MY
BENEFITS
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Note: This benefit provided for Standard Plan (full) coverage only; no provision for “H” Plan (limited) coverage. 

Healthy teeth and gums are an important part of your overall health. That’s why the Plan will pay 100% of covered expenses for preventive dental services when you visit a United Concordia Dental provider for dental care. Your dental benefits network is with United Concordia Dental. Of course, you are free to visit any dentist you wish, but you can save yourself, your covered dependents, and the Plan money if you visit a dentist who participates in the United Concordia Dental Network. You also may locate a participating dental provider by visiting www.unitedconcordia.com. 

What You Need To Do

To find a participating provider, you may visit the United Concordia Dental  website (www.unitedconcordia.com). When you make your appointment, identify yourself as a member of the EWTF. Show the provider your EWTF ID card to be eligible for the PPO discounted rates. If you are having any dental service that is expected to cost more than $600, you must have your dentist complete a “treatment plan” form. These forms are available from the Fund Office.

Maximum Annual Benefit (Age 18 & Older)

The Plan pays for necessary dental care as described in this section, up to $3,000 per covered adult per calendar year. There is no dollar limitation for covered dental services rendered to an eligible patient under age 18.

Submitting your Dental Claims

When you use a United Concordia Dental provider, your dentist will submit your claims for you. All United Concordia Dental dental claims should be electronically transmitted to EDI# 30506 or mailed directly to:

United Concordia Companies, Inc.
Dental Claims
P.O. Box 69421
Harrisburg, PA 17106-9421

EWTF Group Number

The dental group number is 923997.

Non-PPO Dental Coverage

You are not required to visit a United Concordia network provider to receive dental care. If you visit a dentist who does not participate in the United Concordia network, you are responsible for payment of the amount the dentist charges above the network discounted rate in addition to your Patient’s Portion.

You may need to pay for services at the time you receive them and submit a claim form to apply for reimbursement. Send the completed claim form to United Concordia at the following address:

United Concordia Companies, Inc.
Dental Claims
P.O. Box 69421
Harrisburg, PA 17106-9421

Covered Preventive Services

Preventive Services are payable at 100% of the allowance when you visit a PPO provider, or 80% of the allowance when you visit a non-PPO provider, up to an annual maximum of $3,000 (except for dependent children under age 18). 

Covered Basic Dental Services

The schedule on page 12 shows the Basic Dental Services that are covered by this Plan. Most Basic Services are covered at 80% of the allowance, in or out of the network, up to an annual maximum of $3,000 (except for dependent children under age 18). Remember—if you visit a dentist who does not participate in the United Concordia Dental, you are responsible for charges above the allowance, if any. Refer to the Schedule of Benefits for a list of how dental services are paid.

Covered Major Dental Services

The schedule on page 12 shows the Major Dental Services that are covered by this Plan. If you use a United Concordia Dental provider, Major Services are covered at 80% of the allowance up to an annual maximum of $3,000 (except for dependent children under age 18). If you do not use a PPO provider, Major Services are covered at 50% of the allowance.

Covered Orthodontia Services

The Plan provides orthodontia services for members, spouses, and dependent children up to age 26 at 50% of the allowance up to a lifetime benefit of $3,000.

When a Treatment Plan is Required

You are required to submit a “treatment plan” or pre-authorization for Major Services provided by your dentist to United Concordia for prior approval when the cost of the treatment is expected to exceed $600. By submitting a proposed treatment plan in advance, both you and your dentist know what is covered under the Plan before the work is done. This also allows you to authorize direct payment to the dentist.

Continuing Treatment When Your Coverage Ends

If your dental care coverage terminates while you are undergoing certain treatments, your covered dental expenses for these treatments continue to be covered for up to 30 days. The types of treatments that are included under this provision are:

• An appliance or its modification for which an impression was taken prior to termination of dental benefits;
• A crown, bridge or gold restoration for which the tooth was prepared prior to termination of dental benefits; and
• Root canal therapy provided that the pulp chamber was opened prior to termination of dental benefits.

What’s Not Covered

Dental care benefits are not provided for: 

• Any dental care, treatment or supply not prescribed by or under the direction of a dentist;
• Replacement of a lost, stolen, or broken prosthetic device;
• Appliances or restoration for the purpose of splinting, increasing vertical dimension or restoring occlusion;
• Dental services and supplies rendered solely for cosmetic purposes, unless required as a result of an accidental injury sustained while covered under this Plan or unless specifically provided under another provision of this Plan;
• An appliance or its modification, a crown, bridge, or gold restoration, or root canal therapy for which the impression was made, the tooth was prepared, or the pulp chamber was opened prior to coverage under this Plan; 
• Replacement of an existing partial or full denture, splint or fixed bridgework; crowns and/or inlays installed as multiple abutments; splints for periodontal treatment; or prosthetic appliances, fixed or removable, used as an adjunct to periodontal treatment, unless satisfactory evidence is presented to the Fund that the existing denture or bridgework was installed at least 36 months prior to its replacement and the prosthetic appliance, fixed or removable, is required to replace a natural tooth; or
• Dental services or prosthetics, or the fitting of these items, other than as provided in the dental benefit, unless required due to an accidental injury.

Please see Specific Plan / Benefits Exclusions and General Plan Exclusions for an in-depth listing of your Plan’s exclusions.