Bay Area Roofers

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Self-Funded Dental Benefits

This page gives you a snapshot of your dental benefits. Apprentices must go to Delta Care PMI for 2 years before
becoming eligible for Self-Funded Dental benefits.

Plan Summary

DEDUCTIBLES & MAXIMUMS
Deductible Amount The amount of Dental Expense Benefits which must be incurred before benefits are payable under Dental Expense Coverage. Effective January 1, 2004 the deductible increased to $50 per person per calendar year and the family maximum per calendar year increased to $150. The deductible amount does not apply to preventative services.
Maximum Benefit Dental Services per calendar year (effective January 1, 2004) $1,500 Effective January 1, 2001: Orthodontia lifetime maximum while insured (per child) $2,000
Coinsurance Coverage (Paid by Plan) Preventative, 100% of Usual and Customary Charges. Limited to one prophylaxis and bitewing X-rays per 6 month interval; full mouth X-rays, once any 3 year interval; topical fluoride for children under 15 limited to once in any 12 month interval. Other dental services covered, 80% of Usual and Customary Charges. Orthodontics (children only), 50% of Usual and Customary Charges.

COVERED DENTAL EXPENSES. Covered charges are limited to Usual and Customary Charges as defined on page 73 of your booklet, for the same services performed within the particular geographic area concerned.

Covered Dental Expenses included hereunder are the charges of a licensed dentist for Necessary Treatment for which you and your dependents are charged and liable for payment in connection with the following dental services and supplies received, while eligible:

Preventive Services (100% of Usual and Customary Charges)

  • Routine periodic examinations at 6 month intervals including bitewing X-rays.
  • Full mouth X-rays once in any 3-year interval unless special need is shown.
  • Dental prophylactures as prescribed by the dentist but not more than once every 6 months.
  • Topical fluoride applications as prescribed by the dentist but not more than once in any 12-month interval and only if the family member has not reached the age of 15 years.

Regular Restorative (70% of Usual and Customary Charges)
  • Emergency treatment for relief of pain.
  • Regular restorative services – amalgam, stainless steel crowns, synthetic porcelain and plastic restorations.
  • Oral surgery provides for extractions and other oral surgery, including pre- and post-operative care.

Special Restorative (70% of Usual and Customary Charges)
  • Gold restorations when the teeth cannot be restored with another filling material; crowns and jackets when the teeth cannot be restored with a filling material.
  • Non-surgical periodontics – procedures necessary for the treatment of diseases of the gums.
  • Endodontics – includes pulpal therapy and root canal filling.

Prosthetics, Removable and Fixed (70% of Usual and Customary Charges)
  • Provides bridges, partial dentures and complete dentures.
  • Replacement of an existing partial or full removable denture or fixed bridgework, or the addition of teeth to an existing partial removable denture or to bridgework to replace extracted natural teeth, but only if evidence satisfactory to the Administrator’s Office is presented that:
  1. The replacement or addition of teeth is required to replace one or more additional natural teeth;
  2. The existing denture or bridgework was installed at least 5 years prior to its replacement and that the existing denture or bridgework cannot be made serviceable; or
  3. The existing denture is an immediate temporary denture and replacement by a permanent denture is required, and takes place within 12 months from the date of installation of the immediate temporary denture.
  • Space Maintainers.
  • Repair or recementing of crowns, inlays, bridgework, or dentures or relining of dentures.
  • Implants (appliances inserted into bone or soft tissue in the jaw, usually to anchor a denture) are covered after June 1, 2005. The Plan will not pay for any replacement for five years following the completion of the service.


Periodontics (70% of Usual and Customary Charges)

The surgical procedures necessary for the treatment of diseases of the gums and bone supporting the teeth

Injection of antibiotic drugs by attending dentist (70% of Usual and Customary Charges)

Orthodontic care, treatment, services and supplies (50% of Usual and Customary Charges)


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