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Home > Health Plan > D5 - Dental Benefit
DENTAL BENEFIT
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Your eligible dependents are covered only if you elected
Family Coverage and are working enough hours to qualify for full-time coverage.
Your dental coverage pays a significant portion of the cost of covered dental services for you and your eligible dependents.
The Plan pays only for services that are provided by a licensed dentist or dental hygienist, including any required supplies.
Payment for covered dental expenses is limited to a scheduled amount. The most common procedures are listed in the
Schedule of Dental Procedures.
How the Plan Pays Benefits
You pay a $50 deductible per person each calendar year. The deductible does not apply to diagnostic and preventive
services, which are described immediately below.
The Plan pays the balance of the remaining expense for covered dental expenses, up to the maximum amount shown in the
Schedule of Dental Procedures.
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Covered Dental Expenses
The following services and supplies are covered under the Dental Benefit.
Diagnostic and Preventive Services:
- Oral examination, if performed by a dentist
- Prophylaxis (teeth cleaning), if performed by a dentist or dental hygienist; limited to twice a calendar year.
- Necessary x-rays—complete series, including bitewings, limited to once per calendar year; panoramic limited to
once every 2 calendar years
- Fluoride treatments
- Sealants
Other Services:
- Tooth extractions
- Amalgam, acrylic, synthetic porcelain and composite restoration for decaying or broken teeth
- Onlays and crowns
- Space maintainers
- Oral surgery, including extractions and surgical procedures
- Periodontal treatment (treatment of the gums and bones), including, but not limited to, periodontal scaling and
periodontal maintenance procedures
- Endodontic treatment, including root canal therapy
- Initial fitting and replacement of complete and partial dentures and bridges. Replacements will be payable only once
every five years.
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Orthodontic Benefit
Covered orthodontic expenses are payable at 50% up to the lifetime maximum benefit of $1,000.
Temporomandibular Joint Disorders (TMJ): The following services and supplies for treatment of
TMJ are covered expenses payable under the Orthodontic Benefit:
- Occlusal splints
- Orthopedic repositioners
- Panoramic radiographs
- Tomogram x-rays
- Cephalometric x-rays
- Occlusal equilibration
- Magnetic Resonance Imaging
- Temporomandibular joint x-rays
- Injection of Xylocaine, alcohol, Benadryl, saline solutions or Cortisone
- Hydrostatic appliance
- Occlusal guards
- Diagnostic casts
- Facebow transfer
- Arthrocentesis
- Hinge axis mounting
- CT scans.
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Alternate Procedures
In some cases, there is more than one way to treat a dental problem. Your Plan will pay benefits based on the procedure that
will provide a professionally acceptable result as determined by national standards of dental care, in a cost-effective manner.
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Pre-Treatment Estimate
Whenever you expect that your dental expenses for a course of treatment will be more than $500, you may use the
pre-treatment estimate procedure. You and your dentist should complete the regular dental claim
form, indicating the type of work to be performed with the estimated cost. Once it is received, the form will be reviewed
and you and your dentist will be sent a statement showing what the Plan will pay. This procedure lets you know how much you
will have to pay before you begin treatment.
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What’s Not Covered
expenses not covered under the Dental Benefit include the following:
- services or supplies provided or paid for by any other employer’s medical or dental coverage, mutual benefits
association, labor union or similar organization under provisions governing the coordination of benefits
- cosmetic treatment
- replacement of a lost or stolen appliance
- customization of a dental prosthesis, including personalized, elaborate, or precision attachment dentures or bridges
or specialized techniques, unless the prosthesis cannot be made to function without the specialized technique
- periodontal scaling procedures on patients not manifesting Case Type II, III or IV periodontal disease
- complete series (including bitewings) of x-rays more often than once each calendar year
- panoramic x-rays taken in the same year when complete series x-rays are taken
- panoramic x-rays more often than once every two calendar years unless made necessary by a change in dentists
- prophylaxis treatments are limited to a maximum of four per calendar year, as follows: up to two can be dental
prophylaxis (ADA codes 1110/1120); up to four can be periodontal prophylaxis (ADA code 4910) provided that they are
performed as adjunctive periodontal treatment rendered with respect to active periodontal treatment
- temporary bridgework and temporary crowns except when a temporary crown is needed due to a fractured tooth
- anything excluded under the Plan’s General Exclusions and Limitations
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