United Concordia Dental

www.uccifedvip.com

877-394-8224

2024

A Nationwide Dental PPO Plan

IMPORTANT

• Rates: Back Cover

• Summary of Benefits: Page 46

Who may enroll in this plan: All Federal employees, annuitants, and

certain TRICARE beneficiaries in the United States and overseas who

are eligible to enroll in the Federal Employees Dental and Vision

Insurance Program.

This Plan has 5 enrollment regions, including overseas; please see the end of this brochure to determine

your region and corresponding rates. Enrollment Options for this Plan:

•High Option – Self Only

•High Option – Self Plus One

•High Option – Self and Family

•Standard Option – Self Only

•Standard Option – Self Plus One

•Standard Option – Self and Family

Introduction

On December 23, 2004, President George W. Bush signed the Federal Employees Dental and Vision Benefits Enhancement

Act of 2004 (Public Law 108-496). The law directed the Office of Personnel Management (OPM) to establish supplemental

dental and vision benefit programs to be made available to Federal employees, annuitants, and their eligible family members.

In response to the legislation, OPM established the Federal Employees Dental and Vision Insurance Program (FEDVIP).

OPM has contracted with dental and vision insurers to offer an array of choices to Federal employees and annuitants. Section

715 of the National Defense Authorization Act for Fiscal Year 2017 (FY 2017 NDAA), Public Law 114-38, expanded

FEDVIP eligibility to certain TRICARE-eligible individuals.

This brochure describes the benefits of the United Concordia FEDVIP under United Concordia's contract OPM02-

FEDVIP-02AP-14 with OPM, as authorized by the FEDVIP law. The address for our administrative office is:

United Concordia Companies, Inc.

1800 Center Street

Camp Hill, PA 17011

1-877-394-8224

www.uccifedvip.com

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations,

and exclusions of this brochure. It is your responsibility to be informed about your benefits. You and your family members

do not have a right to benefits that were available before January 1, 2024, unless those benefits are also shown in this

brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus

One, you and your designated family member are entitled to these benefits. If you are enrolled in Self and Family coverage,

each of your eligible family members is also entitled to these benefits, if they are also listed on the coverage.

OPM negotiates rates with each carrier annually. Rates are shown at the end of this brochure.

United Concordia Companies, Inc. is responsible for the selection of in-network providers in your area. Contact us at

1-877-394-8224 for the names of participating providers or to request a provider directory. You may also go to our website at

www.uccifedvip.com. Continued participation of any specific provider cannot be guaranteed. Thus, you should choose your

plan based on the benefits provided and not on a specific provider’s participation. When you phone for an appointment,

please remember to verify that the provider is currently in-network. If your provider is not currently participating in the

provider network, you may nominate the dentist. Nomination forms are available on our website www.uccifedvip.com. Just

click onFind a Dentist, then Recommend a Dentist, or call us at 1-877-394-8224 and we will send one to you. You cannot

change plans outside of Open Season because of changes to the provider network.

Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty

in all areas. If you require the services of a specialist and one is not available in your area, please contact us for assistance.

United Concordia and all other FEDVIP plans are not a part of the Federal Employees Health Benefits (FEHB)

Program.

We want you to know that protecting the confidentiality of your individually identifiable health information is of the utmost

importance to us. To review full details about our privacy practices, our legal duties, and your rights, please visit our

website, www.uccifedvip.com then click on the “Privacy” link at the bottom of the page. If you do not have access to the

internet or would like further information, please contact us by calling 877-394-8224.

Discrimination is Against the Law

United Concordia complies with all applicable Federal civil rights laws, to include both Title VII of the Civil Rights Act of

1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, United Concordia does not discriminate,

exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.

Table of Contents

Introduction ...................................................................................................................................................................................1

Table of Contents ..........................................................................................................................................................................1

FEDVIP Program Highlights ........................................................................................................................................................3

A Choice of Plans and Options ...........................................................................................................................................3

Enroll Through BENEFEDS ...............................................................................................................................................3

Dual Enrollment ..................................................................................................................................................................3

Coverage Effective Date .....................................................................................................................................................3

Pre-Tax Salary Deduction for Employees ...........................................................................................................................3

Annual Enrollment Opportunity .........................................................................................................................................3

Continued Group Coverage After Retirement ....................................................................................................................3

Compliance with the American Dental Association (ADA) ...............................................................................................3

How We've Changed for 2024 ......................................................................................................................................................4

Section 1 Eligibility ......................................................................................................................................................................5

Federal Employees ..............................................................................................................................................................5

Federal Annuitants ..............................................................................................................................................................5

Survivor Annuitants ............................................................................................................................................................5

Compensationers .................................................................................................................................................................5

Family Members .................................................................................................................................................................6

Not Eligible .........................................................................................................................................................................6

Section 2 Enrollment .....................................................................................................................................................................7

Enroll Through BENEFEDS ...............................................................................................................................................7

Enrollment Types ................................................................................................................................................................7

Dual Enrollment ..................................................................................................................................................................7

Opportunities to Enroll or Change Enrollment ...................................................................................................................7

When Coverage Stops .......................................................................................................................................................11

Continuation of Coverage .................................................................................................................................................12

FSAFEDS/High Deductible Health Plans and FEDVIP ...................................................................................................12

Section 3 How You Obtain Care .................................................................................................................................................13

Identification Cards/ Enrollment Confirmation ................................................................................................................13

Where You Get Covered Care ...........................................................................................................................................13

Plan Providers ...................................................................................................................................................................13

In-Network ........................................................................................................................................................................13

Out-of-Network .................................................................................................................................................................13

Emergency Services ..........................................................................................................................................................13

Pre-Determination .............................................................................................................................................................13

FEHB First Payor ..............................................................................................................................................................13

Coordination of Benefits ...................................................................................................................................................14

Rating Areas ......................................................................................................................................................................15

Limited Access Area .........................................................................................................................................................15

Alternate Benefit ...............................................................................................................................................................15

Dental Review ...................................................................................................................................................................15

Section 4 Your Cost For Covered Services .................................................................................................................................16

Section 5 Dental Services and Supplies Class A Basic ...............................................................................................................18

Class B Intermediate ...................................................................................................................................................................21

Class C Major ..............................................................................................................................................................................25

Class D Orthodontic ....................................................................................................................................................................33

1 2024 United Concordia Dental Enroll at www.BENEFEDS.com

General Services .........................................................................................................................................................................35

Section 6 International Services and Supplies ............................................................................................................................37

Section 7 General Exclusions – Things We Do Not Cover .........................................................................................................38

Section 8 Claims Filing and Disputed Claims Processes ............................................................................................................40

Section 9 Definitions of Terms We Use in This Brochure ..........................................................................................................41

Non-FEDVIP Benefits Available to Members ............................................................................................................................43

Stop Health Care Fraud! .............................................................................................................................................................45

Summary of Benefits ..................................................................................................................................................................46

Rate Information .........................................................................................................................................................................50

2 2024 United Concordia Dental Enroll at www.BENEFEDS.com

FEDVIP Program Highlights

You can select from several nationwide, and in some areas, regional dental Preferred

Provider Organization (PPO) or Health Maintenance Organization (HMO) plans, and high

and standard coverage options. You can also select from several nationwide vision plans.

You may enroll in a dental plan or a vision plan, or both. Some TRICARE beneficiaries

may not be eligible to enroll in both. Visit www.opm.gov/dental or

www.opm.gov/vision for more information.

A Choice of Plans and

Options

You enroll online at www.BENEFEDS.com. Please see Section 2, Enrollment, for more

information.

Enroll Through

BENEFEDS

If you or one of your family members is enrolled in or covered by one FEDVIP plan, that

person cannot be enrolled in or covered as a family member by another FEDVIP plan

offering the same type of coverage; i.e., you (or covered family members) cannot be

covered by two FEDVIP dental plans or two FEDVIP vision plans.

Dual Enrollment

If you sign up for a dental and/or vision plan during the 2023 Open Season, your coverage

begins on January 1, 2024. Premium deductions start with the first full pay period

beginning on/after January 1, 2024. You may use your benefits as soon as your

enrollment is confirmed.

Coverage Effective Date

Employees automatically pay premiums through payroll deductions using pre-tax dollars.

Annuitants automatically pay premiums through annuity deductions using post-tax

dollars. TRICARE enrollees automatically pay premiums through payroll deduction or

automatic bank withdrawal (ABW) using post-tax dollars.

Pre-Tax Salary Deduction

for Employees

Each year, an Open Season will be held, during which you may enroll or change your

dental and/or vision plan enrollment. This year, Open Season runs from November 13,

2023 through midnight EST December 11, 2023. You do not need to re-enroll each Open

Season unless you wish to change plans or plan options; your coverage will continue from

the previous year. In addition to the annual Open Season, there are certain events that

allow you to make specific types of enrollment changes throughout the year. Please see

Section 2, Enrollment, for more information.

Annual Enrollment

Opportunity

Your enrollment or your eligibility to enroll may continue after retirement. You do not

need to be enrolled in FEDVIP for any length of time to continue enrollment into

retirement. Your family members may also be able to continue enrollment after your

death. Please see Section 1, Eligibility, for more information.

Continued Group

Coverage After

Retirement

FEDVIP abides by the Current Dental Terminology (CDT) codification system in

accordance with standards set by the American Dental Association (ADA).

Current Dental Terminology (CDT)

reserved.

Compliance with the

American Dental

Association (ADA)

3 2024 United Concordia Dental Enroll at www.BENEFEDS.com

How We've Changed for 2024

How we have changed for 2024:

Procedure code D9230 has been added as a covered benefit.

D9230 - Inhalation of nitrous oxide/analgesia, anxiolysis,

eligible for children aged 12 and under based on dental necessity

and for members over 12 years with special needs/intellectual and developmental disabilities.

4 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Section 1 Eligibility

If you are a Federal or U.S. Postal Service employee, you are eligible to enroll in FEDVIP,

if you are eligible for the Federal Employees Health Benefits (FEHB) Program or the

Health Insurance Marketplace (Exchange) and your position is not excluded by law or

regulation, you are eligible to enroll in FEDVIP. Enrollment in the FEHB Program or a

Health Insurance Marketplace (Exchange) plan is not required.

Federal Employees

Certain temporary, intermittent, and seasonal Federal and U.S. Postal Service employees

are now eligible to enroll in FEDVIP. To be eligible, these employees must be expected to

work 130 hours per calendar month for at least 90 days. In addition, certain firefighters

hired under a temporary appointment and intermittent emergency response personnel are

eligible to enroll in FEDVIP. The employing agency must determine and notify these

employees of their eligibility.

Temporary / Seasonal

Employees

You are eligible to enroll if you:

• retired on an immediate annuity under the Civil Service Retirement System (CSRS),

the Federal Employees Retirement System (FERS) or another retirement system for

employees of the Federal Government;

• retired for disability under CSRS, FERS, or another retirement system for employees

of the Federal Government.

Your FEDVIP enrollment will continue into retirement, if you retire on an immediate

annuity or for disability under CSRS, FERS or another retirement system for employees

of the Government, regardless of the length of time you had FEDVIP coverage as an

employee. There is no requirement to have coverage for 5 years of service prior to

retirement in order to continue coverage into retirement, as there is with the FEHB

Program.

Your FEDVIP coverage ends if you retire on a Minimum Retirement Age (MRA) + 10

retirement and postpone receipt of your annuity. You may enroll in FEDVIP again when

you begin to receive your annuity.

Federal Annuitants

If you are a survivor of a deceased Federal/U.S. Postal Service employee or annuitant and

you are receiving an annuity, you may enroll or continue the existing enrollment.

Survivor Annuitants

A compensationer is someone receiving monthly compensation from the Department of

Labor’s Office of Workers’ Compensation Programs (OWCP) due to an on-the-job injury/

illness who is determined by the Secretary of Labor to be unable to return to duty. You are

eligible to enroll in FEDVIP or continue FEDVIP enrollment into compensation status.

Compensationers

An individual who is eligible for FEDVIP dental coverage based on the individual's

eligibility to previously be covered under the TRICARE Retiree Dental Program or an

individual eligible for FEDVIP vision coverage based on the individual's enrollment in a

specified TRICARE health plan. Retired members of uniformed services and National

Guard/Reserve components, including "gray-area" retirees under age 60 and their families

are eligible for FEDVIP dental coverage. These individuals, if enrolled in a TRICARE

health plan, are also eligible for FEDVIP vision coverage. In addition, uniformed services

active duty family members who are enrolled in a TRICARE health plan are eligible for

FEDVIP vision coverage.

TRICARE-eligible

individual

5 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Except with respect to TRICARE-eligible individuals, family members include your

spouse and unmarried dependent children under age 22. This includes legally adopted

children and recognized natural children who meet certain dependency requirements.

This also includes stepchildren and foster children who live with you in a regular parent-

child relationship. Under certain circumstances, you may also continue coverage for a

disabled child 22 years of age or older who is incapable of self-support. FEDVIP rules

and FEHB rules for family member eligibility are NOT the same. For more information

on family member eligibility visit the website at

www.opm.gov/healthcare-insurance/dental-vision/ or contact your employing agency or

retirement system.

With respect to TRICARE-eligible individuals, family members include your spouse,

unremarried widow, unremarried widower, unmarried child, and certain unmarried

persons placed in your legal custody by a court. Children include legally adopted

children, stepchildren, and pre-adoptive children. Children and dependent unmarried

persons must be under age 21 if they are not a student, under age 23 if they are a full-time

student or incapable of self-support because of a mental or physical incapacity.

Family Members

The following persons are not eligible to enroll in FEDVIP, regardless of FEHB eligibility

or receipt of an annuity or portion of an annuity:

• Deferred annuitants

• Former spouses of employees or annuitants. Note: Former spouses of TRICARE-

eligible individuals may enroll in a FEDVIP vision plan.

• FEHB Temporary Continuation of Coverage (TCC) enrollees

• Anyone receiving an insurable interest annuity who is not also an eligible family

member

• Active duty uniformed service members. Note: If you are an active duty uniformed

service member, your dental and vision coverage will be provided by TRICARE.

Your family members will still be eligible to enroll in the TRICARE Dental Plan

(TDP).

Not Eligible

6 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Section 2 Enrollment

You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan. BENEFEDS

is a secure enrollment website (www.BENEFEDS.com) sponsored by OPM. If you do not

have access to a computer, call 1-877-888-FEDS (1-877-888-3337), TTY number

1-877-889-5680 to enroll or change your enrollment.

If you are currently enrolled in FEDVIP and do not want to change plans, your enrollment will

continue automatically. Please Note: your plans’ premiums may change for 2024.

Note: You cannot enroll or change enrollment in a FEDVIP plan using the Health Benefits

Election Form (SF 2809) or through an agency self-service system, such as Employee Express,

PostalEase, EBIS, MyPay, or Employee Personal Page. However, those sites may provide a link

to BENEFEDS.

Enroll Through

BENEFEDS

Self Only: A Self Only enrollment covers only you as the enrolled employee or annuitant. You

may choose a Self Only enrollment even though you have a family; however, your family

members are not covered under FEDVIP.

Self Plus One: A Self Plus One enrollment covers you as the enrolled employee or annuitant

plus one eligible family member whom you specify. You may choose a Self Plus One

enrollment even though you have additional eligible family members; however, the additional

family members are not covered under FEDVIP.

Self and Family: A Self and Family enrollment covers you as the enrolled employee or

annuitant and all of your eligible family members. You must list all eligible family members

when enrolling.

Enrollment Types

If you or one of your family members is enrolled in or covered by one FEDVIP plan, that person

cannot be enrolled in or covered as a family member by another FEDVIP plan offering the same

type of coverage; i.e., you (or covered family members) cannot be covered by two FEDVIP

dental plans or two FEDVIP vision plans.

Dual Enrollment

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual, you may enroll in a

dental and/or vision plan during the November 13, through midnight EST, December 11, 2023

Open Season. Coverage is effective January 1, 2024.

During future annual Open Seasons, you may enroll in a plan, or change or cancel your dental

and/or vision coverage. The effective date of these Open Season enrollments and changes will

be set by OPM. If you want to continue your current enrollment, do nothing. Your

enrollment carries over from year to year, unless you change it.

New hire/Newly eligible

You may enroll within 60 days after you become eligible as:

• a new employee;

• a previously ineligible employee who transferred to a covered position;

• a survivor annuitant if not already covered under FEDVIP; or

• an employee returning to service following a break in service of at least 31 days.

• a TRICARE-eligible individual

Your enrollment will be effective the first day of the pay period following the one in which

BENEFEDS receives and confirms your enrollment.

Opportunities to

Enroll or Change

Enrollment

Qualifying Life Event

A qualifying life event (QLE) is an event that allows you to enroll or change your enrollment

outside of an Open Season.

7 2024 United Concordia Dental Enroll at www.BENEFEDS.com

The following chart lists the QLEs and the enrollment actions you may take:

Qualifying Life Event: Marriage

From Not Enrolled to Enrolled: Yes

Increase Enrollment Type: Yes

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: Yes

Qualifying Life Event: Acquiring an eligible family member (non-spouse)

From Not Enrolled to Enrolled: No

Increase Enrollment Type: Yes

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Losing a covered family member

From Not Enrolled to Enrolled: No

Increase Enrollment Type: No

Decrease Enrollment Type: Yes

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Losing other dental/vision coverage (eligible or covered person)

From Not Enrolled to Enrolled: Yes

Increase Enrollment Type: Yes

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Moving out of regional plan's service area

From Not Enrolled to Enrolled: No

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: Yes

Qualifying Life Event: Going on active military duty, non- pay status (enrollee or spouse)

From Not Enrolled to Enrolled: No

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: Yes

Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from active military duty (enrollee or

spouse)

From Not Enrolled to Enrolled: Yes

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from Leave without pay

From Not Enrolled to Enrolled: Yes (if enrollment cancelled during LWOP)

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: Yes (if enrollment cancelled during LWOP)

8 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Qualifying Life Event: Annuity/ compensation restored

From Not Enrolled to Enrolled: Yes

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Transferring to an eligible position*

From Not Enrolled to Enrolled: No

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: Yes

Change from One Plan to Another: No

*Position must be in a Federal agency that provides dental and/or vision coverage with 50

percent or more employer-paid premium.

The timeframe for requesting a QLE change is from 31 days before to 60 days after the event.

There are two exceptions:

• There is no time limit for a change based on moving from a regional plan’s service area and

• You cannot request a new enrollment based on a QLE before the QLE occurs, except for

enrollment because of the loss of dental or vision insurance. You must make the change no

later than 60 days after the event.

Opportunities to Enroll or Change Enrollment

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual (TEI), you may

enroll in a dental and/or vision plan during the November 13, through midnight EST December

11, 2023, Open Season. Coverage is effective January 1, 2024.

During future annual Open Seasons, you may enroll in a plan, or change or cancel your dental

and/or vision coverage. The effective date of these Open Season enrollments and changes will be

set by OPM. If you want to continue your current enrollment, do nothing. Your enrollment

carries over from year to year, unless you change it.

New hire/Newly eligible

You may enroll within 60 days after you become eligible as:

• a new employee;

• a previously ineligible employee who transferred to a covered position;

• a survivor annuitant if not already covered under FEDVIP; or

• an employee returning to service following a break in service of at least 31 days.

• a TRICARE-eligible individual

Your enrollment will be effective the first day of the pay period following the one in which

BENEFEDS receives and confirms your enrollment.

Qualifying Life Event

A qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled,

allows you to change your enrollment outside of an Open Season.

The following chart lists the QLEs and the enrollment actions you may take.

Qualifying Life Event: From Not Enrolled to Enrolled: Yes

Increase Enrollment Type: Yes

9 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Moving out of regional plan's service area

From Not Enrolled to Enrolled: No

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: Yes

Qualifying Life Event: Going on active military duty, non- pay status (enrollee or spouse)

From Not Enrolled to Enrolled: No

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: Yes

Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from active military duty (enrollee or

spouse)

From Not Enrolled to Enrolled: Yes

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from Leave without pay

From Not Enrolled to Enrolled: Yes (if enrollment cancelled during LWOP)

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: Yes (if enrollment cancelled during LWOP)

Qualifying Life Event: Annuity/ compensation restored

From Not Enrolled to Enrolled: Yes

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: No

Change from One Plan to Another: No

Qualifying Life Event: Transferring to an eligible position*

10 2024 United Concordia Dental Enroll at www.BENEFEDS.com

From Not Enrolled to Enrolled: No

Increase Enrollment Type: No

Decrease Enrollment Type: No

Cancel: Yes

Change from One Plan to Another: No

*Position must be in a Federal agency that provides dental and/or vision coverage with 50

percent or more employer-paid premium and you elect to enroll.

The timeframe for requesting a QLE change is from 31 days before to 60 days after the event.

There are two exceptions:

• There is no time limit for a change based on moving from a regional plan’s service area; and

• You cannot request a new enrollment based on a QLE before the QLE occurs, except for

enrollment because of a loss of dental or vision insurance. You must make the change no later

than 60 days after the event.

Enrollments and enrollment changes made based on a QLE are effective on the first day of the

pay period following the one in which BENEFEDS receives the enrollment or change.

BENEFEDS will send you confirmation of your new coverage effective date.

Once you enroll in a plan, your 60-day window for that type of plan ends, even if 60 calendar

days have not yet elapsed. That means once you have enrolled in either plan, you cannot change

or cancel that particular enrollment until the next Open Season, unless you experience a QLE

that allows such a change or cancellation.

VA Exception for Cancellation

Generally, you may cancel your enrollment only during the annual Open Season. However, if

you are a FEDVIP enrollee paying premiums on a post-tax basis, and you, your family member,

or TEI family member becomes eligible for VA dental or vision benefits, then you may change

your enrollment type or cancel your enrollment within 60 days of receiving notification of VA

dental or vision eligibility. This 60-day period may fall outside of open season. VA dental or

vision eligibility documentation must be submitted to OPM via the BENEFEDS mailbox

([email protected]) within 60 days of notification to support the FEDVIP enrollment

change or cancellation.

Your cancellation is effective at the end of the day before the date OPM sets as the Open Season

effective date. An eligible family member’s coverage also ends upon the effective date of the

cancellation.

If you are a FEDVIP enrollee paying premiums on a pre-tax basis, and you, your family

member, or TEI family member becomes eligible for VA dental or vision benefits, then you may

not change or cancel your FEDVIP enrollment until the next open season.

FEDVIP enrollees can verify if they are paying their premiums on a pre- or post-tax basis by

contacting BENEFEDS at 1-877-888-3337, TTY number 1-877-889-5680.

Coverage ends for active and retired Federal, U.S. Postal employees, and TRICARE-eligible

individuals when you:

• no longer meet the definition of an eligible employee, annuitant, or TRICARE-eligible

individual;

• as a Retired Reservist you begin active duty;

• as sponsor or primary enrollee leaves active duty

• begin a period of non-pay status or pay that is insufficient to have your FEDVIP premiums

withheld and you do not make direct premium payments to BENEFEDS;

When Coverage

Stops

11 2024 United Concordia Dental Enroll at www.BENEFEDS.com

• are making direct premium payments to BENEFEDS and you stop making the payments;

• cancel the enrollment during Open Season;

• a Retired Reservist begins active duty; or

• the sponsor or primary enrollee leaves active duty.

Coverage for a family member ends when:

• you as the enrollee lose coverage; or

• the family member no longer meets the definition of an eligible family member.

Under FEDVIP, there is no 31-day extension of coverage. The following are also

NOT available under the FEDVIP plans

• Temporary Continuation of Coverage (TCC);

• spouse equity coverage; or

• right to convert to an individual policy (conversion policy).

Continuation of

Coverage

If you are planning to enroll in an FSAFEDS Health Care Flexible Spending Account (HCFSA)

or Limited Expense Health Care Flexible Spending Account (LEX HCFSA), you should

consider how coverage under a FEDVIP plan will affect your annual expenses, and thus the

amount that you should allot to an FSAFEDS account. Please note that insurance premiums are

not eligible expenses for either type of FSA.

Please review IRS - Publication 969, Health Savings Accounts and Other Tax-Favored Health

Plans (https://www.irs.gov/forms-pubs/about-publication-969) for additional information about

carryover and contribution amounts for the upcoming tax year. If you have an HCFSA or LEX

HCFSA FSAFEDS account and you have not exhausted your funds by December 31st of the

plan year, FSAFEDS can automatically carry over a set maximum amount of unspent funds into

another health care or limited expense account for the subsequent year. To be eligible for

carryover, you must be employed by an agency that participates in FSAFEDS and actively

making allotments from your pay through December 31st. You must also actively re-enroll in a

health care or limited expense account during the next Open Season to be carryover eligible.

Your re-enrollment must meet the minimum contribution amount for the plan year. If you do not

re-enroll, or if you are not employed by an agency that participates in FSAFEDS and actively

making allotments from your pay through December 31st, your funds will not be carried over.

Because of the tax benefits an FSA provides, the IRS requires that you forfeit any money for

which you did not incur an eligible expense and file a claim in the time permitted. This is known

as the “Use-it-or-Lose-it” rule. Carefully consider the amount you will elect.

Current FSAFEDS participants must re-enroll to participate in the program next year.

See https://www.fsafeds.com or call 1-877-FSAFEDS (372-3337) or TTY:

1-866-353-8058. Note: FSAFEDS is not open to retired employees or to TRICARE eligible

individuals.

If you enroll or are enrolled in a high deductible health plan with a health savings account

(HSA) or health reimbursement arrangement (HRA), you may use your HSA or HRA to pay for

qualified dental/vision costs not covered by your FEHB and/or FEDVIP plans.

FSAFEDS/High

Deductible Health

Plans and FEDVIP

12 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Section 3 How You Obtain Care

You receive an identification card (two cards if you enroll under the Self Plus One or Self

and Family options), which will serve as confirmation of your enrollment. The ID card is

neither a guarantee of benefits nor does your provider need it to render dental services.

Your dentist may call 1-877-394-8224 to confirm your enrollment in the plan and the

benefits available to you. You may print an ID card at www.uccifedvip.com.

It is important to bring your FEDVIP and FEHB identification cards to every dental

appointment because most FEHB plans offer some level of dental benefits separate from

your FEDVIP coverage. Presenting both identification cards can ensure that you receive

the maximum allowable benefit under each Program.

Identification Cards/

Enrollment

Confirmation

You can receive care from any licensed dentist in the United States. However, when you

use a participating provider, your out-of-pocket costs may be lower.

Where You Get Covered

Care

We list plan providers in the provider directory, which we update weekly. The list is

available on our website at: www.uccifedvip.com or by calling FEDVIP customer service

at 1-877-FYI-UCCI (1-877-394-8224).

Plan Providers

In-network care is provided by a participating dentist in United Concordia’s Federal

Dental Program Network. You can locate a participating provider by visiting our website

at www.uccifedvip.com, or by calling FEDVIP customer service at 1-877-FYI-

UCCI (1-877-394-8224)

In-Network

The plan allows for Out-of-Network benefits. The allowable charge will be based on

United Concordia’s Maximum Allowable Charge. A member will pay the coinsurance

plus the difference between the allowed amount and the out-of-network provider’s charge.

Out-of-Network

All expenses for emergency services are payable as any other expense. If you receive

services from an out-of-network dentist, benefits will be paid under the out-of-network

plan provisions. You are responsible for the difference between the allowed amount and

the providers charge.

Emergency Services

Pre-determination is not necessary under this Plan. However, we do recommend that you

request a pre-determination of benefits for more extensive treatments. This will assure

both you and your dentist that the service is covered and indicate how much you can

expect to pay out-of-pocket.

Pre-Determination

When you visit a provider who participates with both, your FEHB plan and your FEDVIP

plan, the FEHB plan will pay benefits first. The FEDVIP plan allowance will be the

prevailing charge in these cases. You are responsible for the difference between the FEHB

and FEDVIP benefit payments and the FEDVIP plan allowance. United Concordia

Dental is responsible for facilitating the process with the FEHB first payor. United

Concordia will coordinate benefits not to exceed members responsibility and will not pay

more than the member is responsible for.

Please ask your dentist to submit the charges to your FEHB plan. Please note that it is not

your responsibility to submit any claim information or an explanation of benefits (EOB)

to United Concordia Dental.

United Concordia Dental may send you a letter asking for other insurance carrier

information if we have an indication of other insurance (but not the carrier details) in

order to determine the first payor. Any claims received during the questionnaire process

are pended for return of the letter providing other insurance information.

It is important to bring your FEDVIP and FEHB identification cards to every dental

appointment because most FEHB plans offer some level of dental benefits separate from

your FEDVIP coverage. Presenting both identification cards can ensure that you receive

the maximum allowable benefit under each Program.

FEHB First Payor

13 2024 United Concordia Dental Enroll at www.BENEFEDS.com

First Payor Example:

When the covered individual has FEHB coverage that offers dental benefits, United

Concordia is always secondary to the FEHB carrier

Services were performed by an In-Network provider

Dentist submitted charge for a one surface amalgam filling: $105.00

In-Network allowance of the Primary Plan: $65.00

FEHB paid as primary carrier ($24.00 applied to coinsurance): $41.00 ($65.00 - $24.00)

United Concordia Allowance: $60.00

United Concordia benefits payable in the absence of other insurance (United Concordia as

primary): $48.00 ($60.00 at 80%)

Payment by United Concordia: $19.00 ($60.00 - $41.00)

Patient’s responsibility to the dentist: $0.00 ($60.00 - $41.00 - $19.00)

United Concordia Dental coordinates benefit payments with non-FEHB carriers. If you

are the policy holder for both FEDVIP and a commercial carrier, the plan that has been in

effect the longest is primary. We also coordinate benefit payments with any other group

health benefits coverage you may have and the payment of dental costs under no-fault

insurance that pays benefits without regard to fault.

United Concordia Dental is the primary payor if we do not have an indication of other

insurance on our enrollment files and there is no indication of other insurance on the claim

form.

COB In-Network Examples:

When United Concordia is secondary to a Non-FEHB dental carrier

Services were performed by an In-Network provider

Provider submitted charge for a two surface amalgam filling: $131.00

In Network allowance of the Primary Plan: $70.00

Payable by Primary Carrier ($5.00 applied to coinsurance): $65.00 ($70.00 - $5.00)

United Concordia Allowance: $60.00

United Concordia benefit in absence of other insurance (United Concordia as primary):

$48.00 ($60.00 at 80%)

Payable by United Concordia (The total payment by the primary and secondary plan

cannot exceed the provider charge): $5.00 ($70.00 - $65.00)

Patient responsibility: $0.00 ($70.00 - $65.00 - $5.00)

COB Out-of-Network Examples:

When the covered individual has FEHB coverage that offers dental benefits, United

Concordia is always secondary to the FEHB carrier

Services were performed by an Out-of-Network Provider.

Provider submitted charge for a one surface amalgam filling: $105.00

In Network allowance of the Primary Plan: N/A

FEHB paid as primary carrier ($24.00 applied to coinsurance): $41.00

United Concordia's Maximum Allowable Charge: $80.00

United Concordia benefits payable in the absence of other insurance (United Concordia as

primary): $48.00 ($80.00 at 60%)

Payment by United Concordia: $48.00

Patient’s responsibility to the provider: $16.00 ($105.00 - $41.00 - $48.00). Since the

provider does not participate in either network, the provider is allowed to balance bill the

member.

Coordination of Benefits

14 2024 United Concordia Dental Enroll at www.BENEFEDS.com

When United Concordia is secondary to a Non-FEHB dental carrier

Services were performed by an Out-of-Network provider

Provider submitted charge for a two surface amalgam filling: $131.00

In Network allowance of the Primary Plan: N/A

Payable by Primary Carrier ($5.00 applied to coinsurance): $65.00

United Concordia's Maximum Allowable Charge: $80.00

United Concordia benefit in absence of other insurance (United Concordia as primary):

$48.00 ($80.00 at 60%)

Payable by United Concordia (The total payment by the primary and secondary plan

cannot exceed the provider charge): $48.00

Patient responsibility: $18.00 ($131.00 - $65.00 - $48.00). Since the provider does not

participate in either network, the provider is allowed to balance bill the member.

Your rates are determined based on where you live. This is called a rating area. If you

move, you must update your address through BENEFEDS. Your rates may change

because of the move.

Rating Areas

If you live in a limited access area and you receive covered services from an out-of-

network provider, we could pay benefits based on our in network plan allowance and

coinsurance. This is dependent on the applicable co-insurance, plan maximums and other

benefit features that apply. You are responsible for any difference between the amount

billed and our payment. To find out if you are in a limited access area, please call United

Concordia's customer service representatives at 1-877-FYI-UCCI (1-877-394-8224)

Monday - Friday, 8 a.m. to 8 p.m., ET.

Limited Access Area

The alternate benefit provision determines how payment is made when there are two or

more clinically acceptable covered dental services available to satisfactorily correct the

same dental condition. This provision states that United Concordia provides the

allowance for the less expensive service available, while still ensuring that you receive the

quality care you need. Should the member and the dentist choose the more expensive

treatment, the member is responsible for the additional charges beyond the allowance for

the alternate service, even if an in-network provider.

Situations where this provision may apply include a composite filling may be the alternate

benefit for a porcelain/ceramic inlay.

Alternate Benefit

United Concordia Dental reviews claims that report single crowns, onlays, fixed

bridgework, impacted third molars, operative periodontics, scaling and root planing or

services that are of a complex or questionable nature. Your dentist must submit

supporting documentation such as x-rays or charting that are required for certain services.

All claims submitted for periodontal soft tissue grafts will require submission of

diagnostic materials and Advisor review. The following diagnostic materials must be

submitted for review:

1. Periodontal charting completed within the past 12 months of the areas(s) being treated,

which must include:

a. Pocket depths; b. Amount of recession measured from the CEJ to the gingival

margin; c.An indication of the amount of keratinized gingiva remaining.

2. A narrative (statement) explaining the reason why the graft(s) is needed.

Dental Review

15 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Section 4 Your Cost For Covered Services

This is what you will pay out-of-pocket for covered care:

Coinsurance is the percentage of our allowance that you must pay for your care. The

allowance will be based on United Concordia Dental’s Maximum Allowable Charge.

For the High Option your coinsurance is as follows:

Class A

In-Network High Option: 0%

Out-of-Network Standard Option: 20%

Class B

In-Network High Option: 20%

Out-of-Network High Option: 40%

Class C

In-Network High Option: 50%

Out-of-Network High Option: 60%

Orthodontics

In-Network High Option: 50%

Out-of-Network High Option: 50%

For the Standard Option your coinsurance is as follows:

Class A

In-Network Standard Option: 0%

Out-of-Network Standard Option: 40%

Class B

In-Network Standard Option: 45%

Out-of-Network Standard Option: 60%

Class C

In-Network Standard Option: 65%

Out-of-Network Standard Option: 80%

Orthodontics

In-Network Standard Option: 50%

Out-of-Network Standard Option: 50%

Coinsurance

For the High Option our Plan includes an Unlimited annual benefit maximum per covered

person for combined Class A, B and C covered services, excluding implant related

services. Implant related Services have a $2500 annual maximum per covered person.

For the Standard Option our Plan includes a $1,500 annual benefit maximum per covered

person for combined Class A, B and C covered services.

Annual Benefit

Maximum

For the High Option, our Plan includes a lifetime benefit maximum of $3,000 per covered

person for Class D orthodontic services and a lifetime benefit maximum of $2,000 per

covered person for dental accident services. Once you reach this amount, you are

responsible for all charges for these services.

For the Standard Option, our Plan includes a lifetime benefit maximum of $2,000 per

covered person for Class D orthodontic services and a lifetime benefit maximum of

$2,000 per covered person for dental accident services. Once you reach this amount, you

are responsible for all charges for these services.

Lifetime Benefit

Maximum

16 2024 United Concordia Dental Enroll at www.BENEFEDS.com

In-network services are services performed by a dentist who is part of United Concordia’s

Federal Dental Program Network. Using a participating dentist may result in lower out-of

pocket-costs. You can locate a participating dentist by visiting our website at

www.uccifedvip.com or by calling 1-877-FYI-UCCI (1-877-394-8224).

In-Network Services

You may use any licensed dentist; however, benefits received out-of-network could result

in higher out-of-pocket costs. A member will pay the coinsurance plus the difference

between the allowance amount and the out of network providers charge.

If you live in a limited access area, your benefits will be paid at the in-network

coinsurance level for covered services. You are responsible for any difference between

the amount billed and our payment. You can determine if you live in an underserved area

by visiting our website at www.uccifedvip.com or by calling 1-877-FYI-

UCCI (1-877-394-8224).

Out-of-Network Services

All expenses for emergency services are payable as all other expenses. If you receive

services from an out-of-network provider, you will be responsible for the difference

between the allowed amount and the provider's charge.

Emergency Services

A dental accident is an injury to sound natural teeth and supporting structures caused by a

violent external force such as a fall or blow to the mouth.

United Concordia pays 100% of the program allowance for covered services specifically

related to accidental dental injuries up to a lifetime maximum of $2,000. This benefit is

separate from the services through the High Option unlimited annual maximum and the

Standard Option $1,500 annual maximum. Further, benefits paid for covered services

related to the accident(s) in excess of $2,000 accrue to the annual benefit maximum.

For a complete list of services covered as dental accident services, call 1-877-FYI-

UCCI (1-877-394-8224).

Dental Accident

The amount we use to determine our payment for covered services. We determine our

Plan allowance as follows: for care rendered to members who reside in limited access

areas, the 75

percentile of Ingenix data for the provider’s location; for care provided to

members who live outside of the 50 states, the District of Columbia or Puerto Rico, the

percentile of Ingenix data for the District of Columbia.

Plan Allowance

In-progress treatment for dependents of retiring active-duty service members who were

enrolled in the TRICARE Dental Program (TDP) will be covered for the 2024 plan year;

regardless of any current plan exclusion for care initiated prior to the enrollee's effective

date.

This requirement includes assumption of payments for covered orthodontia services up to

the FEDVIP policy limits, and full payment where applicable up to the terms of FEDVIP

policy for covered services completed (but not initiated) in the 2024 plan year such as

crowns and implants.

In-Progress Treatment

17 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Section 5 Dental Services and Supplies

Class A Basic

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are necessary for the prevention, diagnosis,

care or treatment of a covered condition and meet generally accepted dental protocols.

•There is no calendar year deductible for the plan benefits.

•High Option annual benefit maximum is Unlimited per covered person.

•Standard Option annual benefit maximum is $1,500 per covered person.

You Pay:

High Option

•In-Network: 0%

•Out-of-Network: 20% coinsurance plus the difference between the allowed amount and the

provider’s charge.

Standard Option

•In-Network: 0%

•Out-of-Network: 40% coinsurance plus the difference between the allowed amount and the

provider’s charge.

Diagnostic and Treatment Services

D0120 Periodic oral evaluation –

Limited to two per calendar year in combination with D0150, D0180, D0145

D0140 Limited oral evaluation – problem focused –

Limited to one per patient per provider every 12 months

D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver -

two per calendar

year

D0150 Comprehensive oral evaluation – new or established patient –

two per calendar year in combination with D0120,

D0180, D0145

D0170 Re-evaluation - limited, problem focused,

integral to diagnostic procedures

D0171 Re-evaluation - post operative office visit,

integral to diagnostic procedures

D0180 Comprehensive periodontal evaluation – new or established patient –

two per calendar year in combination with

D0120, D0150, D0145

D0210 Intraoral – comprehensive series of radiographic images

D0220 Intraoral – periapical first radiographic image

D0230 Intraoral – periapical – each additional radiographic image

D0240 Intraoral – occlusal radiographic image

D0250 Extraoral – film

D0251 Extraoral-Posterior Dental Radiograph -

Limited to 1 per 12 month period. Not covered if related to TMJ.

D0270 Bitewing – single radiographic image

D0272 Bitewings – two radiographic image

D0273 Bitewings – three radiographic image

D0274 Bitewings – four radiographic image

D0277 Vertical bitewings – 7 to 8 radiographic image

D0330 Panoramic radiographic image

Current Dental Terminology

Diagnostic and Treatment Services - continued on next page

18 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Diagnostic and Treatment Services (cont.)

D0372 Intraoral tomosynthesis - comprehensive series of radiographic images -

alternate benefit of a D0210

D0373 Intraoral tomosynthesis - bitewing radiographic image -

alternate benefit of a D0270

D0374 Intraoral tomosynthesis - periapical radiographic image -

alternate benefit of a D0220

D0396 3D printing of a 3D dental surface scan -

Limited to one per lifetime

D0425 Caries susceptibility tests

D0460 Pulp vitality tests -

integral to diagnostic services

D0470 Diagnostic casts -

Limited to one per lifetime

D0601 Caries risk assessment and documentation, with a finding of low risk -

integral to diagnostic services

D0602 Caries risk assessment and documentation, with a finding of moderate risk -

integral to diagnostic services

D0603 Caries risk assessment and documentation, with a finding of high risk -

integral to diagnostic services

D0999 Unspecified diagnostic procedure

Preventive Services

D1110 Prophylaxis – adult –

Limited to two per calendar year; one additional cleaning during pregnancy when registered

in MyDentalBenefits

D1120 Prophylaxis – child –

Limited to two per calendar year

D1206 Topical application of fluoride varnish –

Limited to two per calendar year

D1208 Topical application of fluoride excluding varnish –

Limited to two per calendar year

D1301 Immunization Counseling -

Integral to preventive procedures

D1351 Sealant – per tooth –

Limited to permanent molars through age 18. One sealant per tooth in a 3-year period

D1352 Preventive resin restoration in moderate to high caries risk patient- permanent tooth

D1353 Sealant repair (per tooth)-

Limited to through age 18 on permanent molars and 1 per tooth per 3 years.

D1354 application of caries arresting medication application -

Limited to members age 1 through 6, 2 treatments per tooth

per 12 months; age 7 through 12, 1 treatment per 12 months

D1510 Space maintainer – fixed – unilateral, per quadrant, excludes distal shoe space maintainer –

Limited to one per

three years for members under age 19

D1516 Space maintainer-fixed-bilateral,maxillary-

Limited to one per three years for members under age 19

D1517 Space maintainer-fixed-bilateral,mandibular-

Limited to one per three years for members under age 19

D1520 Space maintainer – removable – unilateral, per quadrant –

Limited to one per three years for members under age 19

D1526 Space maintainer-removable-bilateral,maxillary –

Limited to one per three years for members under age 19

D1527 Space maintainer-removable-bilateral,mandibular –

Limited to one per three years for members under age 19

D1551 Re-cement or re-bond bilateral space maintainer, maxillary -

One per six months for members under age 19

D1552 Re-cement or re-bond bilateral space maintainer, mandibular -

One per six months for members under age 19

D1553 Re-cement or re-bond unilateral space maintainer, per quadrant -

One per six months for members under age 19

D1575 Distal shoe space maintainer- fixed unilateral,per quadrant -

Limited to one per three years for members under age

D2991 Application of hydroxyapatite - regeneration medicament per tooth -

Two per tooth per 12 months ages 1 thru 6; 1

per tooth per 12 months ages 7 thru 12

Additional Procedures covered as Basic Services

D9110 Palliative treatment of dental pain – per visit

D9310 Consultation - Diagnostic service provided by dentist or physician other than requesting dentist or physician

Limited to one per patient per Provider per 12 months in combination with limited evaluation (D0140)

D9311 Consultation with a medical health care professional -

Combination of D9310 and D9311 limited to one per patient

per Provider per 12 months

D1999 Unspecified preventive procedure, by report only

Current Dental Terminology

Additional Procedures covered as Basic Services - continued on next page

19 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Additional Procedures covered as Basic Services (cont.)

Not covered:

•

Plaque control programs

•

Oral hygiene instruction

•

Dietary instructions

•

Sealants for teeth other than permanent molars

•

Over-the-counter dental products, such as teeth whiteners,toothpaste,dental floss,special mouth rinses,fluoride rinses

•

Exams are allowed 2 in calendar year but they cannot be done on the same day by same provider

Current Dental Terminology

20 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Class B Intermediate

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are necessary for the prevention, diagnosis,

care or treatment of a covered condition and meet generally accepted dental protocols.

•Services listed may be subject to Dental Review or an Alternate Benefit may be paid.

•There is no calendar year deductible for the plan benefits.

•High Option annual benefit maximum is Unlimited per covered person.

•Standard Option annual benefit maximum is $1,500 per covered person.

•In-progress treatment for dependents of retiring TDP enrollees will be covered for the 2024 plan

year. This is regardless of any current plan exclusions for care initiated prior to the enrollee's

effective date.

You Pay:

High Option

•In-Network: 20% of our network allowance

•Out-of-Network: 40% coinsurance plus the difference between the allowed amount and the

provider’s charge.

Standard Option

•In-Network: 45% of our network allowance

•Out-of-Network: 60% coinsurance plus the difference between the allowed amount and the

provider’s charge.

Minor Restorative Services

D2140 Amalgam – one surface, primary or permanent –

Limited to one in 24 months for replacement restorations

D2150 Amalgam – two surfaces, primary or permanent –

Limited to one in 24 months for replacement restorations

D2160 Amalgam – three surfaces, primary or permanent –

Limited to one in 24 months for replacement restorations

D2161 Amalgam – four or more surfaces, primary or permanent –

Limited to one in 24 months for replacement

restorations

D2330 Resin–based composite – one surface, anterior –

Limited to one in 24 months for replacement restorations

D2331 Resin-based composite – two surfaces, anterior –

Limited to one in 24 months for replacement restorations

D2332 Resin-based composite – three surfaces, anterior –

Limited to one in 24 months for replacement restorations

D2335 Resin-based composite – four or more surfaces (anterior) –

Limited to one in 24 months for replacement

restorations

D2390 Resin based composite crown-anterior -

Limited to one per 24 months for replacement restorations

D2391 Resin-based composite-one surface-posterior

-Limited to one in 24 months for replacement restorations

D2392 Resin-based composite- two surfaces- posterior

- Limited to one in 24 months for replacement restorations

D2393 Resin-based composite- three surfaces- posterior

- Limited to one in 24 months for replacement restorations

D2394 Resin-based composite–four or more surfaces-posterior-

Limited to one in 24 months for replacement restorations

D2610 Inlay porcelain/ceramic one surface -

Alternate benefit applies ( See Section 4 How to Obtain Care, for definition)

D2620 Inlay porcelain/ceramic two surfaces -

Alternate benefit applies

(see Section 4 How to Obtain Care, for definition)

D2630 Inlay/porcelain/ceramic three surfaces or more -

Alternate benefit applies

(see Section 4 How to Obtain Care, for

definition)

Current Dental Terminology

Minor Restorative Services - continued on next page

21 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Minor Restorative Services (cont.)

D2910 Re-cement or re-bond inlay, onlay, partial coverage restoration –

One per 6 month period; integral within 12

months of the placement of prosthesis

D2915 Re-cement Inlay-

Limited to one per 3 years

D2920 Re-cement or re-bond crown –

One per 6 month period; integral within 12 months of the placement of prosthesis

D2921 Reattachment of tooth fragment -

Limited to one every 24 months

D2930 Prefabricated stainless steel crown – primary tooth –

Covered through age 14 –

Limited to one per patient, per

tooth, per lifetime

D2931 Prefabricated stainless steel crown – permanent tooth –

Covered through age 14 – Limited to one per patient, per

tooth, per lifetime

D2949 Restorative foundation for an indirect restoration -

integral

D2951 Pin retention – per tooth, in addition to restoration

Not Covered:

•

Restorations, including veneers, which are placed for cosmetic purposes only

•

Gold foil restorations

Endodontic Services

D3110 Pulp cap – direct(excluding final restoration) – Integral to restorative procedures

D3120 Pulp cap – indirect(excluding final restoration) – Integral to restorative procedures

D3220 Therapeutic pulpotomy (excluding final restoration)

D3221 Gross pulpal debridement primary & permanent – Integral to restorative procedures

D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development –

Limited to permanent

teeth only, one per tooth per lifetime

D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) –

Limited to primary

incisor teeth for members up to age 6, for primary molars and cuspids up to age 11, and is limited to one per tooth per

lifetime.

D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) –

Limited to primary

incisor teeth for members up to age 6, for primary molars and cuspids up to age 11, and is limited to one per tooth per

lifetime.

Periodontal Services

D4341 Periodontal scaling and root planing – four or more teeth per quadrant –

Limited to one periodontal surgical

procedure per 24 months per area of the mouth; requires submission of diagnostic materials

D4342 Periodontal scaling and root planing – one to three teeth per quadrant

– Limited to one periodontal surgical

procedure per 24 months per area of the mouth; requires submission of diagnostic materials

D4346 Scaling in presence of generalized moderate or severe gingival inflammation-full mouth oral evaluation-Covered

age 16 and older; once per 24 months. Combination of scaling with gingival inflammation and routine prophylaxis cannot

exceed 2 per calendar year.

D4910 Periodontal maintenance –

Limited to 4 periodontal cleanings and 2 routine cleanings within a calendar

year period; the total cannot exceed 4 in a calendar year

D4921 Gingival irrigation with a medicinal agent - per quadrant -

integral to periodontal services

D4999 Unspecified periodontal procedure

Smile for Health®-Wellness is included in the High and Standard Options. This provides enhanced benefits for members

with a qualifying condition. This includes coverage at 100% of our plan allowance for the following procedures: D4240,

D4241, D4260,D4261, D4341, D4342, D4346, and D4910. One additional service is allowed for D4910 and all other

frequency limitations apply. Members with the following conditions are eligible: Diabetes, Heart Disease, Cerebrovascular

Disease (Stroke), Oral Cancer, Lupus, Organ Transplant, and Rheumatoid Arthritis. Members with

those specific

conditions must be registered prior to receiving services and can register at www.uccifedvip.com under MyDenta

lBenefits.

Pregnancy benefit allows the same enhanced benefits during pregnancy for member who are registered in

MyDental

Benefits. All other frequency limitations apply.

Current Dental Terminology

22 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Prosthodontic Services

D5410 Adjust complete denture – maxillary –

Integral within 6 months of the initial or replacement denture

D5411 Adjust complete denture – mandibular –

Integral within 6 months of the initial or replacement denture

D5421 Adjust partial denture – maxillary –

Integral within 6 months of the initial or replacement denture

D5422 Adjust partial denture – mandibular –

Integral within 6 months of the initial or replacement denture

D5511 Repair broken complete denture base, mandibular

D5512 Repair broken complete denture base, maxillary

D5520 Replace missing or broken teeth – complete denture (each tooth)

D5611 Repair resin partial denture base, mandibular

D5612 Repair resin partial denture base, maxillary

D5621 Repair cast partial framework, mandibular

D5622 Repair cast partial framework, maxillary

D5630 Repair or replace broken retentive clasping materials - per tooth

D5640 Replace broken teeth – per tooth

D5650 Add tooth to existing partial denture -

one per arch per 36 months

D5660 Add clasp to existing partial denture- per tooth -

one per arch per 36 months

D5670 Replace all teeth and acrylic on cast metal framework (maxillary)-

one p

er 5 years

D5671 Replace all teeth and acrylic on cast metal framework (mandibular) -

one per 5 years

D5710 Rebase complete maxillary denture

– Limited to one in 36 months; integral within 6 months of the insertion of the

initial or replacement denture

D5711 Rebase complete mandibular denture

– Limited to one in 36 months; integral within 6 months of the insertion of the

initial or replacement denture

D5720 Rebase maxillary partial denture

– Limited to one in 36 months; integral within 6 months of the insertion of the

initial or replacement denture

D5721 Rebase mandibular partial denture

– Limited to one in 36 months; integral within 6 months of the insertion of the

initial or replacement denture

D5725 Rebase hybrid prosthesis -

Limited to one in 36 months; integral within 6 months of the insertion of the initial or

replacement denture

D5730 Reline complete maxillary denture (direct)

– Limited to one in 36 months; integral within 6 months of the insertion

of the initial or replacement denture

D5731 Reline complete mandibular denture (direct)

– Limited to one in 36 months; integral within 6 months of the

insertion of the initial or replacement denture

D5740 Reline maxillary partial denture (direct)

– Limited to one in 36 months; integral within 6 months of the insertion of

the initial or replacement denture

D5741 Reline mandibular partial denture (direct)

– Limited to one in 36 months; integral within 6 months of the insertion

of the initial or replacement denture

D5750 Reline complete maxillary denture (indirect)

– Limited to one in 36 months; integral within 6 months of the

insertion of the initial or replacement denture

D5751 Reline complete mandibular denture (indirect)

– Limited to one in 36 months; integral within 6 months of the

insertion of the initial or replacement denture

D5760 Reline maxillary partial denture (indirect)

– Limited to one in 36 months; integral within 6 months of the insertion

of the initial or replacement denture

D5761 Reline mandibular partial denture (indirect)

– Limited to one in 36 months; integral within 6 months of the insertion

of the initial or replacement denture

D5765 Soft liner for complete or partial removable denture-indirect -

Limited to one in 36 months; integral within 6

months of the insertion of the initial or replacement denture

D5850 Tissue conditioning (maxillary)

Current Dental Terminology

Prosthodontic Services - continued on next page

23 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Prosthodontic Services (cont.)

D5851 Tissue conditioning (mandibular)

D6089 Accessing and retorquing loose implant screw - per screw

D6092 Re-cement or re-bond implant/abutment support -

Limited to one per 6 month period; integral within 12 months of

the placement of prosthesis.

D6093 Re-cement or re-bond implant abutment supported fixed partial dentures -

Limited to one per 6 month period;

integral within 12 months of the placement of the prosthesis

D6930 Re-cement or re-bond fixed partial denture

– Limited to one per 6 month period; integral within 12 months of the

placement of prosthesis

D6980 Fixed partial denture repair, by report

Oral Surgery

D3921 Decoronation or submergence of erupted tooth

D7111 Extraction, Coronal remnants primary tooth

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

D7210 Extraction erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of

mucoperiosteal flap if indicated

D7220 Removal of impacted tooth – soft tissue

D7230 Removal of impacted tooth – partially bony

D7240 Removal of impacted tooth – completely bony

D7241 Removal of impacted tooth-completely bony,with unusual surgical complications

D7250 Removal of residual tooth roots (cutting procedure)

D7251 Coronectomy – intentional partial tooth removal, impacted teeth only

D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth

D7280 Exposure of an unerupted tooth,

one per tooth per lifetime.

D7310 Alveoloplasty in conjunction with extractions – per quadrant

D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

D7320 Alveoloplasty not in conjunction with extractions – per quadrant

D7321 Alveoloplasty not in conjunction with extractions–one to three teeth or tooth spaces,per quadrant

D7471 Removal of exostosis

D7510 Incision and drainage of abscess – intraoral soft tissue

D7910 Suture of recent small wounds up to 5 cm

D7921 Collection and application of autologous blood concentrate product

D7922 Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site -

integral to oral

surgery services

D7971 Excision of pericoronal gingiva

Current Dental Terminology

24 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Class C Major

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are necessary for the prevention, diagnosis,

care or treatment of a covered condition and meet generally accepted dental protocols.

•Services listed may be subject to Dental Review or an Alternate Benefit allowance may be paid.

•All claims submitted for periodontal soft tissue grafts will require submission of diagnostic

materials and Advisor review.

The following diagnostic materials must be submitted for review:

1. Periodontal charting completed within the past 12 months of the areas(s) being

treated, which must include:

a. Pocket depths

b. Amount of recession measured from the CEJ to the gingival margin

c. An indication of the amount of keratinized gingiva remaining

2. A narrative (statement) explaining the reason why the graft(s) is needed.

•There is no calendar year deductible for the plan benefits.

•The High Option annual benefit maximum is Unlimited per covered person, with the exception of

Implant services.

•Implant services in the High Option are limited to an annual maximum of $2,500 per covered

person.

•The Standard Option annual benefit maximum is $1,500 per covered person.

•In-progress treatment for dependents of retiring TDP enrollees will be covered for the 2024 plan

year. This is regardless of any current plan exclusions for care initiated prior to the enrollee's

effective date.

You Pay:

High Option

•In-Network: 50% of our network allowance

•Out-of-Network: 60% coinsurance plus the difference between the allowed amount and the

provider’s charge.

Standard Option

•In-Network: 65% of our network allowance

•Out-of-Network: 80% coinsurance plus the difference between the allowed amount and the

provider’s charge.

25 2024 United Concordia Dental Enroll at www.BENEFEDS.com

Major Restorative Services

D0160 Detailed and extensive oral evaluation – problem focused, by report –

Limited to one per patient per provider per

lifetime

D2510 Inlays – metallic – one surface –