Page 61 - 2022 Large Group benefits

Concordia Flex Dental Benefit category1
Class 1 — Diagnostic/ Preventive services
Low option
option
Preventive option
option
In/Out-of-network2
In/Out-of-network2
In/Out-of-network2
In/Out-of-network2
100% 100% 100% 100% Custom option
In/Out-of-network2
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)
0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% 0 0 0 – 100% Flexible Flexible Flexible 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Class 2
— Basic services
80% Not covered
100% 100% 100% 100% 80% Not covered
80% Not covered
80% Not covered
Class 3 — Major services
80% Not covered
80% Not covered
80% Not covered
80% Not covered
Not Not covered
covered
Not Not covered
covered
Orthodontics for
dependent children to age 19
Maximums & Deductibles (applies to the combination of services
received from network network and non-network dentists)
Not Not covered
covered
Not Not covered
covered
Not Not covered
covered
Not Not covered
covered
$50/$150 Excludes Class 1 1 $0
$1 $1 000 000 Excludes Class 1 1 1 $1 $1 000 000 N/A
N/A
N/A
N/A
1 1 Unmarried dependent dependent students covered
to to to age age 26 Groups with 51+ employees can customize the age age limits for
dependents 2
2
Reimbursement is is is is based on on a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a schedule of maximum allowable charges (MACs) Network dentists dentists agree to to to accept UCD’s allowances as as as payment in in in full for
for
for
covered
covered
services
Non-
network network dentists dentists may bill bill the the the the member for
for
any difference between the the the the allowance allowance and and and and their fee (also known as as as balance billing) Dental plans
are are sold and and and and administered by United Concordia Companies Inc Standard Exclusions and and and limitations apply Other out-of-network reimbursement levels are available 2022 Large Group Plans | Independence Blue Cross 60