Retirees and eligible dependents may enroll.
Rates:
Individual $31.93 per month – billed by United Concordia quarterly ($95.79)
Two People $58.16 per month – billed by United Concordia quarterly ($174.48)
Family $75.55 per month – billed by United Concordia quarterly ($226.65)
Here’s how the benefits of your Retiree Dental Program compare to Active Plan:
| Benefit Category | Basic Dental Program for Retiree Members | Dental Program for Active Members |
|---|---|---|
| Diagnostic and Preventative Services | ||
| Routine Examinations | 80% - once in any 6 consecutive month period. | 100% of the total allowable fee or the amount charged (whichever is lower) |
| Oral Prophylaxis (Teeth Cleaning) | 80% - once in any 6 consecutive month period. | 100% of the total allowable fee or the amount charged (whichever is lower) |
| Fluoride Application | 80% - once in any 6 consecutive month period. | 100% of the total allowable fee or the amount charged (whichever is lower) |
| Pit & Fissure Sealants | Not Covered. | |
| Not Covered. | 80% - once in any 36 consecutive month period, unless special need is shown. |
100%- once in any 36 consecutive month period, unless special need is shown |
| Bitewing X-ray | 80% - once in any 6 consecutive month period. | 100% of the total allowable fee or the amount charged (whichever is lower) |
| Endodontic Services (under local anesthesia) |
||
| Root Canal Treatment | 50%. | 100% of the total allowable fee or the amount charged (whichever is lower) |
| Apicoectomy (Root surgery) | 50%. | 50% of the total allowable fee or the amount charged (whichever is lower) |
| Restorative Services | ||
| Restorative Services | 50%. | 100%. |
| Single unconnected inlays, onlays and crowns | 50%. | 80%. |
| Oral Surgery (under local anesthesia) |
||
| Removal of impacted teeth (partially or completely covered by bone) |
50%. | 80%. |
| Most other Oral Surgery | 50%. | 80%. |
| Periodontics (Gum Treatment) (Under local anesthesia) |
||
| NonSurgical | 50%. | 50%. |
| Surgical | 50%. | 50%. |
| Fixed Prosthetics | ||
| Fixed Bridgework including abutment inlays, onlays and crowns, and pontics |
50%. | 50%. |
| Replacement | 50% - if at least 5 years since initial installation date under this program. | 60% without limitation, as required. |
| Repairs to fixed bridges | 50% - 100%. | 50%. |
| Removable Prosthetics | ||
| Full or Partial Dentures | 50%. | 50%. |
| Replacement | 50% - if at least 5 years since initial installation date under this program. |
50% - Covered only five years since the date of the insertion of the existing inlay, onlay, or crown and only if the inlay, onlay, or crown is unserviceable and cannot be made serviceable |
| Orthodontic Services | Not covered | 50% of the total allowable charges or the amount charged (whichever is lower) with a maximum allowance of $1,200.00. This is a lifetime maximum |
| Repairs to Removable Prosthetics | 50% - 100%. | 60% - 100%. |
| Deductibles | No Deductible. | No Deductible. |
| Maximum Benefits | $1500 per person per year. | No annual cap. |
| Out-of-Area Emergency Services | Covered as specified above. | |