35 $2.93

Employee + Child(ren) $12.40 $5.72

Employee + Spouse $13.02 $6.01
Family $19.07 $8.80

The above is a summary of this benefit option.

Click here for more detailed information on this available benefit option.

2023 Down East Wood Ducks Benefit Guide Page 9