Dental Benefits. Under the TeamstersCare Plan, you and your eligible dependents have three basic options when you need dental care.

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1 Dental Benefits Under the TeamstersCare Plan, yu and yur eligible dependents have three basic ptins when yu need dental care. Optin #1: TeamstersCare Dentists. Yu can use ur in-huse Charlestwn, Chelmsfrd, r Stughtn, MA facilities fr yur dental treatment with n claim frms t file. Preventive visits are available at n cst t yu. Yu make a TeamsterShare Payment f $5 fr filling visits and $10 fr denture, rt canal, and extractin visits. Optin #2: Dentists in ne f the Dental Blue Freedm netwrks. TeamstersCare has an agreement with Blue Crss Blue Shield f MA (BCBSMA) which prvides three netwrks f private dentists wh accept discunted fees. When yu use ne f the Dental Blue Freedm netwrks, yu have t pay part f the cst, and the dentist will file the claim. Optin #3: Nn-Netwrk Dentists. Yu can use any private dentist yu like. Again, yu ll have t share the cst (generally, higher than Dental Blue Freedm netwrk dentist csts), and yu may be required t file a claim. Optin #1: TeamstersCare Dentists Yu and yur family have a cnvenient ptin fr basic dental services: cmplete access t ur TeamstersCare Dental Offices in Charlestwn, Chelmsfrd, and Stughtn. When yu g t a TeamstersCare Dental Office, yu pay nthing fr preventive care visits. Yu make a TeamsterShare Payment f $5 fr filling visits and $10 fr denture, rt canal, and extractin visits. TeamstersCare Dental Offices are staffed by licensed dentists, hygienists, and dental assistants. Sme f ur TeamstersCare dentists are n staff at Tufts and Bstn University Dental Schls. Services Prvided at TeamstersCare In-huse Dental Offices The fllwing general services are available at ur three TeamstersCare Dental Offices: dental examinatins and x-rays (preventive) fluride treatment (preventive) cleaning and scaling (preventive) sealants fillings amalgam and cmpsite (silver and white) rt canals limited t frnt six upper and frnt six lwer teeth simple extractins limited t lse primary r permanent teeth dentures full r partial, n mre frequently than nce every five years denture repair and reline muthguards certain space maintainers secnd pinins emergency care during ffice hurs s lng as the evaluatins and treatment f dental prblems are within the scpe f the services prvided at ur TeamstersCare Dental Offices

2 Making Appintments Dental Office Hurs Mnday thrugh Thursday Open 8 a.m., sme evening appintments until 8 p.m. Friday and Saturday 8 a.m. t 4 p.m. T make an appintment, call the TeamstersCare Dental Office yu plan t visit, using ne f the fllwing numbers: Charlestwn lcal: , ext 1 tll free within Massachusetts: tll free utside Massachusetts: Chelmsfrd lcal: tll free: Stughtn lcal: tll free: When yu make an appintment, the TeamstersCare Dental Offices set aside time exclusively fr yu. Yu will be required t pay $10 if yu d nt: shw up fr yur appintment, r call at least 24 hurs ahead f time t cancel Optin #2: Dental Blue Freedm Netwrk Dentists TeamstersCare has cntracted with Blue Crss Blue Shield f Massachusetts (BCBSMA) fr cverage thrugh a grup f private dentists wh prvide bth rutine and specialty services and, at the same time, helps yu save mney n dental care. TeamstersCare participates in Dental Blue Freedm which gives yu access t Dental Blue PPO, Dental Blue, and Dentemax which is a natinal netwrk. Yu have great flexibility in yur chice f dentists; hwever, yu will receive the largest discunt if yu chse a Dental Blue PPO dentist. The larger netwrk, Dental Blue, ffers access t ver 90% f all practicing dentists in MA, hwever yur share f the csts will generally be higher than with a PPO dentist. If yu re away frm hme, yu als have access t the Dentemax natinal netwrk f BCBS dental prviders. Yur Dental Blue Freedm ID Card Yu will receive a Dental Blue Freedm ID card that yu must shw whenever yu visit a dentist whether r nt that dentist is in ne f the Dental Blue Freedm netwrks. Fr a Dental Blue Freedm dentist the card ensures that yu will receive the TeamstersCare discunt Fr any ther private, nn-netwrk dentist the card prvides infrmatin the dentist will need fr accurate billing T determine whether a particular dentist is in ne f the Dental Blue Freedm netwrks, g t r call BCBSMA s Custmer Service at Have yur Dental Blue Freedm ID card available s yu can refer t it fr TeamstersCare grup infrmatin.

3 Optin #3: Nn-Netwrk Dentists Yu d nt have t g t a dentist in ne f the Dental Blue Freedm netwrks. Yu have the flexibility t g t any dentist yu wish. Hwever, when yu g utside ne f the Dental Blue Freedm netwrks, yu ll generally have t pay an even larger share f the cst, and yu may be invlved in sme paperwrk. Csts fr Dental Blue Freedm Netwrk and Nn-Netwrk Dental Services Dental Blue Freedm Benefits Fee Schedule TeamstersCare has a pre-set Dental Fee Schedule f the dllar amunts it will pay fr cvered dental prcedures when thse prcedures are perfrmed by any dentist ther than ur wn in-huse practitiners in Charlestwn, Chelmsfrd, and Stughtn. The TeamstersCare Dental Fee Schedule is subject t change. T view the current fee schedule, g t r cntact Charlestwn Member Services. Yur Share Fr any given prcedure, the Plan always pays the same amunt, regardless f whether yu g t a Dental Blue Freedm netwrk dentist r a nn-netwrk dentist. In either case, yu pay a prtin f the bill. The difference is, mst likely the Dental Blue Freedm dentist will charge yu less t begin with, because f ur TeamstersCare cntract with BCBSMA. Thus, the balance yu pay t a Dental Blue Freedm netwrk dentist after TeamstersCare makes its pre-set cntributin will almst certainly be smaller than the prtin yu d have t pay t a nnnetwrk dentist. Deductibles and Calendar Year Maximum Except fr diagnstic and preventive services, any dental treatment yu receive utside f the TeamstersCare Dental Offices is subject t a $50 per persn/$100 per family calendar year deductible. Als, there is a calendar year maximum benefit f $2,500 per persn. Orthdntics Orthdntic Services are cvered at 50% f cst, up t a $2,000 lifetime maximum per persn. Cverage is available fr the member, spuse, and eligible dependents. Ttal Health Slutins Yur dental cverage thrugh Dental Blue Freedm includes enhanced benefits thrugh Ttal Health Slutins. This is a prgram which identifies patients with certain health cnditins that are impacted by dental care and prvides them with additinal benefits. These cnditins include crnary artery disease, diabetes, ral cancer and pregnancy. Dental Treatment in the Hspital If yu have a serius medical cnditin and therefre can t be treated in a dental ffice, yur dentist might recmmend that yu be treated in a hspital. Generally, the TeamstersCare dental benefit will share the cst f the dental services yu receive in the hspital but nt any related medical csts. Fr medical cverage and claims, yu ll need t fllw whatever prcedures are apprpriate fr the medical insurance plan in which yu and yur family are enrlled.

4 Dental Expenses Nt Cvered TeamstersCare des nt prvide dental benefits fr the fllwing: services r supplies in a hspital perated by the U.S. gvernment r a gvernment agency services under any gvernment law r prgram t which yu might be entitled treatment f a wrk-related cnditin csmetic dental services unless the prcedure is required because f an accident that happens while yu are cvered by TeamstersCare, subject t the rules f the Plan treatment by anyne ther than a licensed dentist r physician r a qualified dental technician wrking under a dentist s r physician s directin training r supplies used fr dental care educatin treatment fr temprmandibular jint (TMJ) syndrme except fr specific medical cnditins verified by x-ray r ther diagnstic tests experimental prcedures charges exceeding amunts listed in the TeamstersCare Dental Benefits Fee Schedule charges yu r yur family members are nt bligated t pay services prvided fr injuries that result frm a war, declared r undeclared charges fr missed appintments Pre-Treatment Dental Estimates BCBSMA can help yu estimate yur share f dental expenses befre yu re actually treated. If yur dentist recmmends extensive treatment, the dentist can submit a Pre-treatment Estimate Frm t BCBSMA fr an estimate f yur share f the cst. Getting the estimate is vluntary, but it can help avid surprises abut the amunt yu re respnsible fr. Yu can then plan the treatment and manage yur expenses accrdingly. Filing a Dental Claim When yu use a TeamstersCare in-huse dental facility, yu file n claim frms. BCBSMA handles any claim submitted by Dental Blue Freedm netwrk dentists as well as any nn-netwrk claims. If yu have t submit a dental claim yurself, the apprpriate frms shuld be available at yur dentist s ffice. Otherwise, call BCBSMA Member Service directly, at t btain a frm. Imprtant Nte: Yu must submit dental claims within 12 mnths f the date when the service was prvided. Dental claim frms fr in-netwrk and nn-netwrk services shuld be addressed t: Blue Crss Blue Shield f MA P.O. Bx Bstn, MA If yu have any questins abut hw a claim shuld be handled, call BCBSMA at Crdinating with Other Dental Plans If yu r a dependent has ther dental cverage such as thrugh yur spuse s plan any benefits yu receive frm that ther plan will be crdinated with yur TeamstersCare benefit. Taken tgether, ttal payments frm all plans cannt be mre than 100% f the charges (see page 57 fr details n Crdinatin f Benefits).

5 Dental Care Dental Blue Freedm Cntact BCBSMA Member Service t: -btain a claim frm (if nt available frm yur dentist) -determine whether a particular dentist is in the Dental Blue PPO, Dental Blue, r the Dentemax netwrk Mail claim frms t: BCBSMA P.O. Bx Bstn, MA website fr general infrmatin BCBS Member Service