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Concordia Flex Dental
Benefit category1
Class 1 — Diagnostic/ Preventive services
Low option Preventive option Custom option
In/Out-of-network2 In/Out-of-network2 In/Out-of-network2
100% 100% 0 – 100%
100% 100% 0 – 100%
100% 100% 0 – 100%
100% 100% 0 – 100%
80% Not covered 0 – 100%
Class 2 — Basic services
100% 100% 0 – 100%
80% Not covered 0 – 100%
80% Not covered 0 – 100%
Class 3 — Major services
Orthodontics for dependent children to age 19
Maximums & Deductibles (applies to
the combination of services received from network and non-network dentists)
80% Not covered 0 – 100%
80% Not covered 0 – 100%
80% Not covered 0 – 100%
80% Not covered 0 – 100%
80% Not covered 0 – 100%
Not covered Not covered 0 – 100%
Not covered Not covered 0 – 100%
Not covered Not covered 0 – 100%
$50/$150 Excludes Class 1 $0 Flexible
$1,000 Excludes Class 1 $1,000 Flexible
N/A N/A Flexible
Exams
X-rays
Cleanings & fluoride treatments Sealants
Space maintainers
Emergency treatment
Fillings (metal and white fillings)
Simple extractions
Repairs of crowns, inlays, onlays, bridges & dentures Endodontics
Surgical and nonsurgical periodontics
Complex oral surgery
General anesthesia
Inlays, onlays, crowns Prosthetics (bridges, dentures)
Diagnostic, active, retention treatment
Annual program deductible (per person/per family) Annual program maximum (per person)
Lifetime orthodontic maximum (per person)
1. Unmarried dependent students covered to age 26. Groups with 51+ employees can customize the age limits for dependents.
2. Reimbursement is based on a schedule of maximum allowable charges (MACs). Network dentists agree to accept UCD’s allowances as payment in full for covered services. Non-
network dentists may bill the member for any difference between the allowance and their fee (also known as balance billing). Dental plans are sold and administered by United Concordia Companies, Inc. Standard Exclusions and limitations apply. Other out-of-network reimbursement levels are available.
2023 Large Group Plans | Independence Blue Cross 54
