proposed dental benefits for transport workers union

Proposed Dental Benefits for Transport Workers Union

Effective Date: 09/01/2017

Benefit Category F-Plan3W

Class I United Concordia’s Standard Frequency Limitations

Exams 2 every 12 months

X-Rays (Bitewings Only) 1 set every 12 months under age 19 and 1 set every 18 months age 19 and over

X-Rays (All Others) 1 every 5 years for Full Mouth and Panoramic X-Rays Limitations may apply to other types of X-rays.

Cleanings; Fluoride Treatment 2 every 12 months; 1 every 12 months under age 14Sealants 1 per tooth every 3 years to age 16 on permanent first and second molarsPalliative Treatment (Emergency) 2 per 12 months in combination with pulpal debridementSpace Maintainers 1 every 5 years under age 14

Class II

Basic Restorative Not within 24 months of previous placement. Includes coverage for posterior resins.

Simple Extractions Any frequency (no limitations)Repairs of Crowns, Inlays, Onlays, Dentures andBridges

1 per 36 months

Endodontics • Pulpal therapy: primary teeth that have no permanent tooth to replace it• Root canal treatment: one per tooth per lifetime

Non-Surgical Periodontics

• Full mouth debridement: 1 per lifetime• Scaling and root planing : 1 per 36 months (per area of mouth)• Periodontal maintenance: 2 every 12 months (in addition to routine

prophylaxis following active periodontal therapy)Surgical Periodontics Surgical periodontal procedures: 1 per 36 months (per area of mouth)

Guided tissue regeneration: 1 per tooth per lifetimeComplex Oral Surgery May vary by procedureGeneral Anesthesia Limited to 60 minutes per session

Class III

Inlays, Onlays and Crowns Not within 5 years of previous placementProsthetics (Bridges, Dentures) Not within 5 years of previous placement

Class IV

Diagnostic, Active, Retention Treatment for dependents to age 19 Dependent Eligibility

Dependent children covered to age 26. Due to state and federal mandates applying to other states, dependent eligibility may differ from that quoted.

Quote ID: 300235Proposal represents standard plans. Please see https://www.unitedconcordia.com/VariationsfromStandardBenefitPlans for detailsregarding benefit variations for plans available in your area.

Plan TX 02

IMPORTANT INFORMATION ABOUT YOUR PLAN

Concordia Plus Schedule of Benefits

The Member pays a $5 office visit Copayment per visit in addition to the Copayments listed on this Schedule of Benefits.4

This schedule of benefits provides a listing of procedures covered by your plan. For procedures that require a copayment, theamount to be paid is shown in the column titled “Member Pays $.” You pay these copayments to the dental office at the time of service.

4

You must select a United Concordia Primary Dental Office (PDO) to receive covered services. Your PDO will perform the belowprocedures or refer you to a specialty care dentist for further care. Treatment by an Out-of-Network dentist is not covered, except asdescribed in the Certificate of Coverage.

4

Only procedures listed on this Schedule of Benefits are Covered Services. For services not listed (not covered), the Member isresponsible for the full fee charged by the dentist less 25%. Procedure codes and member Copayments may be updated to meetAmerican Dental Association (ADA) Current Dental Terminology (CDT) in accordance with national standards.

4

For a complete description of your plan, please refer to the Certificate of Coverage and the Schedule of Exclusions and Limitations inaddition to this Schedule of Benefits.

4

ADACode

ADADescription

MemberPays $

CLINICAL ORAL EVALUATIONS

D0120 0Periodic Oral Evaluation - Established Patient

D0140 0Limited Oral Evaluation - Problem Focused

D0145 0Oral Evaluation For A Patient Under 3 YearsOf Age And Counseling With PrimaryCaregiver

D0150 0Comprehensive Oral Evaluation - New OrEstablished Patient

D0160 0Detailed And Extensive Oral Evaluation -Problem Focused, By Report

D0170 0Re-Evaluation-Limited, Problem Focused(Established Patient; Not Post-Operative Visit)

D0171 0Re‐Evaluation ‐ Post-Operative Office Visit

D0180 0Comprehensive Periodontal EvaluationRADIOGRAPHS/DIAGNOSTIC IMAGING (including interpretation)

D0210 0Intraoral - Complete Series Of RadiographicImages

D0220 0Intraoral- Periapical First Radiographic Image

D0230 0Intraoral- Periapical Each AdditionalRadiographic Image

D0240 0Intraoral - Occlusal Radiographic Image

D0250 0Extra-oral - 2D Projection Radiographic ImageCreated Using A Stationary Radiation Source,And Detector

D0251 0Extra-oral Posterior Dental Radiographic Image

D0270 0Bitewing - Single Radiographic Image

D0272 0Bitewings - Two Radiographic Images

D0273 0Bitewings - Three Radiographic Images

D0274 0Bitewings - Four Radiographic Images

D0277 0Vertical Bitewings - 7 To 8 RadiographicImages

D0322 0Tomographic Survey

D0330 0Panoramic Radiographic ImageTESTS AND EXAMINATIONS

D0460 0Pulp Vitality Tests

D0470 0Diagnostic Casts

ADACode

ADADescription

MemberPays $

ORAL PATHOLOGY LABORATORY

D0601 0Caries Risk Assessment And Documentation,With A Finding Of Low Risk

D0602 0Caries Risk Assessment And Documentation,With A Finding Of Moderate Risk

D0603 0Caries Risk Assessment And Documentation,With A Finding Of High Risk

DENTAL PROPHYLAXIS

D1110 0Prophylaxis, Adult

D1120 0Prophylaxis, ChildTOPICAL FLUORIDE TREATMENT (office procedure)

D1206 0Topical Application Of Fluoride Varnish

D1208 0Topical Application Of Flouride ‐ ExcludingVarnish

OTHER PREVENTIVE SERVICES

D1351 10Sealant - Per Tooth

D1353 10Sealant Repair - Per Tooth

D1354 15Interim Caries Arresting MedicamentApplication

SPACE MAINTENANCE (passive appliances)

D1510 30Space Maintainer - Fixed, Unilateral (ToothNumbers Or Tooth Area Required)

D1515 55Space Maintainer - Fixed, Bilateral

D1520 55Space Maintainer - Removable, Unilateral

D1525 70Space Maintainer - Removable, Bilateral

D1550 5Re‐Cement Or Re‐Bond Space Maintainer

D1555 5Removal Of Fixed Space Maintainer

D1575 30Distal shoe space maintainers - fixed -unilateral

AMALGAM RESTORATIONS (including polishing)

D2140 5Amalgam - One Surface, Primary OrPermanent

D2150 5Amalgam - Two Surfaces, Primary OrPermanent

D2160 10Amalgam - Three Surfaces, Primary OrPermanent

TX 02Current Dental Terminology ©2016 American Dental Association. All rights reserved. Page 1Base 16 (10/12) TX 02

ADA Code

ADA Description

Member Pays $

AMALGAM RESTORATIONS (including polishing)

D2161 10Amalgam - Four Or More Surfaces, Primary Or Permanent

RESIN-BASED COMPOSITE RESTORATIONS -

D2330 15Resin-Based Composite - One Surface, Anterior P a Pe a e

D2331 20Resin-Based Composite - Two Surfaces, Anterior P a Pe a e

D2332 20Resin-Based Composite - Three Surfaces, Anterior P a Pe a e

D2335 25Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior) P a Pe a e

D2390 30Resin-Based Composite Crown, Anterior

D2391 20Resin-Based Composite - One Surface, Posterior P a Pe a e

D2392 30Resin-Based Composite - Two Surfaces, Posterior P a Pe a e

D2393 50Resin-Based Composite - Three Surfaces, Posterior P a Pe a e

D2394 80Resin-Based Composite - Four Or More Surfaces, Posterior P a Pe a e

CROWNS - SINGLE RESTORATIONS ONLY

D2750 255Crown, Porcelain Fused To High Noble Metal u

D2751 255Crown-Porcelain Fused To Predominantly Base Metal

u

D2752 255Crown, Porcelain Fused To Noble Metal u

D2780 255Crown - 3/4 Cast High Noble Metal u

D2781 255Crown - 3/4 Cast Predominantly Base Metal u

D2782 255Crown - 3/4 Cast Noble Metal u

D2790 235Crown, Full Cast High Noble Metal u

D2791 235Crown - Full Cast Predominantly Base Metal u

D2792 235Crown, Full Cast Noble Metal u

D2794 235Crown-Titanium u

OTHER RESTORATIVE SERVICES

D2910 5Re-Cement Or Re‐Bond Inlay, Onlay, Veneer Or Partial Coverage Restoration

D2915 5Re‐Cement Or Rebond Indirectly Fabricated Or Prefabricated Post And Core

D2920 5Re-Cement Or Re‐Bond Crown

D2930 20Prefabricated Stainless Steel Crown - Primary Tooth

D2931 20Prefabricated Stainless Steel Crown - Permanent Tooth

D2940 10Protective Restoration

D2949 0Restorative Foundation For An Indirect Restoration

D2950 50Core Buildup Including Any Pins When Required

D2951 0Pin Retention - Per Tooth, In Addition To Restoration

D2952 75Post And Core In Addition To Crown, Indirectly Fabricated

u

D2953 75Each Additional Indirectly Fabricated Post - Same Tooth

u

D2954 60Prefabricated Post And Core In Addition To Crown

D2957 40Each Additional Prefabricated Post - Same Tooth

D2971 50Additional Procedures To Construct New Crown Under Existing Partial Denture Framework

PULP CAPPING

ADA Code

ADA Description

Member Pays $

PULP CAPPING

D3110 10Pulp Cap - Direct (Excluding Final Restoration)

D3120 10Pulp Cap - Indirect (Excluding Final Restoration)

PULPOTOMY

D3220 35Therapeutic Pulpotomy (Excluding Final Restoration)

D3221 50Pulpal Debridement, Primary And Permanent Teeth

D3222 35Partial Pulpotomy For Apexogenesis-Permanent Tooth With Incomplete Root Development

ENDODONTIC THERAPY ON PRIMARY TEETH

D3230 100Pulpal Therapy (Resorbable Filling)-Anterior, Primary Tooth (Excluding Final Restoration)

D3240 100Pulpal Therapy (Resorbable Filling)-Posterior, Primary Tooth (Excluding Final Restoration)

ENDODONTIC THERAPY (including treatment plan, clinical procedures and follow-up care)

D3310 205Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)

D3320 245Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)

D3330 325Endodontic Therapy, Molar (Excluding Final Restoration)

APICOECTOMY/PERIRADICULAR SERVICES

D3410 150Apicoectomy - Anterior

D3421 150Apicoectomy - Bicuspid (First Root)

D3425 160Apicoectomy - Molar (First Root)

D3426 70Apicoectomy (Each Additional Root)

D3427 160Periradicular Surgery Without Apicoectomy

D3430 30Retrograde Filling - Per RootSURGICAL SERVICES (including usual postoperative care)

D4210 95Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

D4211 35Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

D4212 0Gingivectomy Or Gingivoplasty To Allow Access For Restorative Procedure, Per Tooth

D4240 165Gingival Flap Procedure, Including Root Planing - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

D4241 85Gingival Flap Procedure, Including Root Planing - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

D4260 255Osseous Surgery (Including Elevation Of A Full Thickness Flap And Closure) – Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

D4261 155Osseous Surgery (Including Elevation Of A Full Thickness Flap And Closure) – One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

NON-SURGICAL PERIODONTAL SERVICES

D4341 60Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant

D4342 45Periodontal Scaling And Root Planing - One To Three Teeth Per Quadrant


ADA Code

ADA Description

Member Pays $

NON-SURGICAL PERIODONTAL SERVICES

D4346 30Scaling In Presence Of Generalized Moderate Or Severe Gingival Inflammation - Full Mouth, After Oral Evaluation

D4355 30Full Mouth Debridement To Enable Comprehensive Evaluation And Diagnosis

OTHER PERIODONTAL SERVICES

D4910 30Periodontal Maintenance

D4921 25Gingival Irrigation - Per QuadrantCOMPLETE DENTURES (including routine post delivery care)

D5110 330Complete Denture - Maxillary u

D5120 330Complete Denture - Mandibular u

D5130 330Immediate Denture - Maxillary u

D5140 330Immediate Denture - Mandibular u

PARTIAL DENTURES (including routine post-delivery care)

D5211 265Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)

u

D5212 265Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)

u

D5213 385Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)

u

D5214 385Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rest And Teeth)

u

D5221 265Immediate Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests and Teeth)

u

D5222 265Immediate Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests and Teeth)

u

D5223 385Immediate Maxillary Partial Denture - Case Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)

u

D5224 385Immediate Mandibular Partial Denture - Case Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)

u

ADJUSTMENTS TO DENTURES

D5410 15Adjust Complete Denture - Maxillary

D5411 15Adjust Complete Denture - Mandibular

D5421 15Adjust Partial Denture - Maxillary

D5422 15Adjust Partial Denture - MandibularREPAIRS TO COMPLETE DENTURES

D5510 25Repair Broken Complete Denture Base u

D5520 20Replace Missing Or Broken Teeth-Complete Denture (Each Tooth)

u

REPAIRS TO PARTIAL DENTURES

D5610 25Repair Resin Denture Base u

D5620 20Repair Cast Framework u

D5630 25Repair Or Replace Broken Clasp - Per Tooth u

D5640 25Replace Broken Teeth-Per Tooth u

D5650 25Add Tooth To Existing Partial Denture u

D5660 30Add Clasp To Existing Partial Denture - Per Tooth

u

ADA Code

ADA Description

Member Pays $

REPAIRS TO PARTIAL DENTURES

D5670 270Replace All Teeth And Acrylic On Cast Metal Framework (Maxillary)

u

D5671 285Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular)

u

DENTURE REBASE PROCEDURES

D5710 80Rebase Complete Maxillary Denture u

D5711 80Rebase Complete Mandibular Denture u

D5720 80Rebase Maxillary Partial Denture u

D5721 80Rebase Mandibular Partial Denture u

DENTURE RELINE PROCEDURES

D5730 45Reline Complete Maxillary Denture (Chairside)

D5731 45Reline Complete Mandibular Denture (Chairside)

D5740 45Reline Maxillary Partial Denture (Chairside)

D5741 45Reline Mandibular Partial Denture (Chairside)

D5750 65Reline Complete Maxillary Denture (Laboratory) u

D5751 65Reline Complete Mandibular Denture (Laboratory)

u

D5760 65Reline Maxillary Partial Denture (Laboratory) u

D5761 65Reline Mandibular Partial Denture (Laboratory) u

OTHER REMOVABLE PROSTHETIC SERVICES

D5850 20Tissue Conditioning, Maxillary

D5851 20Tissue Conditioning, Mandibular

D5863 330Overdenture - Complete Maxillary

D5864 385Overdenture - Partial Maxillary

D5865 330Overdenture - Complete Mandibular

D5866 385Overdenture - Partial MandibularFIXED PARTIAL DENTURE PONTICS

D6210 235Pontic-Cast High Noble Metal u

D6211 235Pontic-Cast Predominatly Base Metal u

D6212 235Pontic-Cast Noble Metal u

D6214 235Pontic - Titanium u

D6240 255Pontic-Porcelain Fused To High Noble Metal u

D6241 255Pontic-Porcelain Fused To Predominantly Base Metal

u

D6242 255Pontic-Porcelain Fused To Noble Metal u

FIXED PARTIAL DENTURE RETAINERS - CROWNS

D6750 255Retainer Crown, Porcelain Fused To High Noble Metal

u

D6751 255Retainer Crown - Porcelain Fused To Predominantly Base Metal

u

D6752 255Retainer Crown, Porcelain Fused To Noble Metal

u

D6780 255Retainer Crown, 3/4 Cast High Noble Metal u

D6781 255Retainer Crown - 3/4 Cast Predominantly Base Metal

u

D6782 255Retainer Crown - 3/4 Cast Noble Metal u

D6783 255Retainer Crown - 3/4 Porcelain/Ceramic u

D6790 235Retainer Crown, Full Cast High Noble Metal u

D6791 235Retainer Crown, Full Cast Predominantly Base Metal

u

D6792 235Retainer Crown, Full Cast Noble Metal u

D6794 235Retainer Crown - Titanium u

OTHER FIXED PARTIAL DENTURE SERVICES


ADACode

ADADescription

MemberPays $

OTHER FIXED PARTIAL DENTURE SERVICES

D6930 5Re‐Cement Or Re-Bond Fixed Partial DentureEXTRACTIONS (includes local anesthesia, suturing, if needed, and

routine postoperative care)D7111 10Extraction, Coronal Remnants - Deciduous

ToothD7140 15Extraction, Erupted Tooth Or Exposed Root

(Elevation And/Or Forceps Removal)SURGICAL EXTRACTIONS (includes local anesthesia, suturing, if needed,

and routine postoperative care)D7210 60Extraction, Erupted Tooth Requiring Removal

Of Bone And/Or Sectioning Of Tooth, AndIncluding Elevation Of Mucoperiosteal Flap IfIndicated

D7220 65Removal Of Impacted Tooth - Soft Tissue

D7230 90Removal Of Impacted Tooth - Partially Bony

D7240 105Removal Of Impacted Tooth - Completely Bony

D7241 110Removal Of Impacted Tooth - CompletelyBony, With Unusual Surgical Complications

D7250 50Removal Of Residual Tooth Roots (CuttingProcedure)

D7251 105Coronectomy-Intentional Partial Tooth Removal

OTHER SURGICAL PROCEDURES

D7280 115Exposure Of An Unerupted ToothALVEOLOPLASTY (surgical preparation of ridge for dentures)

D7310 45Alveoloplasty In Conjunction With Extractions -Four Or More Teeth Or Tooth Spaces, PerQuadrant

D7320 60Alveoloplasty Not In Conjunction WithExtractions - Four Or More Teeth Or ToothSpaces, Per Quadrant

D7321 40Alveoloplasty Not In Conjunction WithExtractions - One To Three Teeth Or ToothSpaces, Per Quadrant

SURGICAL INCISION

D7510 35Incision And Drainage Of Abscess - IntraoralSoft Tissue

OTHER REPAIR PROCEDURES

D7960 80Frenulectomy - Also Known As Frenectomy OrFrenotomy - Separate Procedure NotIncidental To Another Procedure

LIMITED ORTHODONTIC TREATMENT

D8010 775Limited Orthodontic Treatment Of PrimaryDentition

D8020 775Limited Orthodontic Treatment Of TransitionalDentition

D8030 775Limited Orthodontic Treatment Of AdolescentDentition

D8040 775Limited Orthodontic Treatment Of The AdultDentition

INTERCEPTIVE ORTHODONTIC TREATMENT

D8050 1300Interceptive Orthodontic Treatment Of PrimaryDentition

D8060 1300Interceptive Orthodontic Treatment OfTransitional Dentition

COMPREHENSIVE ORTHODONTIC TREATMENT

D8070 2400Comprehensive Orthodontic Treatment OfTransitional Dentition

D8080 2400Comprehensive Orthodontic Treatment OfAdolescent Dentition

ADACode

ADADescription

MemberPays $

COMPREHENSIVE ORTHODONTIC TREATMENT

D8090 2600Comprehensive Orthodontic Treatment OfAdult Dentition

MINOR TREATMENT TO CONTROL HARMFUL HABITS

D8210 560Removable Appliance Therapy For Control OfHarmful Habits

u

D8220 560Fixed Appliance Therapy For Control OfHarmful Habits

u

OTHER ORTHODONTIC SERVICES

D8660 120Pre‐Orthodontic Treatment Examination ToMonitor Growth And Development

D8680 95Orthodontic Retention (Removal OfAppliances, Construction And Placement OfRetainer(S)

UNCLASSIFIED TREATMENT

D9110 0Palliative (Emergency) Treatment Of DentalPain, Minor Procedures

PROFESSIONAL CONSULTATION

D9310 0Consultation - Diagnostic Service Provided ByDentist Or Physician Other Than RequestingDentist Or Physician

D9311 0Consultation With A Medical Health CareProfessional

PROFESSIONAL VISITS

D9430 0Office Visit For Observation (During RegularlyScheduled Hours) - No Other ServicesPerformed

D9440 35Office Visit After Regularly Scheduled HoursMISCELLANEOUS SERVICES

D9932 0Cleaning And Inspection Of RemovableComplete Denture, Maxillary

D9933 0Cleaning And Inspection Of RemovableComplete Denture, Mandibular

D9934 0Cleaning And Inspection Of Removable PartialDenture, Maxillary

D9935 0Cleaning And Inspection Of Removable PartialDenture, Mandibular

D9991 0Dental Case Management - AddressingAppointment Compliance Barriers

D9992 0Dental Case Management - Care Coordination

D9993 0Dental Case Management - MotivationalInterviewing

D9994 0Dental Case Management - Patient EducationTo Improve Oral Health Literacy

FOOTNOTES

u Charges for lab fees or the use of precious(high noble) or semi precious (noble) metal arenot covered and therefore are not included inthe copayment for crowns, bridges, pontics,inlays and onlays. The total patient charge forhigh noble metal and the applicable dental labfees may not exceed the primary care dentist'sactual charge or $225, which ever is lower


GENERAL PROPOSAL TERMS:

• United Concordia’s dental plan is the only plan offered for acceptance or consideration. The quoted information isinvalid if any other dental carrier is offered for coverage.

• Rates assume the group does not currently have dental coverage with United Concordia Dental. If the group iscurrently covered under a United Concordia Dental insurance policy, the rates quoted in this proposal are not valid,and the renewal rates will apply. Please contact your United Concordia sales representative for more information.

United Concordia Dental may pay the selling broker or benefit consultant ("producer") compensation for the promotionand sale of the products and services offered in this proposal. In addition to our standard compensationarrangements, we may make additional cash payments or reimbursements to selling producers in recognition of theirmarketing and distribution activites, persistency levels and volumes of business.

•

We encourage producers and their clients to discuss what commissions or other compensation may be paid inconnection with the purchase of products and services from United Concordia Companies, Inc. If you have questionsregarding compensation programs related to your insurance plan, you may view the information on producercompensation that is available on our website at www.unitedconcordia.com.

•

• All proposed rates, guarantees and caps assume no change to the proposed benefit design or effective date. UnitedConcordia reserves the right to re-evaluate proposed rates and benefits if any state or federally mandated benefits orfees are imposed.

United Concordia Dental is not available to accept business submitted by or pay commissions to producers who arenot appointed. Any binder check or other premium payment collected from a group by non-appointed producers, andis then submitted for acceptance to United Concordia Dental directly or through United Concordia Dental salespersonnel, will be rejected and returned to the non-appointed producer. Your quotation of rates to groups orsubmission of business to United Concordia Dental will constitute acceptance of and agreement to comply with theserules regarding appointment and commission payments.

•

• United Concordia Dental may offer premium rate discounts to groups that purchase additional lines of insurancecoverage from other insurance companies that are affiliated with United Concordia Dental. You may be eligible forone or more of these multiple policy discounts. Contact your United Concordia sales representative regardingeligibility. The multiple policy discount programs offered by United Concordia Dental may change or terminate at anytime without prior notice.

• Underwriting guidelines for any FFS plan, offering orthodontic coverage, are as follows:• If any FFS plan has 10-24 enrolled contracts, orthodontics is available on a takeover basis only. Groups that do

not currently have orthodontic coverage are not eligible for this benefit. Proof of prior orthodontic coverage (priorcarrier summary plan description) is required as part of the implementation package.

• United Concordia Dental requires a minimum of 10 enrolled contracts on the FFS plan.

• Multiple Option rating guidelines:• For groups offered multiple policies, underwriting guidelines apply on a per policy basis.• If a FFS plan design is offered with another plan under the same policy, a minimum of 5 enrolled contracts is

required on each FFS plan, unless orthodontia is covered. If orthodontia is covered on the FFS plan, a minimumof 10 enrolled contracts on a FFS plan is required, with proof of prior orthodontic coverage.

• A minimum of 2 enrolled is required on every DHMO program offered.• A minimum of 5 enrolled is required on every FFS program offered, unless orthodontia is covered.• A minimum of 10 enrolled is required between all plans offered in a multi option offering.

Quote ID: 300235

• Dental plans cover only dental benefits, are administered by United Concordia Companies, Inc., and underwritten by United Concordia Life and Health Insurance Company, United Concordia Insurance Company of New York, UnitedConcordia Insurance Company, United Concordia Dental Plans, Inc., United Concordia Dental Plans of California, Inc., United Concordia Dental Plans of Kentucky, Inc., United Concordia Dental Plans of the Midwest, Inc., UnitedConcordia Dental Plans of Pennsylvania, Inc., and United Concordia Dental Plans of Texas, Inc. For information about the companies licensed and policies/contracts offered in your state, visit the “Disclaimers” link at www.UnitedConcordia.com. Administrative and claims offices located at 4401 Deer Path Road, Harrisburg, PA 17110 (888-483-9930). United Concordia Insurance Company, CA certificate of authority # 3739-0, is domiciled at 2198 EastCamelback Road, Suite 260, Phoenix, AZ 85016. Vision rider benefits are administered by Davis Vision Insurance Administrators in CA and by Davis Vision, Inc. in all other states. Vision discounts are not insurance, are under separatecontract, and are only available from Davis Vision providers. Dental plans begin on the agreed effective date and renew subject to the terms of the Group Policy/Contract. The Policy/Contract specifies the agreed upon renewal,termination and rate/benefit provisions and any applicable notice requirements.

• Certain dental plans and their provisions may vary or be unavailable in some states. All plans have exclusions and limitations which may affect any benefits payable. DHMO members must select an in-network primary dentist and have areferral to in-network specialists unless authorized by the company or a POS plan is purchased. Fee-for-service and DHMO products are delivered under separate contracts.

• Dental plans begin on the agreed effective date and renew subject to the terms of the Group Policy/Contract. The Policy/Contract specifies the agreed upon renewal, termination and rate/benefit provisions and any applicable noticerequirements.

• Employees/members may be subject to enrollment restrictions, eligibility requirements or waiting periods for insurance, and must also meet the group’s eligibility requirements.• Consult the policy/contract, or contact your agent or account representative for specific provisions and details of availability.

proposed dental benefits for transport workers union

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