If you are contemplating dental work in excess of $300, you are strongly encouraged to submit a pre-treatment estimate of the work to be performed. After a dental examination, the dentist will send a copy of the treatment plan, including the cost of treatment, to the Trust Office. The Trust Office will estimate the benefits available and inform your dentist.

If predetermination of benefits is not requested, the Trust Office retains the right to pay the claim on the basis of the amount of benefits, which would have been paid, had predetermination been requested.

Pre-determination is encouraged, particularly if the course of treatment is expected to involve total dental charges of $300 or more.

For a dental charge to be covered, it must be made by a legally licensed dentist, or a licensed dental hygienist working under the direction of a legally licensed dentist, or a licensed denturist providing services within the scope of their license.

The following "preventative" charges, if considered reasonable and customary, are covered dental services that are paid at 80%:

1. Oral examination, two times per calendar year.
2. Prophylaxis (dental cleanings), are paid at 85%, two times per calendar year.
3. Topical application of fluoride for children under 19 years of age, not more than two applications per person per calendar year.
4. Dental sealant applied to permanent molar(s) for children under 19 years of age.
5. Dental x-rays:
   1. Full mouth set of x-rays, including panoramic (one set or panoramic in each period of three consecutive years).
   2. Bite wing x-rays, two sets per calendar year.

The following "other" basic and major charges, if considered reasonable and customary, are covered dental services that are paid at 50%:

1. Space maintainers for children 12 years of age and under.
2. Extractions.
3. Restorative type fillings.
4. General and local anesthetic when administered with oral surgery (certain guidelines apply).
5. Treatment of periodontal and other diseases of the gums and tissues supporting the teeth.
6. Dental implants
7. Endodontic treatment, including root canal, if tooth is opened while covered.
8. Injection of antibiotic drugs.
9. Re-cementing of crowns, inlays and bridgework.
10. Relining of dentures once every two years.
11. Emergency palliative treatment.
12. Inlays, onlays, gold fillings or crowns.
13. Initial installation of fixed bridgework including inlays and crowns, to replace one or more natural teeth extracted while covered under the plan or extracted while covered under the dental plan that was replaced by this plan, if the person was covered on the day prior to his or her effective date of coverage under this plan.
14. Initial installation of partial or full dentures (excluding adjustments for the six-month period following installation), to replace one or more natural teeth extracted while covered under this plan or extracted while covered under the dental plan that was replaced by this plan, if the person was covered on the day prior to his or her effective date of coverage under this plan.
15. Replacement of existing bridgework by new bridgework, or the addition of teeth to existing dentures or bridgework. However, only replacements and additions to existing dentures or bridgework will be covered if evidence satisfactory to the Trust Office is furnished that one of the following applies:
    1. The replacement or addition of teeth is required to replace one or more teeth extracted while the person is covered under this plan, or extracted while the person was covered for such extraction under the dental health coverage plan replaced by this plan if the person was insured under such plan on the day immediately prior to his or her effective date of coverage under this plan;
    2. The existing denture or bridgework cannot be made serviceable and was installed at least two years prior to its replacement.

No benefits will be paid for the following:

1. Jaw treatment, including TMJ and MPD.
2. Sealants, except as specifically provided under “Covered Dental Services”.
3. Charges for any treatment, including material and supplies, not begun and completed while the person is covered under the plan.       
4. Charges for treatment, material or supplies furnished by other than a legally licensed dentist or licensed denturist except charges for scaling or cleaning performed by a hygienist under the direction of a legally licensed dentist.
5. Charges for treatment, materials or supplies for cosmetic purposes, including, but not limited to, personalization or characterization of dentures.
6. Charges for dentures, crowns, inlays, onlays, bridgework or other treatment, materials or supplies provided to alter vertical dimension or alter occlusion.
7. Charges for prosthetic appliances (including, but not limited to bridges and crowns) and the fitting of them, which were ordered while the person was not covered by this plan, or which were ordered while the person was covered by this plan, but were not delivered and installed while so covered.
8. Charges for installation of a dental appliance, a crown, a bridge or gold restoration furnished within 30 days after the date of termination of an person’s coverage for dental benefits under the plan, will be covered charges if:
   1. An impression for such appliance is taken prior to the date of termination of coverage,
   2. The tooth was prepared for the crown, bridge or gold restoration prior to the date of termination of coverage, and
   3. The person is not entitled to payment for such installation under health coverage of any type or source.
9. The prosthesis replacement rule requires that replacements or additions to existing dentures or bridgework will be covered only if evidence satisfactory to the Trust Office is furnished that one of the following applies:
   1. The replacement or addition of teeth is required to replace one or more teeth extracted while the person is covered under this plan, or extracted while the person was insured for such extraction under the dental health coverage plan replaced by this plan, if the person was insured under such plan on the day immediately prior to his or her effective date of coverage under this plan.
   2. The existing denture or bridgework cannot be made serviceable and was installed at least two years prior to its replacement.
10. Replacement crowns, inlays or onlays on the same teeth are covered only once in a five-year period.
11. Charges for failure to keep a scheduled appointment with the dental provider.
12. Charges for treatments, materials, or supplies that are experimental in nature.
13. Charges that are not dentally necessary and/or are not recognized by the American Dental Association.
14. Charges in excess of the reasonable and customary charges for the services, supplies or treatments provided.
15. All items listed under “General Exclusions”.