Teachers' Dental Plan Maximum Reimbursement Levels
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1 Teachers' Superannuation Commission Dentist Payment Schedule Teachers' Dental Plan Maximum Reimbursement Levels January 1, 2019 Teachers' Teachers' Dental Dental Description Code Plan Description Code Plan Level I 100% - Preventive Services - Reimbursed - once per 24 months at 100% of the dental charges to the maximums indicated below Oral Examination new patient-primary new patient-mixed new patient - permanent Tests I.c. - new patient - limited previous patient (twice per year) specific emergency Stomatognathic, dysfunctional Prosthodontic I.c. Orthodontic new patient casts Polishing (once per year) Scaling * (8 units per year) * Photographs * * * * Study Models - unmounted * * mounted * * (*2 units per year maximum reimbursed at 100% of Treatment Planning the dental charges indicated above.) (*6 units per year maximum reimbursed at 85% of the dental charges indicated above.) Topical Flouride Application Oral Hygiene Instruction (once per year) X-Rays Sealants full mouth (once per 24 months) bitewing/apicals (twice per year) Topical Application Appliances Mouth Guards Space Maintainers Anatomic Modifications Porcelain/Ceramic Level II 85% - Basic and Routine Services
2 Reimbusement at 85% of Dental charges to the maximums indicated below Amalgam, Composite or Onlays - Metal Acrylic Fillings Porcelain/Ceramic Retentive Pins Posts Extractions Dental Surgery (including x-rays and lab) Residual Root Removal Alveoplasty Surgical Excision Surgical Incision TMJ - Appliance Splints * * Oral Surgery Inlays - Metal Endodontics Root Canal Therapy Composite
3 Appliance * Periapical Services * * * * * * * * Adjustments, Repairs * * I.c Surgical Retrofilling Surgical Services - Miscellaneous Periodontal Splinting Occlusal Adjustment Pulpotomy Emergency Treatment for Dental Pain Pulpectomy Pulp Capping Sedative Dressing Anesthesia Emergency Services Bleaching - Non Vital Periodontics-Non Surgical Root Planing
4 * Professional Services * * * * * * * * * I.c. * I.c. * I.c. * Repairs to Existing * * Dentures * * * * * * * * * * * * * * Relines and Rebasing of * * Existing Dentures * * * * * * * * * * * * * * * Denture Adjustments * * * * * * * Stainless Steel Crown * * Recementing Existing * Inlay or Crown * * * * Note: * Laboratory charges are eligible expenses where * applicable. These costs will be reimbursed at 85% under * the Basic and Routine sections. * ** I.c. will be reimbursed at 85% of dentist charge. Initial Installation or * Replacement of Fixed * I.c. Level III 60% - Major Restorative - Reimbursed at 60% Bridges of Dental charges to the maximum indicated below. * * Plastic Bonding * * * * * * * Initial Installation or * Replacement of Crown * * * * * * * * * * * * * * * * * Initial Installation or * * Replacement of Complete * * or Partial Dentures * * * * * * * * Rebase complete denture Repairs and Recementing * Maxillary (upper)
5 of Existing Fixed Bridge * Mandibular (lower) * Maxillary and Mandibular * Rebase partial denture * Maxillary (upper) * Mandibular (lower) * Maxillary and Mandibular * * Repairs to Existing Dentures * * Repair, no impression required * Complete * Maxillary (upper) * Mandibular (lower) Partial Note: * Laboratory charges are eligible expenses where Maxillary (upper) applicable. These costs will be reimbursed at 60% under Mandibular (lower) the Major Restorative Services. Repair, impression required Complete ** I.c. will be reimbursed at 60% of dentist charge. Maxillary (upper) Mandibular (lower) 1. Procedure Codes involving the use of gold will be Partial covered if no other substitute is deemed suitable. Maxillary (upper) Where gold is elective, only the cost of customary Mandibular (lower) substitute will be considered for reimbursement. NOTE: All services include laboratory charges. 2. Placement of crowns, bridges or dentures will be covered if existing appliance is at least five (5) years old and cannot be made serviceable or where necessitated through the removal of additional natural teeth while insured. Major Services - Reimbursed at 60% of Denturists charges to the maximum plan reimbursement. Initial Installation or Replacement Complete Dentures 3. The administrator is authorized to establish liability Maxillary (upper) under the plan based on the least expensive benefit if Mandibular (lower) it will produce a professionally adequate result. Maxillary and Mandibular Partial Denture, Acrylic Base, Level IV 50% - Orthodontic Services for Audlts and No Clasps (1 tooth) Dependent Children - Maxillary (upper) Reimbursed at 50% of dental charges. Mandibular (lower) Maxillary and Mandibular Reimbursement is provided at 50% for all reasonable Partial Denture (semi-precision) Metal Base, Cast or and customary charges for orthodontic services for adults Wrought Clasp and Rests (tooth borne) and dependent children of eligible teachers to a lifetime Maxillary (upper) * maximum of $2,000 per individual. Where a teacher Mandibular (lower) * is married to a teacher and both are eligible for dental Maxillary and Mandibular * coverage, the lifetime maximum for each dependent Partial Denture (semi-precision) Metal Base, Cast or will amount to $4,000 per individual. Wrought Clasp and Rests (free end) Maxillary (upper) * DENTURISTS Mandibular (lower) * Routine Service - Reimbursed at 85% of Denturists Maxillary and Mandibular * charges to the maximum plan reimbursement Partial Denture (precision) Metal Base, Cast or Wrought Clasps and Rests (free end) Relines and Rebases to Maxillary (upper) * Existing Dentures Mandibular (lower) * Reline complete denture Wrought Clasps * (self polymerizing) Installation of additional tooth or teeth clasps to Maxillary (upper) existing dentures (necessitated through removal of Mandibular (lower) natural tooth or teeth while insured) Maxillary and Mandibular * Reline partial denture * (self polymerizing) Maxillary (upper) Note: * Casting costs are eligible expenses where Mandibular (lower) applicable. These costs will be reimbursed at 60% Maxillary and Mandibular under the Major Services. Reline complete denture (lab processed) 1. Procedures involving the use of gold will be covered Maxillary (upper) if no substitute is deemed suitable. Where gold is Mandibular (lower) elective, only the cost of customary substitute will be Maxillary and Mandibular considered for reimbursement. Reline partial denture (lab processed) 2. Replacement of dentures will be covered if existing Maxillary (upper) appliance is at least five (5) years old and cannot be Mandibular (lower) made serviceable, or where necessitated through the Maxillary and Mandibular removal of additional natural teeth while insured.
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Dental Metropolitan Life Insurance Company Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic (fillings, extractions) Type C: Major (bridges, dentures) Type D:
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
Dental Benefits Summary
CODE PROCEDURE Office Visit Copay PATIENT PAYS CODE $5 DIAGNOSTIC PROCEDURE PATIENT PAYS D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 FMS (inc. BWX) D0330 Panoramic X-Ray
An Overview of Your. Dental Benefits. Educators Health Alliance
An Overview of Your Dental Benefits Educators Health Alliance 2 \ DENTAL BENEFITS OVERVIEW \ 5 A Dental Plan Exclusively for Educators Health Alliance Members Something to Smile About... The EHA makes