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Procedures
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Fee-for-Service
Self-funded (Indemnity)
Scheduled Dental Plan
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Important information about the Plan
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You may use any licensed dentist., Benefits are payable based on the scheduled allowances, which are detailed by procedure on pages 72 through 85 of your Summary Plan Description.
All claims for services rendered must be submitted directly to the Trust Fund Administrative Office for processing.
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| Deductible |
$50 per person, per calendar year; deductible does not apply to first exam including teeth cleaning and bitewing x-rays, undergone by each family member each calendar year. |
| Annual Maximum |
$1,000 per person per calendar year
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| Diagnostic
Oral Examination, Full Mouth X-rays, Bitewing X-rays, Emergency treatment (during office hours)
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Scheduled allowances cover approximately 50% to 70% of charges |
| Preventive
Prophylaxis, Topical fluoride, Sealants (per tooth), Space maintainers
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Scheduled allowances cover approximately 50% to 70% of charges |
| Periodontic
Subgingival curettage, Gingivectomy, Muco-gingival or osseous surgery
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Scheduled allowances cover approximately 40% to 60% of charges |
| Endodontic
Pulp capping, Pulptomy, Root Canals, Apicoectomy
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Scheduled allowances cover approximately 60% to 80% of charges |
| Restorative (other than crowns)
Amalgram - primary & permanent teeth
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Scheduled allowances cover approximately 35% to 55% of charges |
| Crowns and Bridges
Crowns per unit -
- Full gold
- Predominately base metal
- Porcelain
- Pin Build-up, Post and core
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Scheduled allowances cover approximately 45% to 65% of charges
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| Prosthodontics
Dentures - complete or partial, adjustments, reline (office) & rebase
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Scheduled allowances cover approximately 45% to 65% of charges |
| Oral Surgery
Simple extractions, Surgical extractions Impactions, Frenectomy
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Scheduled allowances cover approximately 30% to 50% of charges |
| Orthodontia
Full Banding
Retention
Records Fee
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| Emergency Out-of-Area Treatment |
Benefits are payable as indicated above |
