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Health
& Welfare Dental
Dental - Summary of
Benefits
Dental services are divided into three parts:
Part I - Preventative Dentistry,
Part II - Restorative
Dentistry, and
Part III Major Dentistry.
Co-payment rates will vary depending which Part the
service is categorized as, and which Plan you are
enrolled. Listed below is an overview of covered
charges by Part.
Once you have determined whether a procedure is
covered, you can review your
co-payment and deductible
to calculate your out-of-pocket expenses. Annual maximums
range between $500 to $2,000 per
covered individual.
|
Part I - Preventative Dentistry |
| Cleaning |
Two times per calendar year |
| Exam |
Two times per calendar year |
| 2 Bitewings |
Two times per calendar year |
| Flouride Treatment |
Once per calendar year |
| Panoramic or full mouth X-ray |
Once every 24 months |
| Sealants (unrestored teeth only
no age limit) |
Once every 24 months |
| Space Maintainer |
No age limit |
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|
Part II - Restorative
Dentistry/Oral Surgery |
| Fillings |
Once per calendar year
(reduced to amalgam rate on posterior teeth) |
| Periodontal scaling and root planing |
Once every 24 months per
quadrant |
| Periodontal maintenance |
Four times per year |
| General anesthesia |
Not a covered expense |
| Nitrous Oxide |
Only dependents age 12 or under |
| Intravenous Sedation |
Only when treatment warrants |
| Pill Sedation |
Not a covered expense |
| Behavior management |
Not a covered expense |
|
Part III - Major Dentistry/Prosthesis** |
| Night Guard (for bruxism) |
Replacement once every 5 years |
| Bridge |
Replacement once every 5 years |
| Crown |
Replacement once every 5 years |
| Partial or full denture |
Replacement once every 5 years |
| Implants |
Replacement once every 5 years |
| Inlays/onlays |
Replacement once every 5 years |
**Please note that all major dentistry is paid on the
seat date but the patient must be eligible on the
preparation date. All major work reduced to the gold or
metallic rate on posterior teeth
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