Scheduled Dental Benefits

Dental benefits are paid based on a Dental Fee Schedule that lists commonly covered dental procedures and the maximum amount allowed for each procedure with a $2,000 annual maximum. If expenses exceed the Dental Fee Schedule maximums or the $2,000 annual maximum, this plan will not pay the additional costs. These expenses are not subject to the $200 annual deductible or $2,300 annual coinsurance maximum.

Preauthorization – Scheduled Dental Benefits

We strongly recommend that you preauthorize dental benefits if expenses are expected to be $500 or more. To preauthorize benefits, your dentist must submit to the Trust Office a written description of the proposed treatment, his or her usual fee for the treatment and current x-rays of diagnostic quality showing the need for the treatment, if required. The Trust Office will evaluate this material and provide you and your dentist a written estimate of benefits payable under this plan.

General Anesthesia

If your dentist recommends intravenous sedation or general anesthesia for dental care that is routinely provided without general anesthesia (for example, multiple fillings for a young child under age seven), you must preauthorize these services with the Trust Office. If approved, general anesthesia is subject to the maximums listed on the Dental Fee Schedule and the $2,000 annual dental benefit maximum.

Hospitalization

If your dentist recommends hospital care for dental procedures, you must preauthorize these services with the Trust Office. Hospital care for dental procedures will not be approved unless appropriate treatment (as determined by the plan) cannot be provided without the use of hospital facilities or a medical condition, unrelated to the proposed dental treatment, makes hospital care medically necessary. If hospital care is approved, the hospital costs are paid under medical benefits and are subject to the annual deductible and coinsurance provisions of the medical plan. The dental procedures (including anesthesia) are subject to the maximums listed on the Dental Fee Schedule and the $2,000 annual dental benefit maximum.

Diagnostic Services

Diagnostic services refers to locating and identifying dental decay and disease through the use of exams and x-rays. The following diagnostic services are covered:

• One routine oral examination in a six-month period. Consultations and office visits count toward the six-month oral examination limit.
• A maximum of four supplementary bitewing x-rays once in a 12-month period.
• Complete full mouth x-rays (including bitewings) or panoramic x-rays once in a 60-month period.
• Emergency examinations.
• Examinations by a specialist in an American Dental Association (ADA) recognized specialty, when considered necessary dental care.

Preventive Services

Preventive services refers to a program of regular dental care designed to alleviate or minimize dental decay and disease. The following preventive services are covered:

• Dental prophylaxis (cleaning) once in a six-month period.
• For dependent children under age 19 only, the topical application of fluoride or fluoride varnish once in a six-month period.
• Fluoride varnish is also allowed for “caries-active adults.” Caries-active adults are individuals over 19 years of age who exhibit a dentition with progression or deepening of carious lesions, or who routinely present at recall with two or more new (enamel or root) carious lesions in a 12-month period.
• For dependent children under age 19 only, the application of fissure sealants on occlusal surfaces of bicuspids and molars once in a 36-month period. The bicuspids and molars must have intact occlusal surfaces and cannot have decay or any prior restoration. The repair or replacement of a sealant on any tooth within this 36-month period is considered part of the original service.
• Space maintainers but only when used to maintain space for the eruption of permanent teeth. The replacement of a space maintainer that was previously covered under this plan is not covered.

Restorative Services

Restorative services refers to the process of replacing a lost tooth part by artificial means such as a filling or a crown. Services must restore hard tooth surfaces that are visibly decayed or fractured and restoration must be to a state of functional acceptability. The following restorative services are covered:

• Fillings consisting of silver amalgam or composite resins. If a composite resin filling is placed on a posterior tooth, benefits are available up to the amount allowed for a silver amalgam filling. A filling on any tooth surface is covered only once in a 24-month period. When multiple restorations involving contiguous surfaces of the same tooth are performed on the same day, the allowance is limited to that of a multisurface restoration.
• Initial placement of crowns, veneers and onlays for decayed or fractured teeth when amalgam or composite resin fillings will not adequately restore the tooth. If a tooth can be restored with a filling material such as amalgam or composite resin, the benefit is paid as if one of these materials was used.
• Replacement crowns, veneers and onlays but only when the existing restoration was seated at least 60 months prior to replacement and only if the existing crown has new decay present or significant fracture (50 percent or more) that cannot be repaired with a filling material such as amalgam or composite resin.
• Post cores and buildups with pins but only once per tooth in a 60-month period and only when an x-ray and narrative indicate an absence of sufficient tooth structure remaining circumferentially for crown retention. If a post core is reported with a restoration or core buildup on the same day, the amalgam or composite core buildup is considered part of the post and core benefit.
• Pin retention once per tooth when necessary on a permanent tooth and completed on the same day as the restoration. A maximum of three pins will be reimbursed per filling.
• Prefabricated resin crowns, prefabricated stainless steel crowns with a window, or full stainless steel crowns once in a 24-month period.

Benefits for crowns, veneers and onlays are considered for payment at such time as they have been permanently seated provided the individual is eligible at the time of initial preparation. If the individual loses eligibility after the preparation date, the individual is allowed 60 days after the loss of eligibility to have the restoration permanently seated.

Endodontic Services

Endodontic services refers to the treatment of diseases of the nerves and blood vessels within the tooth. The following endodontic services are covered but only when the tooth can be restored to functional acceptability:

• Procedures for pulpal and root canal therapy, including pulp exposure treatment. Root canal treatment on the same tooth is covered only once in a 24-month period. Coverage of root canal therapy performed in conjunction with overdentures is limited to two teeth per arch. X-rays taken for root canal therapy, other than the initial periapical x-ray, are included within the scheduled maximum for the root canal therapy.
• Pulpotomy on primary teeth.
• Gross pupal debridement of primary and permanent teeth.
• Apexification, apicoectomy, retrograde filling, and hemisection.

Periodontic Services

Periodontic services refers to the diagnosis and treatment of disease in the surrounding and supporting tissues of the teeth. The following periodontic services are covered:

• Periodontal scaling and root planing for each quadrant once in a 12-month period. These services are covered only when a definitive diagnosis and periodontal pocket depth charting demonstrate that this is necessary dental care. A prophylaxis performed the same day as periodontal scaling or root planing is not covered.
• Periodontal maintenance (in lieu of regular dental prophylaxis). This benefit is available not more than three times in a 12-month period and must follow active periodontal treatment (i.e., root planing and/or other surgical procedures).
• Site-specific therapy is limited to two sites per quadrant once in an 18-month period. Site-specific therapy must be preceded by scaling and root planing a minimum of six weeks and a maximum of six months prior to such treatment. Periodontal surgical benefits are not allowed in the same quadrant for two years following placement of the site-specific therapy.
• Periodontal surgery per site is covered once in a 36-month period including, but not limited to, gingivectomy, osseous surgery, gingival flap surgery, and soft tissue grafts. Periodontal surgery must be preceded by scaling and root planing a minimum of six weeks and a maximum of six months prior to such treatment.
• Crown lengthening, unless performed on the same date as a crown preparation or restoration.

Prosthodontic Services

Prosthodontic services refers to the replacement of missing teeth by artificial means. Benefits are available for dentures, bridges, partial dentures, and related items, as well as the adjustment or repair of an existing prosthetic device but only within the following limitations:

• Benefits are available for a full, immediate or overdenture. If you elect any other service or supply such as, but not limited to, personalized restoration or specialized treatment (soft liners, cutting bars and the like), benefits are available up to the appropriate amount for a full, immediate or overdenture.
• When a partial denture is required, benefits are available for a cast chrome or acrylic partial denture. This allowance also applies toward the cost of any other procedure that may be provided such as a more elaborate or precision device. Benefits are available for the use of a crown as an abutment to a partial denture only when the tooth is decayed to the extent that a crown would be required whether or not a partial denture is required.
• If a bridge is required, benefits are available for single abutment crowns. Double or triple abutment crowns are not covered.
• Benefits for complete or partial dentures are considered for payment at the time the appliance is permanently seated, provided the individual was eligible at the time the initial preparation and impressions were done. If the individual loses eligibility after the initial preparation and impressions were completed, the individual is allowed 60 days after loss of eligibility to have the appliance permanently seated.
• Repair or recementing of crowns, bridgework or dentures.

Frequency limitations apply to certain prosthodontic services and supplies as follows:

1. The replacement of an existing prosthetic appliance after 60 months but only if the appliance cannot be made serviceable. Services necessary to render the appliance serviceable are covered.
2. Replacement of a partial denture or fixed bridgework (including Maryland bridges) after 60 months but only if the appliance cannot be made serviceable, unless replacement is required to replace one or more teeth extracted after the existing partial denture or bridgework was installed.
3. Denture adjustments and relines but only if these services are provided more than six months after the initial placement occurs. Later, relines and rebases (but not both) are covered once in a 12-month period.

Exodontic Services

Exodontic services refers to the removal of teeth, the surgical preparation of the mouth for the insertion of dentures, and the surgical and adjunctive treatment for minor pathological conditions. The following exodontic services are covered:

• Removal of teeth (extractions).
• Alveolectomy.
• Incision and drainage of abscess.
• Surgical and adjunctive treatment for minor pathological conditions.
• Frenectomy.
• Ridge extension for the insertion of dentures (vestibuloplasty).
• Intravenous or general anesthesia in a dental office in conjunction with covered oral surgery procedures (excluding single simple extractions).

Adjunctive Services

• Emergency palliative treatment.
• Limited adjustments to occlusion (eight teeth or less) such as the smoothing of teeth or reducing cusps once in a 12-month period.
• Night guards or occlusal guards (for bruxism only) but only once per lifetime.