For Active Employees

How can I find out whether I live in an HMO’s or prepaid dental plan’s service area?

Service areas are determined by zip code. You can get a list of HMO service area zip codes from the Administrative Office.
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Dental Expense Benefits

 

  PPO Plans Prepaid (HMO) Plans
Plan Administrator

CIGNA DPPO (Radius Network)

United Concordia

Dental Plan Option

High

Medium

Low

 

Annual Benefit Maximum

$2,500

$1,500

$1,500

None

Dental Preferred Provider

100%

100%

80%

Not Applicable

Preventive & Diagnostic Services

X-rays, Complete (including exam)

$85.00

$53.90

$45.00

No charge

X-rays, First Periapical

25.00

11.45

14.00

No charge

X-rays, Next Periapical

12.00

7.65

5.00

No charge

X-rays, 2 Bitewings (including exam)

36.00

19.10

15.00

No charge

X-rays, 4 Bitewings (including exam)

47.00

26.75

20.00

No charge

Prophylaxis, Adult

61.00

47.75

30.00

No charge

Prophylaxis, Child

60.00

38.20

30.00

No charge

Restorative Services

Amalgam, 1 Surface

$70.00

$43.55

$30.00

No charge

Amalgam, 2 Surfaces

85.00

55.45

40.00

No charge

Composite Resin, 1 Surface

100.00

51.50

40.00

No charge

Crown, Porcelain with Metal

650.00

412.80

300.00

$60.00 (plus cost of metal)

Other Services

Perio Scale

$175.00

$99.00

$40.00

No charge

Simple Extraction

85.00

43.55

30.00

No charge

Orthodontia (Adults & Children)

Refer to your Schedule of Benefits

$1,500 for children up to age 19, plus start up fees. $2,000 for adults plus start up fees. 2-year maximum length of treatment; additional usual and customary charges thereafter.

Filing a Claim

If you use a network dentist, the dentist's office will usually file the claim for you. If you use a non-network dentist, you will usually need to file a claim yourself. Call CIGNA Dental at 1-800-244-6224 to request a form. You should submit your claim within 90 days from the date you receive service.

You will need to provide

  • The date or dates the service was rendered;
  • The nature of the treatment plan and the type of service or supply furnished; and
  • The name, address, and signature of the dentist who provided the services.

Mail your completed claim form to the following address:

United Concordia Dental Claims
PO Box 69421
Harrisburg, PA 17106-9421