Carrier: United Concordia Policy Number: 740096 Eligibility: ALADS Retirees Your Monthly Contribution: Member only $11.60   Member plus 1 dependent $22.05   Member plus 2 or more dependents $32.43 Summary of Benefits: Sample Covered Procedures (Member Pays)      Diagnostics + Preventive No Charge           Office visit, per visit No Charge           Periodic oral evaluation No Charge           X-rays No Charge           Prophylaxis (cleaning), once every 6 months No Charge      Restorative + Oral Surgery             Amalgam fillings (primary or permanent) No Charge           Resin filling (anterior) $15           Single tooth extraction $20           Removal of impacted tooth, soft tissue $25           Removal of impacted tooth partially bony $30           Removal of impacted tooth completely bony $40      Prosthetics + Endodontics             Crown - resin (laboratory) $69           Crown - porcelain fused to noble metal,                        excluding molars $175           Denture - Complete maxillary or mandibular $175           Root canal therapy - anterior $75           Root canal therapy - bicuspid $75           Root canal therapy - molar $75      Orthodontics             Dependent children to age 19 $1,500           Adults and covered full-time students $2,000

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This is a summary only, please refer to the actual policy for complete details
These benefits represent the "standard" benefits.
There may be modifications for some states due to mandated benefits that are not reflected in this benefit plan design

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