Administered by Welfare & Pension Administration Service, Inc. All Participants of the Hotel Employees Restaurant Employees Health Trust
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1 Hotel Employees Restaurant Employees Trust Funds nd Avenue, Suite 300 P. O. Box Seattle, Washington Phone (206) or (800) Fax (206) Administered by Welfare & Pension Administration Service, Inc. TO: FROM: All Participants of the Hotel Employees Restaurant Employees Health Trust The Board of Trustees RE: Dental Plan Changes Effective January 1, 2008 This is a Summary of Material Modification describing a recent benefit change adopted by the Board of Trustees. Please be sure that you and your family read this notice carefully. It should be kept with your benefit booklet or insurance records for future reference. This is to inform you of important changes to your Dental Plan benefits that go into effect January 1, The following materials are enclosed: o New Language for Dental Implant Benefits o New Schedule of Benefits for Pacific Dental Alliance Providers o New Pacific Dental Alliance Provider Listing o New Schedule of Benefits for Non-Pacific Dental Alliance Providers Please read these documents carefully and keep them with your Plan Booklet, and other important Trust documents so you can refer to them when necessary. If you have any questions regarding these changes, please contact the Administration Office at Trust Administration Office Hotel Employees Restaurant Employees Health Trust GG:mc opeiu#8 S:\SHARED SEC\Docs\F19\F19-02 Dental Benefit Ltr.doc Enclosures
2 HOTEL EMPLOYEES RESTAURANT EMPLOYEES HEALTH TRUST Dental Benefit Update The following provisions will be included under the Dental Plan effective January 1, 2008: o Implants Surgical placement or removal of implants or attachments to implants is covered up to the allowance of a crown. Replacement of implants and superstructures is covered only after 5 years have elapsed from any prior provision of the implant. These benefits are subject to the calendar year maximum provided by the plan. GG:mc opeiu#8 S:\SHARED SEC\Docs\F19\F19-02DentUpdateJan08.doc
3 HOTEL EMPLOYEES RESTAURANT EMPLOYEES HEALTH TRUST SCHEDULE OF DENTAL BENEFITS EFFECTIVE JANUARY 1, 2008 FOR PACIFIC DENTAL ALLIANCE PROVIDERS Benefit Allowance Procedure Description Current Revised Code Effective 1/1/08 Diagnostic 150 Comprehensive Oral Evaluation $31 $ Xray - Complete Series $68 $ Intraoral Periapical Each Add. $3 $5 Preventive 1110 Prophylaxis - Adult $70 $90 Restorative 2391 Resin - One Surface, Posterior $89 $ Resin - Two Surface, Posterior $119 $ Resin - Three Surface, Posterior $150 $ Resin - Four Surface, Posterior $134 $220 Endodontics 3310 Root Canal Therapy - Anterior $300 $ Root Canal Therapy - Bicuspid $400 $ Root Canal Therapy - Molar $500 $650 Periodontics 4341 Periodontal Scaling and Root Planning $94 $ Periodontal Maintenance $73 $125 Prosthodontics 5110 Complete Dentures - Maxillary $600 $ Complete Dentures - Mandibular $600 $750 Oral Surgery 7140 Extraction - Erupted Tooth or Root $70 $ Surgical Extraction - Erupted $150 $200 - OVER - mc opeiu#8 S:\SHARED SEC\XLSHEETS\F19-02PDA /26/07
4 The dental offices listed below will accept the HERE Trust Dental Plan as payment-in-full. This means HERE members and their families who are covered by the Trust Dental Plan will pay nothing for dental care provided within the limits of the dental plan.* Bellevue/Factoria (425) SE 40 th Lane Ste 201 Edmonds (425) Highway 99 Ste 100 Kent/Covington (253) SE 271 st St. Ste 211 Spokane (North) (509) E. Holland Ave. Washington State Locations (Offices of Pacific Dental Alliance) Bellingham (360) Lee Family Dental 3800 Byron Ave. Ste 122 Everett (425) Evergreen Way Ste 212 Mt. Vernon (360) Patel Dental Care 120 S. 15 th St. Ste A Spokane Valley (509) E. Cataldo Ave. Bremerton (360) Wheaton Way Ste B Federal Way (253) Sterling Dental Care Pacific Hwy S. Ste 111 Olympia/Tumwater (360) Capitol Blvd. SW Tacoma (253) S. Oakes St. Ste 103 Burien (206) st Ave. S. Kennewick (509) W. Deschutes Ave. Puyallup (253) nd St. E. Ste D Dentists: Steven Paige, Aditi Agarwal, Kenza Houki, Choong Lee, Bob Virk, Evy Kollia, Danlu Lee, Wendy Yeung, Katherine Kim, Rattan Bains, Naguib Youssef, Andrea Doan, Michael Nguyen, Navdeep Virk, Trent Webb, Angelina Fu, Gabor Klade, Spencer Cammack, Joe Lee, Varun Sharma, Jasjot Mann, Rezene Laurel, Michael Kim, Shioon Kim, Raman Patel. Oregon State Locations (Offices of Access Dental) Gresham (503) E. Powell Blvd. Drs.: Bob Virk and Brian Waldau Clackamas (503) SE Sunnyside Rd., Suite 250 Drs.: Bob Virk and Benjamin Beard This offer applies to members covered by the HERE Trust Dental Plan. This offer is valid through January Implants, implant crowns, crowns with gold, all porcelain crowns, porcelain onlays/inlays, and specialty services performed in or out of these offices are not included. - OVER - mc opeiu#8 S:\SHARED SEC\Docs\F19\F19PDALocations.doc 12/26/07
5 HOTEL EMPLOYEES RESTAURANT EMPLOYEES HEALTH TRUST SCHEDULE OF DENTAL BENEFITS EFFECTIVE JANUARY 1, 2008 FOR NON PACIFIC DENTAL ALLIANCE PROVIDERS Benefit Allowance Procedure Revised Description Current Code Effective 1/1/08 Diagnostic 120 Periodic Oral Examination $19 $ Emergency Oral Examination $25 $ Limited Oral Evaluation $25 $ Comprehensive Oral Evaluation $23 $ Xray - Complete Series $48 $ Intraoral Periapical First Film $7 $ Intraoral Periapical Each Add. $4 $3 240 Intraoral Occlusal Film $22 $ Bitewings Four Films $19 $ Panoramic Film $46 $ Pulp Vitality Tests $16 $25 Preventive 1110 Prophylaxis - Adult $34 $ Dental Prophylaxis - Children $34 $ Fluoride (Excluding Prophy) - Children $16 $ Fluoride (Excluding Prophy) - Adult $16 $ Sealant per Tooth $0 $ Space Maintainer Fixed Unilated $113 $ Space Maintainer Fixed Bilateral $170 $150 Restorative 2140 Amalgam One Surface $32 $ Amalgam Two Surface $49 $ Amalgam Three Surface $67 $ Amalgam Four/More Surface $85 $ Comp Resin One Surface Anterior $45 $ Comp Resin Two Surface Anterior $69 $ Comp Resin Three Surface Anterior $102 $ Comp Resin Four/More Surface Anterior $134 $ Resin - One Surface, Posterior $48 $ Resin - Two Surface, Posterior $74 $ Resin - Three Surface, Posterior $110 $ Resin - Four Surface, Posterior $134 $ Crown Porcelain with High Noble $365 $ Crown Porcelain with Predomina $365 $ Crown Porcelain with Noble Metal $365 $ Crown Full Cast High Noble Metal $322 $ Recement Crown $27 $ Prefab Stainless Steel Crown $87 $ Crown Buildup $84 $ Pin Retention per Tooth Addition $21 $ Cast Post/Core in Addition to $123 $ Prefab Post/Core in Add to Crown $108 $150 Endodontics 3110 Pulp Cap Direct (Excl Final Resin) $22 $ Therapeutic Pulpotomy Excluded $50 $ Root Canal Therapy - Anterior $235 $ Root Canal Therapy - Bicuspid $316 $ Root Canal Therapy - Molar $391 $ Four/More Canals Excluding $0 $ Anterior Retreatment of Root Canal $316 $500 - OVER -
6 SCHEDULE OF DENTAL BENEFITS EFFECTIVE JANUARY 1, 2008 FOR NON PACIFIC DENTAL ALLIANCE PROVIDERS Benefit Allowance Procedure Revised Description Current Code Effective 1/1/08 Endodontics (cont.) 3347 Bicuspid Retreatment of Root Canal $468 $ Molar Retreatment of Root Canal $563 $700 Periodontics 4210 Gingivectomy Gingivoplasty 4 $155 $ Gingival Curettage Per Quadrant $55 $ Crown Lengthening Hard Tissue $155 $ Osseous Surg-Inc Flap Entry $348 $ Bone Replacement Graft $179 $ Free Soft Tissue Graft $181 $ Provisional Splinting Extracor $139 $ Periodontal Scaling and Root Planning $82 $ Periodontal Maintenance $60 $73 Prosthodontics 5110 Complete Dentures - Maxillary $542 $ Complete Dentures - Mandibular $542 $ Immediate Upper Denture $542 $ Immediate Lower Denture $542 $ Upper Partial Acrylic Base $278 $ U Partial Cast Metal Frame $581 $ L Partial Predom Base Cast Bas $581 $ Repair Broken Complete Denture $47 $ Replace Missing/Broken Tooth $38 $ Repair Resin Denture Base $47 $ Repair Cast Framework $62 $ Repair or Replace Broken Clas $55 $ Replace Broken Teeth Per Tooth $38 $ Add Tooth to Existing Partial $62 $ Reline Upper Partial Denture $139 $ Reline Upper Complete Denture $155 $ Reline Lower Complete Denture $155 $ Reline Lower Partial Denture $155 $ Reline Lower Partial Denture $155 $ Interim Complete Denture (Upper) $193 $ Interim Partial Stayplate Dent $193 $ Interim Partial Stayplate Lower $193 $ Tissue Conditioning Maxillary $62 $60 Other 6241 Pontic Porcelain with Predominant $297 $ Crown Porcelain with Predomina $379 $ Recement Bridge $49 $80 Oral Surgery 7111 Simple Extraction First Tooth $42 $ Extraction - Erupted Tooth or Root $42 $ Surgical Extraction - Erupted $68 $ Removal of Impacted Tooth So $98 $ Removal of Impacted Tooth Pa $135 $ Removal of Impacted Tooth Co $179 $ Surgical Removal of Residual $78 $ Alveoloplasty in Conjunct W/E $98 $ Surg Incision & Drain of Abcess $41 $125 mc opeiu#8 S:\SHARED SEC/XLSHEETS/F19-02PDAIncrJan08 12/27/07
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Age Limitation Covered One per 6 months per dentist or dental group. Only one exam (D0120) every 6 months per dentist or dental D0120 iodic oral evaluation 0-20 No group. D0140 Limited oral evaluation
CHOICES Patients Covered dental services
CHOICES Patients Covered dental services Important points: There is a $7 co-pay for each covered service visit at the UF College of Dentistry except for some denture therapy services which may require
Staywell FL Child Medicaid Plan Benefits
The following is a complete list of dental procedures for which benefits are payable under this Plan. For beneficiaries under age 21, additional coverage may be available with documentation of medical
TX Prepaid DHMO Dental
TX Prepaid DHMO Dental Good news about dental benefits for employees of Pearland Independent School District A Dental Plan Means Healthy Smiles Because you are a valued employee, we are pleased to offer
Dental Benefits Summary
PATIENT PAYS PATIENT PAYS CODE PROCEDURE CODE PROCEDURE Office Visit Copay $0 DIAGNOSTIC D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series Images D0330 Panoramic
GUARANTY ASSURANCE COMPANY
Effective: July 1, 201 2 Member Eligibility: (866) 436-3093 GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual Procedure Code Procedure Description DiagnOstiC D0999 Disposables
SCHEDULE OF BENEFITS. Tests and Examinations D0460 Pulp vitality tests $0 D0470 Diagnostic casts $0
SCHEDULE OF BENEFITS DENTAL PLAN This sample Schedule of Benefits lists the services available to you under your SafeGuard plan as well as the copayments associated with each procedure. There are other
Improve your smile and overall well-being with. Dental Health Services. Dental Health Services. Difference today!
Improve your smile and overall well-being with Dental Health Services Great oral health is essential for your overall well-being. With a Dental Health Services plan, you can achieve a healthy smile while
LIST OF COVERED DENTAL SERVICES PREVENTIVE SERVICES
The Guardian Life Insurance Company of America A Mutual Company Incorporated 1860 by the State of New York 7 Hanover Square, New York, New York 10004 (212)598-8000 DENTAL POLICY OUTLINE OF COVERAGE This
DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008
DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO TABLE OF ALLOWANCE The Delta Dental PPO table plan
Delta Dental PPO EPO PLAN DESIGN THE NORFOLK CONSORTIUM
Delta Dental PPO EPO PLAN DESIGN THE NORFOLK CONSORTIUM SCHEDULE OF BENEFITS AND COPAYMENTS/ The benefits shown below are performed as deemed appropriate by the attending Dentist subject to the limitations
EXHIBIT A PROCEDURE DESCRIPTION MSP50809 CDT CODE
D0120 Periodic Exam 28.00 D0140 Limited Oral Evaluation Problem Focused 42.00 D0145 Oral Evaluation for a Patient Under Three Years of Age and Counseling with Primary Caregiver 38.00 D0150 Comprehensive
PLEASE READ IMPORTANT PLAN INFORMATION AT THE END OF THIS SCHEDULE
Careington Corporation Care POS Schedule CI-4 Please Call 800-290-0523 for Customer Service ***Discount plans are not insurance*** This schedule applies to services provided by a participating General
Dominion Dental Services
Dominion Dental Services Plan 603X Presented by Professional Benefit Administrators 1 (800) 578-2082 SUMMARY OF BENEFITS AND COPAYMENTS Enrollee pays DIAGNOSTIC Office Visit/Infectious Disease Control.....$
02130 Cavities involving three surfaces 10.00
( ) 02130 Cavities involving three surfaces 10.00 AMALGAM RESTORATIONS, PERMANENT TEETH: 02140 Cavities involving one tooth surface $ 5.00 02150 Cavities involving two tooth surfaces 8.00 02160 Cavities
23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company
www.bcbsla.com 23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company 1 Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are
CIGNA Dental Care (*DHMO) Patient Charge Schedule
A2O07 CIGNA Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered
Access Dental Family DHMO
866-569-9900 HTTPS://MYDENTAL.GUARDIANLIFE.COM SCHEDULE OF BENEFITS Access Dental Family DHMO This Schedule of Benefits lists the services available to you under your Access Dental Individual & Family