CARPENTERS HEALTH & WELFARE DENTAL BENEFITS

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1 CARPENTERS HEALTH & WELFARE DENTAL BENEFITS Introduction The dental plan offers you and your eligible dependents financial protection against the cost of dental care expenses resulting from non occupational sickness or injury. The dental benefits are paid directly out of the assets of the Plan. However, the Plan has a contract with Delta Dental of Missouri, LLC under which Delta Dental receives, and processes dental claims on the Plans behalf. The Plan encourages preventive and ongoing maintenance care. Dental care benefits are provided automatically to members eligible under the Active Classification and their eligible dependents. Dental care benefits are available as an optional coverage at additional premium to members eligible under the Non Active Classification and their eligible dependents upon enrollment under that classification. Thereafter, Non Active members may enroll during open annual enrollment. The premium is determined periodically by the Trustees. Benefits Paid by the Plan FEE TYPE Delta Dental PPO Delta Dental Premier or OON Deductible, preventative none $25 Deductible, basic or major $25 $25* Annual Benefit Maximum $2,000** $2,000** Lifetime Benefit Maximum for Orthodontia $1,500 $1,500 *One time deductible per calendar year. If deductible previously fulfilled, no further deductible required. **Annual maximum benefit does not apply to dependent children ages 0 up to 19 for preventive dental services. Generally The Plan has an agreement with Delta Dental LLC to provide you and your dependents with access to a network of dentists. Under these agreements, dental care providers who are members of the Delta Dental network have agreed to charge specified fees for their services and in most cases, these fees are lower than their normal fees. The Delta Dental Network is made up of two separate Networks, Delta Dental PPO and Delta Dental Premier. To receive the highest level of benefits, you must receive care from a Delta Dental PPO Network Provider. Although you may go to any dental care provider you choose for dental care, you will receive the highest level of reimbursement from the Plan when you use a Delta Dental PPO provider. A Delta Dental PPO Provider Directory can be obtained from the Fund Office upon request or you can also access the Network s website for a list of Providers at and selecting the Networks tab/ Delta Dental PPO. Selecting your Dentist You may visit the dentist of your choice and select any dentist on a treatment by treatment basis. It is important to remember your out of pocket costs will vary depending on your choice. You have three options: (1) Delta Dental PPO Network Delta Dental s PPO network consists of dentists who have agreed to accept payment based on the lesser of usual fees or the applicable PPO Maximum Plan Allowance and to abide by Delta Dental policies. The network offers you cost control and claim filing benefits as well as the highest fee schedule allowable by the Plan. You will have the least

2 out of pocket for your dental services if a Delta Dental PPO Network dentist is used and preventive type services are covered at 100%. (2) Delta Dental Premier Network Delta Dental s Premier network consists of dentists who have agreed to accept payment based on the lesser of filed fees or the applicable Premier Maximum Plan Allowance. This Network also offers you some cost control and claim filing benefits. However, your out of pocket expenses will be higher with a Premier dentist due to the lower fee schedule allowable by the Plan and the lower discounts negotiated. (3) Non Participating (Out of Network) Dentist If you go to a non participating dentist (not contracted with Delta Dental plan), your benefit is based on the lesser of the dentist s billed charge or the amount allowed under the Plan s out of network fee schedule allowable. It is your obligation to make full payment to the dentist and file your own claim within 365 days from the date your claim is incurred in order to be reimbursed for these claims. Predetermination of Benefits Whenever the charges of a dentist for a proposed course of treatment are expected to be $300 or more and is not emergency care, a predetermination of benefits is advised. By using this procedure, you will have an advance estimate of what portion of the cost will be covered. The dentist s treatment program is filed to Delta Dental for predetermination of benefits prior to services being performed. This treatment program details the condition of the patient s mouth, the dentist s proposed services and the charges for those services. Delta Dental will then determine whether the treatment and the related expenses are appropriate, and will notify you and your dentist of the estimated benefits payable based on the planned course of treatment. If a description of the procedures to be performed and an estimate of the dentist s charges are not submitted in advance, benefits will be payable in accordance with the standard features of the Plan and may be less than you expect. Predetermination of benefits is not intended to interfere with your relationship with your dentist. Rather, it is intended to provide useful information to you and your dentist. You are both informed, in advance of the treatment, of the estimated benefits payable for the proposed course of treatment and of the expenses that will remain your full responsibility. Alternate Treatment Plan Situations frequently arise where there are two or more possible methods of treating a particular dental condition. In these situations, the amount included as covered dental expenses will be limited to the reasonable and customary charges for services that are customarily employed nationwide in the treatment of that condition and recognized by the dental profession to be appropriate in accordance with broadly accepted nationwide standards of dental practice, taking into account the total current oral condition of the covered individual. Seeking a higher cost treatment plan when another lower cost treatment plan is just as proven and effective may result in you paying more out of pocket it is always advisable to obtain a predetermination in advance to know what your options are. See exclusion # 36. Annual Dental Deductible The annual dental deductible is the amount of covered dental expenses you must pay each year before you receive dental benefits from the Plan. The deductible is the first $25 of covered expenses submitted to the Plan for dental care incurred in each calendar year. The $25 deductible is waived for preventative care services that are obtained from a Delta Dental PPO Network Dentist. The deductible does not apply to orthodontia care.

3 Annual Benefit Maximum The maximum calendar year benefit for all covered dental services for each covered individual per calendar year is $2,000. However, please note that the annual maximum limitation does not apply to dependent children ages 0 up to 19 for preventive dental services. The maximum benefit for covered orthodontia expenses for each covered individual s lifetime is $1,500 per lifetime. Dental Benefits Paid by the Plan Generally Subject to all other provisions of this Plan, dental benefits are payable at 100% up to the maximum fee shown in the Dental Fee Schedule for PPO Network Services and for Premier and Out of Network Dentists. The dental plan is not designed to cover all of your dental expenses. Please refer to the current Dental Fee Schedule for more information. Oral Surgery The Plan will treat as covered expenses services related to the surgical removal of teeth performed at the physician s office. Surgeries where it is medically necessary to perform the services in an ambulatory surgical center or hospital must be pre approved to determine appropriateness of care. Covered charges may also include related radiology, pathology and anesthesiology. Any portion of a charge that exceeds the fee schedule allowable is not covered by the Plan. Dental Benefits Exclusions and Limitations No benefits are provided under these Dental Care Provisions for any of the following: 1. Services or supplies for which the enrollee, absent this coverage, would normally incur no charge, such as care rendered by a dentist to a member of his immediate family or the immediate family of his spouse. 2. Services or supplies arising out of the course of any occupation or employment for compensation, profit or gain, or for which the covered individual may be entitled to or receives benefits under any applicable Workers' Compensation Act, Occupational Disease policy or similar law (including settlement of a claim). 3. Charges for services not specified in the Dental Fee Schedule. However, if a charge for a particular service is not included in the Dental Fee Schedule, but the Schedule contains one or more services which, according to customary dental practices, are separately suitable for the dental care of that condition, then a charge will be considered to have been incurred for a service listed in the Schedule that would have produced a professionally satisfactory result. 4. Anything not furnished by a dentist, except X rays ordered by a dentist and services by a licensed dental hygienist under the dentist s supervision. 5. Services or supplies performed for cosmetic purposes or to correct congenital malformations. 6. Charges that are not reasonably necessary or customarily provided for the covered individual s dental condition. 7. Services furnished by or for the U.S. government or any other government unless payment is legally required, or to the extent provided under any governmental program or law under which the individual is, or could be, covered. 8. A denture or fixed bridgework or adding teeth thereto, or a crown or gold restoration, if the denture, fixed bridge, crown or gold restoration is a replacement or modification of one installed less than five years previously.

4 9. Services or supplies related to temporomandibular joint (TMJ) dysfunction (this involves the jaw hinge joint connecting the upper and lower jaws). 10. Duplication or replacement of lost or stolen appliances. 11. Diseases contracted or injuries or conditions sustained as a result of any act of war. 12. Denture adjustments for the first six months after the dentures are initially received. Separate fees should not be charged by participating dentists. 13. Tooth preparation, temporary crowns, bases, impressions and anesthesia or other services which are part of the complete dental procedure. These services are considered components of, and included in the fee for the complete procedure. Separate fees may not be charged by participating dentists. 14. Analgesia, including Nitrous Oxide, duplication of radiographs or temporary appliances. 15. A portion of a charge for a service in excess of the fixed schedule amount detailed on the Fee Schedule. 16. Any dental services to the extent that benefits are payable under the medical benefits of this Plan. 17. Services rendered beyond the scope of a dentist s or service provider s license or charges for services or supplies that do not meet accepted standards or dental practice or that are experimental or investigative in nature. (See definition of experimental or investigative in Appendix D.) 18. Oral hygiene and dietary instruction or plaque control programs. 19. Failure to keep a scheduled appointment with the dentist. 20. Completion of claim forms. 21. Charges for personalization or characterization of dentures. 22. Charges for services or supplies that are cosmetic or reconstructive in nature, unless required as a result of an accidental injury and provided as soon as medically appropriate. Generally, cosmetic and reconstructive procedures alter appearance but do not restore or improve impaired physical function. Facings on crowns, or pontics, posterior to the second bicuspid will always be considered cosmetic. 23. Charges for medications, infection control or medical waste disposal. 24. Injury or sickness resulting from participation in, or as a consequence of having participated in, any criminal or illegal conduct or enterprise. 25. Benefits are limited to two routine examinations and cleanings per calendar year. 26. Treatment, services or supplies received as a result of any injury or sickness sustained due to the act or omission of a third party, unless the covered individual has fully complied with the reimbursement and subrogation provisions of this Plan. 27. Charges for fluoride or sealants are limited to dependents up to the age of A panoramic film with or without other films is considered equivalent to a full mouth series for coverage purposes. Coverage for multiple radiographs on the dame date of service will not exceed the coverage level for complete mouth series. 29. Endodontic (root canal treatment) on the same tooth is covered only once in a 2 year period. Retreatment of the same tooth is allowed when performed by a dental office.

5 30. Charges for replacement of filling restorations are only covered once in a 24 month period, unless the damage to that tooth was caused by accidental injury not related to the normal function of the tooth or teeth. 31. If an existing bridge or denture cannot be repaired satisfactory, a replacement will be covered only once in 5 years, but not during the first year of Coverage Benefits. 32. Dental benefits for an initial or replacement crown, jacket, labial veneer, inlay or onlay on or for a particular tooth will only be provided once in 5 years, unless the damage to that tooth was caused by accidental injury not related to the normal function of the tooth or teeth. 33. If your coverage is terminated before an orthodontic treatment plan is completed, coverage will be provided only to the end of the month of termination. 34. Benefits will not be paid for repair or replacement of an orthodontic appliance. 35. After completion of your orthodontic treatment plan or reaching your orthodontic lifetime maximum, no further orthodontic benefits will be provided. 36. If you receive care from more than on dentist or service provider for the same procedure, benefits will not exceed what would have been paid to one dentist for the procedure (including, but not limited to prosthetics, orthodontics, and root canal therapy). If alternative treatments are available, your coverage will only pay for the least costly professionally satisfactory treatment. This would include, but is not limited to, services such as composite resin filling on molar teeth, in which case the benefits are based on the allowed amount for an amalgam (silver) filling; or services such as implants, in which case the benefits may be based on the allowed amount for a fixed bridge or removable partial denture. 37. Sealants are limited to caries free occlusal surfaces of the first and second permanent molars. 38. A panoramic film with or without other films is considered equivalent to a full mouth series for coverage purposes. Coverage for multiple radiographs on the same date of service will not exceed the coverage level for complete mouth series. 39. If coverage is terminated before completion approved orthodontic treatment for any reason, all benefits for such approved treatment will cease with payment through the end of the month in which the effective date of such termination occurs. 40. After the completion of orthodontic Dental Services in an approved treatment plan, no further orthodontic benefits will be provided unless the lifetime maximum has not been reached. 41. All Coordination of Benefit Rules, definitions, filing limits and other limitations applicable to the medical plan are also applicable to the dental plan. How to file a Claim Your claims must be filed within 365 from the day in which services were rendered. The Plan is not obligated to pay claims submitted after this period. If a claim is denied due to a PPO or Premier participating dentist s failure to make timely submission, you will not be liable to such dentist for the amount which would have been payable by the Plan, provided you advised the dentist of your eligibility for benefits at the time of treatment. Services obtained at an out of network provider are your responsibility to file for reimbursement consideration with the Plan.

6 Additional Plan Definitions Dental A. DDMO refers to Delta Dental of Missouri (a member of the Delta Dental Plans Association), and its successors and assigns. B. Delta Dental Plan means a member of the Delta Dental Plans Association, including DDMO. C. Delta Dental PPO or PPO means the preferred provider organization available from and through DDMO pursuant to this Agreement. D. Dental Services or Dental Care means those necessary services and care for which coverage and benefits are provided for under the terms and provisions of the Plan. E. Dentist means a dentist duly licensed and legally qualified to practice dentistry at the time and place covered dental services are performed. F. Maximum Plan Allowance means the amount determined by Delta Dental as the highest amount allowed for a particular procedure, service, or item for the particular Dentist or service provider. The amount allowed for a particular Dentist or service provider depends on its, his or her participation status (e.g., PPO Dentist, Premier Dentist or Non Participating Dentist). L. Premier Dentist mean a Dentist or service provider who has or participates under a participation agreement with a Delta Dental Plan for rendering Dental Care and to accept payment based on the applicable Maximum Plan Allowance for a Premier Dentist. M. Non Participating Dentist or Out of Network Dentist means a Dentist or service provider who does not have or participate under a participation agreement with a Delta Dental Plan for rendering Dental Care and who has not agreed to accept payment based on the applicable Maximum Plan Allowance for a Premier Dentist or PPO Dentist. N. Participating Dentist or In Network Dentist means a Dentist or service provider who has or participates under a participation agreement with a Delta Dental Plan for rendering Dental Care and who has agreed to accept payment based on the applicable Maximum Plan Allowance for a Premier Dentist or PPO Dentist. O. PPO Participating Dentist or PPO Dentist mean a Dentist or service provider who has or participates under a participation agreement with a Delta Dental Plan for rendering Dental Care and to accept payment based on the applicable Maximum Plan Allowance for a PPO Participating Dentist. P. PPO Program means the program available through DDMO under which Participants have access to DDMO s network of PPO Dentists and DDMO s network of Premier Dentists for their dental benefits, and dental benefits may also be available when services are rendered by a Non Participating Dentist. Q. Schedule of Benefits means the Carpenters Dental Fee Schedule which sets forth the extent to which benefits will be provided to an eligible member or an eligible dependent. S. Treatment Plan means a written report showing the recommended treatment of any dental disease, defect or injury for an Enrollee prepared by a Dentist, as a result of any examination made by such Dentist, while Membership is in effect for the Enrollee. How to Appeal a Denied Claim or Adverse Benefit Determination After receiving notice of claim denial, the covered person or his/her authorized representative must submit a written request to the Board of Trustees for their review and final decision. Any request for

7 review must be filed within 180 days of the date of the claim denial. A request for review must be directed to: Board of Trustees Benefit Plans Administrator Carpenters Health and Welfare Plan 1419 Hampton Avenue St. Louis, Missouri When requesting a review, the claimant or his/her authorized representative should state the reason they believe the claim denial was improper and submit any comments, documents, records or other information which is considered appropriate. The Trustees will consider all such submissions as part of the review. The claimant or his/her authorized representative may have reasonable access to, and copies of, all documents, records or other information relevant to the claim upon request free of charge. As required by law, the Board of Trustees claim review will not give deference to the original claim decision. If the original claim denial was the result of a medical judgment, the Plan will consult with a healthcare professional who has the appropriate training and experience to render an informed opinion. The healthcare professional will not be the one used for the original claim determination of his/her subordinate. Such individual or entity will be disclosed upon written request to the Board of Trustees. The Board of Trustees, as fiduciaries of the Plan, will generally make a decision on the review within 45 days after receipt of the request for review, unless special circumstances require an extension of time for processing in which case a decision will be made as soon as possible, but not later than 90 days after receipt of the request for review. If such an extension is required, a claimant or his/her authorized representative will be notified within 45 days after receipt of the request for review. Notice of the Trustees decision to deny the appeal in whole or in part on the review will be in writing and will include the specific reasons for the decision, as well as specific references to the pertinent Plan provisions on which the decision is based and other information of the types contained in the initial notice advising the member that the claim has been denied. The decision of the Trustees is final. Any civil action under Section 502(a) of the Employee Retirement Income Security Act must be filed within two years of the date of the Trustees decision. Please refer to the Plan Document located on the website at for additional information.