TRICARE Dental Plan Benefits and Coverage

The TDP's contract year runs from February 1 through January 31. The annual maximum payment is $1,200 per enrollee per contract year, for non-orthodontic services. Payment for certain diagnostic and preventive services is not applied against the annual maximum.

There is a lifetime maximum of $1,500 per member for orthodontic treatment. If a member receives orthodontic services, payments for these services will not exceed $1,500 during the member's eligibility lifetime. Orthodontic diagnostic services will be applied to the $1,200 annual maximum.

The accumulation of charges against the maximums is based on the allowable charges, less any cost shares. The allowable charge is the amount that United Concordia will pay for any procedure. The cost share is the portion of the allowed amount the member must pay. Cost shares are not charged against the maximums.

Your cost share is determined by your pay grade and whether you are stationed within the continental U.S. (CONUS) or outside the continental U.S. (OCONUS). The following table reflects the cost share percentages.

Type of Service	Pay Grades E-1 - E-4 (CONUS)	All Other Pay Grades (CONUS)	OCONUS
Diagnostic	0%	0%	0%
Preventative (except sealants)	0%	0%	0%
Emergency Treatment	0%	0%	0%
Sealants	20%	20%	0%
Basic Restorative	20%	20%	0%
Endodontic	30%	40%	0%
Periodontic	30%	40%	0%
Oral Surgery	30%	40%	0%
Other Restorative	50%	50%	50%
Prosthodontic	50%	50%	50%
Orthodontics	50%	50%	50%
General Anesthesia	40%	40%	0%
Intravenous Sedation	50%	50%	0%
Consultation/Office Visit	20%	20%	0%
Medication	50%	50%	0%
Post Surgical Services	20%	20%	0%
Miscellaneous Services (occlusal guard, athletic mouthguard, bleaching)	50%	50%	0%

Outside the Continental U.S. (OCONUS) Payments

In the OCONUS service area, the Government pays for any costs in excess of United Concordia's allowable charge up to the billed charge. This applies to all enrollees except Selected Reserve and IRR family members and IRR (other than Special Mobilization Category) members. The Government will not pay for the portion of the member's maximum that has already been paid by United Concordia nor will the Government pay for any costs once the maximums have been met.

Visit www.TRICAREdentalprogram.com to learn more.

For general information about TRICARE, call the toll-free TRICARE information line for your region found at the TRICARE Contact Us web page.