Download NCFlex Dental Benefit Comparison Worksheet

2016
NCFlex Dental Benefit Comparison Worksheet
The NCFlex dental plan is administered by United Concordia and underwritten by
United Concordia Life and Health Insurance Company
Compare Your Rates1
with NCFlex premium taken
out pre-tax, you save an
estimated 30%!
Employee Only
Employee & Spouse
Employe & Child
Employee & Children
Family (Spouse and Children)
Low Option
Pre-Tax
Low Option
Cost
Low Option
$21.22
$14.85
$10.61
$42.78
$29.95
$21.39
$41.04
$28.73
$20.52
$52.28
$36.60
$26.14
$73.22
$51.25
$36.61
Deduction amount based on . . .
12 pay periods / year
Low
Option
Pre-Tax
Cost
$7.43
$14.97
$14.36
$18.30
$25.63
24 pay periods / year
Type I—Diagnostic/Preventive Services
Oral Examinations, Cleanings, X-rays, Topical
100%
Fluoride, Sealants and Space Maintainers
Type II—Basic Services
Fillings, Simple Extractions
50%
General Anesthesia, Oral Surgery (wisdom teeth
50%
extractions)
Endodontics, Re-cement Crowns, Inlays, Bridges,
50%
Repair of Removable Dentures
Periodontic Services, Periodontal Maintenance
after Therapy
Type III—Major Services
Crowns, Dentures, Bridges, Fixed Bridge Repairs,
Not covered
Denture Adjustments/Relining
Implants
Not covered
Type IV—Orthodontics (dependent children up to age 19)
Diagnostic, Active, Retention Treatment
(dependent children up to age 19)
Not covered
High
Option
$18.44
$36.98
$35.48
$44.85
$65.29
12 pay periods / year
NCFlex
Low Option
BENEFIT CATEGORY3
High
Option
$36.88
$73.96
$70.96
$89.70
$130.58
High
Option
Pre-Tax
Cost
$25.82
$51.77
$49.67
$62.79
$91.41
NCFlex
High Option
High
Option
Pre-Tax
Cost
$12.91
$25.89
$24.84
$31.40
$45.70
24 pay periods / year
Your State or Employer
Sponsored Plan Information
100%
80%
80%
80%
50%
50%
50%
50%
(25% initial payments with
subsequent monthly
payments; dependent
children to age 19)
Program Maximums/Deductibles
Calendar-Year Maximum (per dependent child)
$1,000
Type I & II only
Lifetime Orthodontic Maximum
(per dependent child up to age 19)
Not applicable
Calendar-Year Deductible
(per covered person/per family)
$25/$75
Type I & II only
$2,500
Type I, II & III only
$1,500
(dependent children
to age 19)
$50/$150
Type II & III only
DENTAL TRANSFER WAITING PERIOD
The following waiting period applies:
If you currently participate in:
State- or Employer-Sponsored Plan
with Orthodontics
State- or Employer-Sponsored Plan
without Orthodontics
Late Entrant
(not enrolled in any dental option
prior to enrollment)
And you are
enrolling:
Low Option
High Option
Low Option
High Option
Low Option
Type I
(Diagnostic/
Preventive)
None
None
None
None
None
High Option
None
Type II
(Basic)
Type III
(Major)
Type IV
(Orthodontics)
None
None
None
None
None
N/A (not covered)
None
None
N/A (not covered)
None
12 months2
N/A (not covered)
None
None
12 months2
1. Amount saved dependent on member’s tax bracket.
2. Orthodontic coverage for dependent children up to age 19. Enrollment will default to 12-month waiting period ONLY for Type IV (Orthodontic Services). Prior coverage credit towards
orthodontics will be awarded upon receipt of documentation showing continual coverage in a benefit plan offering orthodontic coverage.
3. Some exclusions or limitations may apply. See 2016 NCFlex Enrollment Guide and Certificate of Coverage for details.
This document is for illustrative purposes only. In the event of any discrepancy between what is illustrated and the plan document or certificate, the plan document or certificate will govern.
EEM-0107-0915