Dental Expense Coverage

This Plan works like the Blue Cross Network (PPO) Plan. When you receive services, the Plan pays a percentage of covered costs; you pay the remaining percentage and any costs that aren’t covered. The Plan is self-funded by the Trust Fund and administered by the Dental Plan listed on the Quick Reference Chart.

You may use any dentist you choose, but you will generally pay less out of pocket if you use a PPO dentist.

	Delta Dental Contracted Dentist	Non-PPO Premier or Non-Delta Dental Dentist
Calendar Year Maximum Active Plan	$2,000 (does not apply to Dependent Children of Active Employees up to age 19)
Calendar Year Maximum Retiree Plan	$2,000
Calendar Year Deductible	$50 per individual $100 per family
Plan Paid Coinsurance	Based on Delta Contracted Rates	Based on the Allowed Charges as determined by the Dental Plan
Diagnostic & Preventive	100%, No Deductible	80%,  No deductible
Restorative	80%	60%
Oral Surgery	80%	60%
Periodontal	80%	60%
Endodontics	80%	60%
Prosthodontic	80%	60%
Orthodontics provided only to Dependent Children Limitations apply	50% of Allowed Charges up to a Lifetime Maximum of $2,500 Benefits are payable in 3 installments automatically issued over the course of 12 months, beginning with the date of banding. The first installment is 50% of the orthodontic benefit and the remaining two installments of 25% are issued at 6 months and 12 months. If orthodontic treatment began before you become eligible, the Dental Plan’s payments will begin with the first payment due to the dentist following your eligibility date.

Payment of Allowed Charges is based on the Dental Plan’s contract with their network provider or the Dental Plan’s determination of the Allowed Charges for non-PPO dentist.  Non-PPO dentists may balance bill you for any billed charges that exceed that amount.

The Plan covers “Dentally Necessary” treatment that meets all of the following conditions:

• The care and treatment is appropriate given the symptoms, and is consistent with the diagnosis, if any. “Appropriate” means that the type, level, and length of service and setting are needed to provide safe and adequate care and treatment;
• It is rendered in accordance with generally accepted dental practice and professionally recognized standards;
• It is not treatment that is generally regarded as experimental or unproven; and
• It is specifically allowed by the licensing statutes which apply to the provider who renders the service.

In instances where there are optional methods of treatment, the allowance for the least expensive procedure will be paid.

The Dental Plan provides benefits for all necessary procedures to assist the dentist in evaluating the existing condition and the dental care needed by the patient. The following limitations apply:

• Diagnostic and preventive services are not subject to the annual Deductible.
• Charges for examinations and consultations are covered twice in a calendar year.
• Full mouth x-rays are covered once in each five year period while covered under any Dental Plan.
• Bitewing x-rays are covered twice in a calendar year for children under age 18 and once in a calendar year for adults, and are not payable as a separate benefit in the same year as a full-mouth series.
• Dental prophylaxis is covered twice per calendar year.
• Fluoride treatment is covered twice in a calendar year while covered under any Dental Plan.
• Space maintainers are covered through age 12 and not more than once every five years.
• Oral pathology charges for the examination of oral tissue are covered.
• Diagnostic casts are covered only as an orthodontic benefit.

The Plan provides benefits for extractions and other oral surgery including the following:

• Benefits for extractions include local anesthesia, x-rays and postoperative care.
• Benefits for the removal of tumors, cysts and neoplasms when a copy of the histopathological report is submitted.

The Dental Plan provides amalgam, synthetic porcelain and plastic restorations. The following services and limitations apply:

• Composite (resin) restorations are covered on anterior teeth and the facial surface of bicuspids. Posterior composite restorations are an optional benefit and payment is limited to the cost of the equivalent amalgam restoration.
• Sealants are covered for permanent non-restored teeth every 2 years. Restorations in teeth where sealants have been applied are covered after 12 months have elapsed since the application of the sealants. Replacement of sealants on non-carious teeth is covered only after two years.
• Replacement of an existing filling is covered after the previous filling has been in place for 24 months.
• Multiple fillings on a single tooth surface are covered as a single surface filling.
• Benefits for crowns, inlays, onlays and cast restorations are provided only when the tooth shows extensive coronal destruction, as documented by x-rays or study models, and the tooth cannot be restored with an amalgam or composite filling.
• Replacement of a cast restoration is limited to once every five years while covered under any Dental Plan unless the Dental Plan determines that the replacement is required because the restoration is unsatisfactory as a result of poor quality of care, or because the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissue since the original placement.
• Benefits will be paid for repair or re-cementation of an inlay, onlay, bridge or crown after 12 months or more have elapsed since the initial placement or previous re-cementation or repair.

The Plan provides for pulpal therapy and root canal filling subject to the following:

• Endodontic therapy includes initial treatment, interim and final x-rays, temporary fillings and follow-up care.
• Pulpotomies are provided when performed on primary teeth that have not begun to exfoliate.
• Root canal therapy is covered once in a 12-month period.

The Plan provides benefits for procedures necessary for the treatment of diseases of the gums and bones supporting the teeth with the following limitations:

• If full quadrants do not require treatment, the benefit payable for root planing and gingival curettage is determined by the number of teeth that require treatment.
• Benefits for periodontal surgery are payable when need is documented following visits for non-surgical periodontal therapy and a subsequent re-evaluation.
• Covered non-surgical periodontal therapies include root planing and gingival curettage are covered no more frequently than every 24 months in each quadrant.

The Plan provides benefits for bridges, partial dentures and complete dentures. The Plan provides for replacement of missing teeth using standard techniques. The following are limitations on prosthodontic benefits:

• Prosthodontic appliances are covered only once every five years while eligible under any Dental Plan unless the Dental Plan determines that there has been such an extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory.
• Replacement of a second molar is covered only as part of a prosthesis that replaces adjacent missing teeth.
• The allowance for a removable partial denture includes all teeth and clasps.
• For patients under age 16, the Plan covers interim dentures.
• The Plan provides for a rebase once every two years.
• The Plan provides for a reline 12 months after a rebase or a previous reline.
• The Plan provides for a reline six months after the placement of a denture.
• The Plan provides for an office reline three months following placement of an immediate denture.

The following are excluded from prosthodontic benefits:

• Specialized techniques, personalization and characterization.
• Precision attachments.
• Experimental procedures.
• Surgical correction by grafts for denture retention purposes.
• Inter-occlusal recording or analysis.
• Unusual diagnostic techniques.
• Procedures associated with overdentures.
• Stress-breakers
• Appliances to alter vertical dimension.

• Charges for services with respect to congenital or developmental malformations, jaw repositioning, cosmetic surgery, or dentistry for solely cosmetic reasons except as specifically provided for under Orthodontic Care below.
• Services and supplies for which patients are not required to pay, or which are furnished by a hospital or facility operated by the federal government or any authorized agency thereof, or furnished at the expense of such government agency except to the extent that such services are reimbursable to the Veterans Administration for non-service connected conditions under 38 U.S.C. 629.
• Services and supplies which are furnished by any person, hospital or organization who or which, regardless of the patient’s financial ability, normally makes no charge therefore in the absence of eligibility for dental benefits.
• Dental expenses incurred which may be paid under any other benefit provided by this Trust Fund.
• Any hospital costs or any fees charged by the dentist for hospital treatment.
• Charges for anesthesia, other than general anesthesia administered by a licensed dentist in connection with covered oral surgery.
• Charges made by a relative of the Participant, except for Allowed Charges which constitute out-of-pocket expenses to such providers.
• Services or supplies received as a result of accidental bodily injury or sickness arising out of, or in the course of, employment, including self-employment.
• Services not performed by a Dentist, except x-rays ordered by a Dentist and services by a licensed dental hygienist under the Dentist’s supervision.
• Services or supplies which are not Dentally Necessary, not customarily provided for dental care, or that are primarily for cosmetic purposes.
• Dietary planning or oral hygiene instruction.
• Surgical Implants (materials implanted into or on bone or soft tissue) or the removal of implants. However, the Dental Plan will make an allowance for the appliance actually placed on the implant(s), i.e. crowns, bridges, partial or full dentures. Single crowns will be paid as a pontic. The Plan would then not pay for any replacement for at least 5 years.
• Athletic mouthpieces.
• Appliances, surgical procedures or restorations to restore tooth structure lost due to abrasion, erosion or attrition or to alter vertical dimension or for rebuilding or maintaining chewing surfaces due to teeth being out of alignment or occlusion, or for stabilizing teeth (such services include but are not limited to equilibration and periodontal splinting)
• Full mouth reconstruction and treatment of congenital malformations.
• Extra-oral grafts (grafting of tissues from outside the mouth to oral tissue).
• Prosthodontic services or any single procedure started prior to the date you became eligible for services under this Trust Fund.
• Replacement of lost or stolen appliances which are less than five years old.
• Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joint or associated musculature, nerves, and other tissues.
• Replacement of existing restorations for any purpose other than restoring structure damaged by active tooth decay.
• Laminate veneers.
• Outpatient prescription medication related to dental or orthodontic treatment (except for fluoride for children up to age 6 with a prescription).
• Charges for completion of claim forms.

The Plan provides benefits for orthodontic services for Dependent children only when rendered by a licensed dentist.

If care is terminated for any reason during the course of treatment, the obligation of the Plan will cease with payment to the date of termination. If, in the combined judgment of the attending orthodontist and the orthodontic consultant, the reason for termination of treatment was because of the failure of the patient to cooperate with the treatment plan, the patient would not be eligible for any further orthodontic benefits under the Indemnity Dental Plan.

The Plan provides benefits for corrective, interceptive and preventive orthodontic treatment to realign natural teeth, to correct malocclusion, to provide pre-orthodontic guidance and to provide growth and development evaluation.

Orthodontic treatment will not be provided for the following:

• Replacement of lost or broken appliances or retainers.
• Treatment rendered by an orthodontist who is not licensed.
• Orthodontic expenses incurred which may be paid under any other benefit provided by this Trust Fund.
• Orthodontic treatment arising out of, or in the course of, employment, including self-employment.
• Extended orthodontic treatment due to the Participant’s failure to comply with treatment instructions.