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Dental Benefits Summary for Affiliated Workers Association |
Network: Concordia Advantage Plus |
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Benefit Category 1 |
CONCORDIA FLEX PLAN |
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In-Network 2 |
Non-Network 2 |
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Class I - Diagnostic/Preventative Services (Excluded from Annual Program Maximum) |
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Exams |
100% |
100% |
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Bitewing X-rays |
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All Other X-rays |
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Cleanings & Fluoride Treatments (includes 1 additional cleaning during pregnancy) |
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Sealants |
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Palliative Treatment |
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Class II - Basic Services |
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Basic Restorative (Fillings) |
50% |
50% |
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Simple Extractions |
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Space Maintainers |
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Repairs of Crowns, Inlays, Onlays, Bridges & Dentures |
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Endodontics |
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Nonsurgical Periodontics |
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Surgical Periodontics |
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Complex Oral Surgery |
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General Anesthesia |
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Class III – Major Services (6 month waiting period) |
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Inlays, Onlays, Crowns |
50% |
50% |
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Prosthetics (Bridges, Dentures) |
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Maximums & Deductibles (cumulative of network and non-network) |
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Annual Program Deductible (per person/ per family) |
$50/$150 |
$50/$150 |
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Excludes Class 1 |
Excludes Class 1 |
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Annual Program Maximum (per person) |
$1,000 |
$1,000 |
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Excludes Class 1 |
Excludes Class 1 |
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Reimbursement |
Advantage Plus |
Advantage |
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Representative listing of covered services – certificate of coverage provides detailed description of benefits |
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1. Unmarried dependent children covered to age 26. |
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2. Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. Non-network dentists may bill the member for any difference between our allowance and their fee. United Concordia Dental's standard exclusions and limitations apply. |
