DENTAL PLAN B / SCHEDULED BENEFITS / EFFECTIVE APRIL 1, 2011

Transcription

1 (206) / TRUST OFFICE: ZENITH AMERICAN SOLUTIONS DENTAL PLAN B / SCHEDULED BENEFITS / EFFECTIVE APRIL 1, 2011 imum benefit is $2,000 per calendar year per Covered Person. For patients age 0-18, preventive and some minor restorations are not applied to the $2,000 calendar year maximum. For all services, any difference between the dental charge and the Plan s payment schedule will be the patient s responsibility. Exams Two per calendar year Prophylaxis (Cleaning and Scaling) Two per calendar year Periodontal Prophylaxis One every three months One Full Mouth X-ray and One Panoramic X-ray allowed per calendar year; Bitewings are as necessary Fluoride Two per calendar year; Up to age 19 Sealant Allowed for each tooth; Up to age 19 DENTAL PRE-DETERMINATION OF BENEFITS For all dental services in connection with crowns and periodontal treatment, a Dental Treatment Plan must be submitted to the Trust Office for predetermination of benefits. If the Trust determines that alternate procedures, services, or courses of treatment may be performed to correct a dental condition, the maximum amount that Scheduled Plan B will cover is payment for the least expensive procedure which will produce a professionally satisfactory result as determined by the Trust. LIMITATIONS: (1) Oral examinations limited to two per calendar year. (2) Cleaning and Scaling of teeth limited to two per calendar year. (3) Complete mouth x-ray limited to one per calendar year. (4) Fluoride and Sealants limited to age 19. (5) Periodontal prophylaxis limited to one every three months. (6) A prosthetic device will not be provided more than once in every 5-year period. Said 5-year period will be measured from the date on which the existing appliance was last supplied, whether under the current dental agreement or under any prior dental agreement. Services which are necessary to make an appliance satisfactory will be provided in accordance with the agreement. The term existing as used in this paragraph is intended to include an appliance that was placed as the inception of the aforementioned 5-year period, but, for whatever reason, is no longer in the possession of the patient. (7) Services related to the treatment of Temporomandibular Joint Syndrome (TMJ) are limited to a combined medical/dental Plan Lifetime maximum of $1, (8) Should the patient fail to follow through on a prescribed course of treatment, and subsequently develops a more extensive necessary course of treatment, Plan B shall only be responsible for the initially prescribed course of treatment. EXCLUSIONS: (1) Oral hygiene instruction. (2) Services and supplies furnished solely for cosmetic purposes. (3) Nitrous oxide. (4) Replacement to any existing removable denture or partial denture or fixed bridge unless: a. Additional natural teeth are being replaced. b. The existing denture or bridge either was installed more than 5 years prior to replacement or cannot be made satisfactory. (5) Gold restorations when other materials can be used satisfactorily (i.e. amalgam, composite, resin). (6) Expenses incurred after termination of eligibility from Plan B except for the following: a. Prosthetic devices which are fitted, ordered and pre-certified by the Trust Office prior to termination but were delivered to the Covered Person within 60 days after the date of termination. b. Treatment in process that is completed within 60 days after the date of termination provided that the first visit and plan of treatment were completed prior to date of termination. (7) Charges for treatment when an optional plan of treatment is available at a lesser fee (8) Experimental procedures. (Services and supplies that are, in the Trust s judgment, experimental or investigational. These include any that are not recognized as accepted dental practice in our service area and any for which the required approval of a government agency has not been granted at the time of service.) (9) Services that are not necessary dental care. (10) War related conditions (treatment of any condition caused by, or arising out of, an act of war, armed invasion or aggression). (11) Gnathologic recordings (recording of jaw movement and position). (12) Care, treatment or supplies furnished by a program or agency funded by any government. (13) Charges made for services or supplies furnished while the Covered Person is confined in a Hospital unless such confinement is deemed to be medically necessary and dental treatment in a dental office will cause significant risk to patient s health. (14) DENTAL IMPLANTS AND ALL RELATED SERVICES. (15) EXPENSES FOR ORTHODONTIC TREATMENT OR CORRECTION OF MALOCCLUSION. *** ORTHODONTICS ARE NOT COVERED *** (16) Care and treatment for which there would not have been a charge if no coverage had been in force.

2 (206) / DENTAL PLAN B SCHEDULED BENEFITS / PAGE 2 s not listed are not covered by the Dental Plan INITIAL ORAL EXAM * AMALGAM-2 SURFACES * PERIODIC ORAL EXAM * AMALGAM-3 SURFACES * EMERGENCY ORAL EXAM AMALGAM-1 SURFACE * LIMITED ORAL EVAL-PROB FOCUSED AMALGAM-2 SURFACES * COMPREHENSIVE ORAL EVALUATION * AMALGAM-3 SURFACES * DETAILED/EXTENSIV EVAL-PROBLEM AMALGAM-4+ SURFACES * RE-EVALUATION-LIMITED FOCUSED PIN RETAINED * COMPREHENSIVE PERIO EVALUATION COMPOSIT/RESIN 1 SURF * FULL MOUTH X-RAYS * COMPOSIT/RESIN 2 SURF * INTRAORAL-SINGLE XRAY * COMPOSIT/RESIN 3 SURF * INTRAORAL-ADDL X-RAY * COMPOSITE RESIN * INTRAORAL-OCCL X-RAY * RESIN BASED COMPOSITE CROWN AN EXTRAORAL-SINGLE XRAY * RESIN-BASED COMPOSITE 1 SURF * EXTRAORAL-ADDL X-RAY * SURFACE COMPOSITE POSTERIOR * BITEWING-FIRST X-RAY * RESIN-BASED COMPOSITE 3 SURF BITEWINGS-TWO FILMS * SURFACE COMPOSITE BITEWINGS-FOUR FILMS * GOLD FOIL-1 SURFACE VERTICAL BITEWINGS 7-8 FILMS * GOLD FOIL-2 SURFACES FACIAL BONE FILM GOLD FOIL-3 SURFACES SIALOGRAPHY GOLD-INLAY 1 SURFACE PANORAMIC SINGLE XRAY GOLD-INLAY 2 SURFACES BACTERIOLOGIC STUDIES GOLD-INLAY 3 SURFACES PULP VITALITY TESTS ONLAY - METALLIC -2 SURFACES DIAGNOSTIC CASTS ONLAY-METALIC 3 SURFACES ACCESSION OF TISSUE,GROSS EXAM ONLAY-METALIC 4 + SURFACES ACCESSION OF TISSUE,MICRO EXAM PORCELAIN INLAY 1-SUR OTHER ORAL PATHOL PROC, BY RPT PORCELAIN INLAY 2-SUR PROPHYLAXIS ADULTS * PORCELAIN INLAY 3-SUR PROPHYLAXIS CHILDREN * ONLAY-PORCELAIN/CERAMIC 2 SURF PROPHY WITH FLUORIDE - CHILD * ONLAY-PORCELAIN/CERAMIC 3 SURF TOPICAL APPL FLUORIDE - CHILD * , ONLAY-PORCEL/CERAMIC 4+ SURF TOP APP FLOURIDE-ADUL * INLAY-COMPOS/RESIN 1 SURFACE PROPHY WITH FLUORIDE - ADULT INLAY-COMP/RESIN 2 SURFACES TOP FLUORIDE VARNISH/MOD-HIRIS , INLAY-COMP/RESIN 3 + SURF SEALANT - PER TOOTH * ONLAY-COMP/RESIN 2 SURF SPACE MAINTAINER * ONLAY-COMP/RESIN 3 SURF SPACE MAINTAINER * , ONLAY-COMP/RESIN 4 + SURF SPACE MAINT-FIXED * PLASTIC ACRYLIC CROWN SPACE MAINT-REMOVABLE * PLASTIC/METAL CROWN RECEMENT SPACE MAINT * PLASTIC/METAL CROWN AMALGAM-1 SURF REST * PLASTIC/METAL CROWN

3 (206) / DENTAL PLAN B SCHEDULED BENEFITS / PAGE 3 s not listed are not covered by the Dental Plan PORCELAIN CROWN RETREATMNT ROOT CANAL-ANTERIOR PORCELAIN/METAL CROWN RETREATMNT ROOT CANAL-BICUSPID PORCELAIN/METAL CROWN , RETREATMNT ROOT CANAL MOLAR PORCELAIN/METAL CROWN APEXIFICATION CROWN 3/4 CAST HIGH NOBLE METL APEX/RECALCIFICATION-INTERIM CROWN 3/4 CAST PREDOM BASE MTL APEX/RECALCIFICATI-FINAL VISIT CROWN 3/4 CAST NOBLE METAL APICOECTOMY CROWN 3/4 PORCELAIN/CERAMIC APICOECT/PERIRAD SURG-BICUSP GOLD FULL CAST CROWN APICOECT/PERIRAD SURG-MOLAR NON-PRECIOUS MET CRN APICOECT/PERIRAD SUR EACH ADDL SEMI-PRECIOUS MET CRN RETROGRADE FILLING PROVISIONAL CROWN ROOT RESECTION RECEMENT INLAYS ENDOSSEOUS IMPLANTS RECEMENT CROWNS INTENTIONAL REIMPLANT W/SPLINT PREFAB STAINLESS CROW SURG TOOTH ISOLATION PREFAB STAINLESS CROW HEMISECTION PREFAB RESIN CROWN CANAL PREP/FITTING PREFAB STAINLESS CROWN W/RESIN GINGIVECTOMY/OPLASTY (4+TEETH) STAINLESS STEEL CROWN PRIMARY GINGIVECTOMY/OPLASY (1-3TEETH) SEDATIVE FILLINGS GINGIVAL FLAP PROC (4+TEETH) CROWN BUILDUPS GINGIVAL FLAP PROC (1-3 TEETH) PIN RETENTION PER TOO APICALLY POSITIONED FLAP CAST POST AND CORE CROWN LENGTHENING HARD TISSUE CAST POST W/CROWN OSSEOUS SURG (4+ TEETH) QUAD PREFAB POST & CORE OSSEOUS SURG (1-3 TEETH) QUAD ADDL PREFAB POST, SAME TOOTH BONE REPLCMNT GRAFT-FIRST SITE LABIAL VENEER LAB PRO BONE REPLCMNT GRAFT EACH ADDL CROWN REPAIR BIO MATERIALS AID TISSUE REGEN PULP CAP DIRECT GUIDED TISS REGENERAT RESORBED PULP CAP INDIRECT GUIDED TISS REGENERA NONRESORB VITAL PULPOTOMY SURGICAL REVISION PROCEDURE GROSS PULPAL DEBRIDEMENT PEDICLE GRAFTS-SOFT PULPAL THERAPY ANTERIO/PRIMARY FREE SOFT TISS GRAFTS PULPAL THERAPY POSTERI/PRIMARY SUBEPITHELIAL CONN TISS GRAFT ENDODONTIC THERAPY - ANTERIOR DISTAL OR PROX WEDGE W/NO SURG ENDODONTIC THERAPY-BICUSPID SOFT TISSUE ALLOGRAFT ENDODONTIC THERAPY-MOLAR COMB CONN TISS/DOUBLE PEDICLE TRMT OF ROOT CANAL OBSTRUCTION SPLINT-INTRACORONAL INCOMPLETE ENDODONTIC THERAPY SPLINT-EXTRACORONAL INTERNAL ROOT REPAIR LIMITED OCCL ADJ ROOT CANAL-4 CANALS PERIODONTAL SCALING-QUAD

4 (206) / DENTAL PLAN B SCHEDULED BENEFITS / PAGE 4 s not listed are not covered by the Dental Plan PERIO SCALING & ROOT PLANNING DENTURE-TEMPORARY LWR FULL MOUTH DEBRIDEMENT TEMP PART STAYPLATE U PERIODONTAL PROPHY TEMP PART STAYPLATE L COMPLETE UPR DENTURE TISSUE CONDITIONING COMPLETE LWR DENTURE TISSUE CONDITIONING MANDIBULAR , IMMEDIATE UPR DENTURE , OVERDENTURE COMPLETE , IMMEDIATE LWR DENTURE , OVERDENTURE PARTIAL PARTIAL UPR DENTURE TOOTH AND CLASP UNIT PARTIAL LWR DENTURE REPLACE OF PRECISION ATTACHMEN PARTIAL UPR DENTURE CAST GOLD PONTIC PARTIAL LWR DENTURE CAST PONTIC , MAXILLARY PARTIAL DENTURE CAST PONTIC , MANDIBULAR PARTIAL DENTURE FLX PORCELAIN/MET PONTIC PARTIAL DENTURE PORCELAIN/MET PONTIC COMPLETE DENTURE ADJ PORCELAIN/MET PONTIC ADJU COMP DENTURE LOW PONTIC - PORCELAIN/CERAMIC PARTIAL DENTURE ADJ PLASTIC/METAL PONTIC PARTIAL DENTURE ADJ PLASTIC/METAL PONTIC REPAIR COMPL DEN BASE PLASTIC/METAL PONTIC REPLACE BROKEN TEETH PROVISIONAL PONTIC REPAIR DENTURE CAST METAL RETAINER REPAIR DENTURE RETAINER - PORC/CERAM FOR PROS REPLACE DENTURE TOOTH REPAIR BRIDGE REPLACE DENT TOOTH-EA ADDT'L INLAY-PORC/CERAMIC, 2 SURF ADD TOOTH PART/DENT INLAY-CAST HIGH NOBLE METAL, ADD TOOTH/PART DENT INLAY-CAST HIGH NOBLE METAL, REATTACH DENTURE CLSP INLAY-CAST BASE METAL, 2 SURF RPLC TEETH/ACRYLIC ON MTL FRAM INLAY-CAST BASE METAL, DUPL COMPLETE DENTURE INLAY-CAST NOBLE METAL, 2 SURF RELEASE COMP LOWER DE INLAY-CAST NOBLE METAL, DUPL PARTIAL DENTURE ONLAY-PORC/CERAM, 2 SURF REL LOWER PARTIAL DEN ONLAY-PORC/CERAM, RELINE COMPL DENTURE ONLAY-CAST HIGH NOBLE METAL, RELINE COMPL DENTURE ONLAY-CAST HIGH NOBLE METAL, RELINE PART DENTURE ONLAY-CAST BASE METAL,2 SURF RELINE PART DENTURE ONLAY-CAST BASE METAL, RELINE COMPL DENTURE ONLAY-CAST NOBLE METAL, 2 SURF RELINE COMPL DENTURE ONLAY-CAST NOBLE METAL, RELINE PART DENTURE PLASTIC/METAL CROWN RELINE PART DENTURE PLASTIC/METAL CROWN DENTURE-TEMPORARY UPR PLASTIC/METAL CROWN

5 (206) / DENTAL PLAN B SCHEDULED BENEFITS / PAGE 5 s not listed are not covered by the Dental Plan , CROWN PORCELAIN/CERAMIC ALVEOLOPLASTY/QUAD PORCELAIN/METAL ABUTMENT ALVEOPLASTY IN CONJUNCTION WIT PORCELAIN/METAL ABUTMENT ALVEOLOPLASTY/QUAD PORCELAIN/METAL ABUTMENT STOMATOPLASTY/ARCH GOLD 3/4 CAST ABUTMENT , STOMOPLASTY/ARCH BASE METAL 3/4 CROWN RADICAL EXCISE-LESION NOBLE METAL 3/4 CROWN EXCISION OF BENIN LESION > PORC/CERAMIC 3/4 CROWN EXCISION OF BENIGN LESION,COMP GOLD FULL CAST ABUTMENT EXCISION OF MALIG LESION < NON-PRECIOUS MET ABUTMENT EXCISION OF MALIG LESION > SEMI-PRECIOUS MET ABUTMENT EXCISION OF MALIG LESION,COMP PROVISIONAL RETAINER CROWN EXCISION TUMOR-LESION CONNECTOR BAR EXCISION TUMOR-LESION RECEMENT BRIDGE REMOVE CYST OR TUMOR STRESS/BREAKER REMOVE CYST OR TUMOR PRECISION ATTACHMENT REMOVE CYST OR TUMOR CAST POST AND CORE REMOVE CYST OR TUMOR CAST POST/BRIDGE RET REMOVAL OF EXOSTOSIS PREFAB POST AND CORE REMOVAL OF EXOSTOSIS - P/SITE BUILD UP POST & CORE REMOVAL OF TORUS PALATINUS COPING-METAL REMOVAL OF TORUS MANDIBULARIS EACH ADDL CAST POST SURG REDUCT OSSEOUS TUBEROSITY EACH ADDL PREFAB POST I & D OF ABSCESS BRIDGE REPAIR, BY RPT I & D OF ABSCESS CORONAL REMNANTS-DECIDUOUS TOO REMOVAL FOREIGN BODY EXTRACTION, ERUPTED TOOTH REMOVE FOREIGN BODIES EXTRACT TOOTH ERUPTED SEQUESTRECTOMY EXTRACT SOFT IMPACT MAXILLARY SINUSOTOMY EXTRACT PART IMPACT SUTURE SIMPLE WOUNDS EXTRACT TOTAL IMPACT FRENECTOMY EXTRACT TOTAL IMPACT EXCISION OF TISSUE SURG ROOT RECOVERY EXC PERICORONAL GINGI ORAL FISTULA CLOSURE PALLIATIVE TREATMENT TOOTH REPLANTATION GENERAL ANESTHESIA TOOTH TRANSPLANTATION GEN ANESTH EACH 15 MI SURG EXPOSE OF TOOTH INTRAVENOUS SED/ANALG-1ST 30MI MOBILIZ ERUPT TOOTH TO AID IV SEDATION, EACH ADDL 15 MIN BIOPSY OF HARD TISSUE PROF CONSULTATION BIOPSY OF SOFT TISSUE HOUSE CALLS SURG REPOSITIONING HOSPITAL CALLS TRANSSEPTAL FIBEROTOM OFFICE VISIT

6 (206) / DENTAL PLAN B SCHEDULED BENEFITS / PAGE 6 s not listed are not covered by the Dental Plan OFFICE VISIT OCCLUSAL GUARD APPLIC OF DESENSITIZING RESIN MINOR OCCL ADJUSTMENT SPECIAL CONSULTATION OCCLUSAL ADJUST COMPL POSTSURGICAL TREAT Root Canal Therapy includes treatment plan, clinical procedures and follow-up care; excludes final restoration. Free Soft Tissue Grafts not payable if performed in conjunction with Osseous Surgery or Gingivectomy. Extractions include local anesthesia and routine post-operative care. THERE IS NO MISSING TOOTH CLAUSE. BENEFITS WILL BE CONSIDERED BASED ON THE DATE THE PROSTHETIC IS SEATED.