DENTAL BENEFITS Fund Name: Fund ID: L500 SPD Version: January 1, 2015 & Who is covered? Employees and their dependents Dental Fee Schedule: January 1, 2016 (Retirees and their dependents are not eligible) Revised: 4/27/17 SA Trust Fund Office Contact Information: To access eligibility, claims status and summary of benefits for medical, dental and/or vision as well as to contact the Trust Fund Office for general questions, please visit our Provider Portal or email: www.memberbenefitsonline.com staff@teamstersfood.org DHMO Network: Liberty Dental (Not administered by BeneSys) (888)703-6999 www.libertydentalplan.com Orthodontic care is available through the PPO Plan for eligible dependents. See Orthodontic section. Self-Funded Dental PPO Network: Western Dental Plan Management / Coastal Dental Find a PPO Dentist: www.wdpminc.com Plan Type/Union: Teamsters and Food Preferred Providers: For status of claims and pre-determinations, call Coastal Dental (877)937-6462 Mail claims and pre-determinations to: Coastal Dental PO Box 3470 Camarillo, CA 93011-3470 Non-Preferred Providers: For status of claims and pre-determinations visit www.memberbenefitsonline.com or email staff@teamstersfood.org. Mail claims and pre-determinations to: PO Box 2340 West Covina, CA 91793 The following summary of benefits are for PPO Participants only (Plan code L500). To view the entire breakdown of benefits please refer to the Schedule of Benefits. Copies are available on our Provider Portal, www.memberbenefitsonline.com. Services are paid based on Schedule of Benefits. Page 1 of 8
BENEFITS Deductible Annual Maximum COMMENTS/LIMITATIONS None $2,000 per person per calendar year Appeal Coordination of Benefits The member has 180 days from the date of the denial to submit an appeal for consideration. Birthday Rule / Non-duplicated This Plan will not coordinate with any HMO coverage. Dependent Age Limit 26 Certain dental procedures which have been started for you or your Dependent while eligible for benefits under this Dental Program will be covered under the same conditions and limitations as described elsewhere in this section, even though you or your Dependent is no longer eligible to receive benefits. Extended Coverage Missing Tooth Clause Out of Area Pre-Determination/ Pre-Authorization Timely Filing Limit Waiting Period This extended coverage is limited to crowns, bridges, partials and dentures if the impressions were taken or castings were made, but remain unfinished, and the appliances have not been fitted or seated on the date that the Participant s eligibility terminates. It will not include any procedures for dental defects which may have been diagnosed earlier, even if the treatment plan received prior approval from the Trust, unless it is one of the procedures listed above and the operational work was started prior to termination of eligibility. None Members that do not live within a 15 miles radius of a Preferred Provider Dental Office, the Plan will pay benefits in accordance with the Schedule of Benefits for Out of Area services by provided by a Non-Preferred Provider Dentist. Required for all crowns, bridges, endodontic treatment, periodontal, prosthodontic, oral surgery, orthodontic treatment and any treatment costing $750 and over. All periodontal treatment must be pre-authorized and submitted with pocket markings and/or radiographs, a definitive periodontal case type diagnosis and treatment plan. Dental procedures not listed in the Dental Fee Schedule or specifically excluded, may be submitted for consideration by submitting a pre-authorization. In addition, the Plan may require patient to see a selected Dentist for special consultation. Pre-determination requirement is applicable when this Plan is secondary. 1 year from the date of service. None DIAGNOSTIC/EVALUATIONS Page 2 of 8
Exams (Oral Evaluations) Specialist Consultations Emergency Exam (Oral Evaluation) Bitewings + Recall X-rays Full Mouth or Panoramic Film + Bitewings Evaluation for Specific Tooth Once every 6 months. Payable to specialists for case presentation evaluation and only if no other treatment is performed on the same day. Payable when an emergency evaluation is done and no treatment is performed on the same day. If emergency Palliative treatment is performed, a palliative emergency treatment allowance can be given if no other treatment is performed on the same day. DIAGNOSTIC/X-RAYS Once every 12 months, at a maximum benefit of one half the full mouth series allowance. Payable no more than once every 36 months. Total allowance for individual x-rays cannot exceed the full mouth allowance. 3 additional x-rays may be covered per patient per year if they are required for a specific diagnosis. The benefit of these x-rays will not exceed the allowance for 2 bitewing x-rays. Prophylaxis Tooth number should be noted on the claim form. PREVENTATIVE Once every 6 months. Only the allowance of a prophylaxis is payable when prophylaxis and periodontal treatment are performed on the same day. Fluoride Once per 12 month period for patients under age 17. Sealants Fissure Sealants Space Maintainers Occlusal Guards Permanent molar teeth only on patients under age 17, once every 2 years. Treatment is available only to dependent children and is applicable only to permanent molars one application per tooth, once every 24 months. No limit. Pre-authorization is required. RESTORATIVE Post and Core Crowns, Bridges, Inlays and Onlays, and Veneers Covered only for a tooth that has had root canal therapy. Payable only if x-rays and/or study models demonstrate that the tooth cannot be restored with amalgam or composite. Page 3 of 8
Cast Restorations, Crowns, Full Partial Denture and Bridges Fillings Covered once in a 24 month period. Covered once every 24 months. Composite resin fillings are covered on anterior teeth only. Surfaces are as follows: One surface filling-mesial, Distal or Facial only. Two surfaces filling- Mesial-Distal, Distal-Incisal or Mesial-Incisal only. Three surfaces filling -Mesial, Distal, Incisal only. Amalgam will be paid in lieu of benefits for a composite restoration to a posterior tooth. Restoration on the same surface as a sealant is not covered within 2 years of a sealant. ENDODONTICS Pulpotomy Root Canal Periodontal Maintenance Periodontal Surgery Root Planning and Scaling Covered only on deciduous teeth. Benefits are not payable when x-rays demonstrate incomplete root canal therapy. Effective 1/1/16, claims with dates of services 1/1/16 and after, are not subjected to the restriction below. A retreatment root canal for any tooth, within an 18 month period cannot be performed by the same doctor/dentist who performed the original root canal. PERIODONTICS Only payable following periodontal surgery. Covered only following initial non-surgical treatment involving periodontal scaling and root planning. Not covered if pocket measurements are less than 5 millimeters. Claims, diagnostic quality x-rays and periodontal charting for periodontal treatment must be submitted for pre-authorization prior to any services being performed. Maximum of 2 quadrants per visit, not to exceed 4 quadrants during any 24 month period. Dentures Not covered when combined with prophylaxis on the same day. PROSTHODONTICS Relines and adjustments are covered once at least 6 months following denture placement and once every 2 years thereafter. Interim partial dentures are covered to replace upper anterior and/or bicuspid teeth or lower anterior teeth and/or first bicuspid teeth. Page 4 of 8
Interim dentures are covered only prior to placement of a fixed bridge. Fixed Bridge Implant Deep Sedation/General Anesthesia Not covered when there is a large number of missing teeth in the same arch and/or moderate to advance bone loss is evident. A fixed bridge and a partial denture placed in the same arch within a 24 month period is not covered. A single implant is payable to replace a single missing tooth only. Neither adjacent abutment should require a case restoration. GENERAL SERVICES Payable to a maximum of two 15 minute increments per visit. ORTHODONTIC Age Limit Dependent children under 19 Orthodontic Deductible Pre-Orthodontic Treatment (POT) Orthodontic Lifetime Maximum None Plan pays $175 to a Panel Orthodontist Plan pays $1,850 to a Panel Orthodontist ($650 for the initial banding fee, and $75 x 16 months. Patient pays extended treatment fees after 24 months.) Plans pays $1,200 to a NON-Panel Orthodontist Cephalometric x-rays, dental x-rays, tracings and photographs, and study models are not covered. Pre-Authorization To find a Panel Orthodontist visit: www.wdpminc.com. Plan Type/Union: Teamsters and Food An orthodontic treatment plan must be submitted for approval prior to the commencement of care. Must include all of the following: 1. Completed dental form 2. Panoramic x-ray 3. PA x-rays of anterior teeth 4. Head film tracing 5. Intraoral and extraoral photographs Mail orthodontic pre-authorizations to: PO Box 2340 Page 5 of 8
West Covina, CA 91793 Waiting Period Extended Coverage This Plan does not auto pay. Provider is required to submit a claim for processing. The claims address is provided on the 1 st page. The Employee-Parent must have 9 months of consecutive eligibility. Once care (banding) has begun under this Program, the Trust will pay the benefits as stated above even though the Employee- Parent or the Dependent loses eligibility under the Dental Care Program before the treatment program is completed. DENTAL AND ORTHODONTIC EXCLUSIONS Dental: No payment will be made under this Plan for expenses incurred for any of the following: 1. Dental services furnished at a hospital or facility by the U.S. Government or any authorized agency thereof, or furnished at the expense of such government or agency, except for services furnished by the Veteransʼ Administration for non-service connected conditions under 38 U.C.S. 1728; 2. Any Disability covered by Workersʼ Compensation or Occupational Disease Law; 3. Dental expenses resulting from war (including any armed aggression resisted by the armed forces of any country or combination of countries) whether such war is declared or undeclared, or any act incidental to such war; 4. Any procedure which is not listed on the Dental Schedule of Benefits except when approved by the Trustʼs Dental Consultant; 5. Dental expenses which you are not legally obligated to pay for which are furnished without charge. Examples: Laboratory charges incurred in the construction of a denture; fluoride solution used to treat teeth; metal charges for metal used in the construction of a crown or bridge; 6. Dental expenses which are paid for or reimbursable by or through a local, state or federal agency; 7. Any treatment or service not provided by a Dentist, except x-rays ordered by a Dentist and services of a licensed Dental Hygienist, or Registered Dental Assistant (with proper credentials of expanded functions); 8. Any treatment or service not necessary or customarily provided for dental care; 9. Dental expenses incurred in connection with any dental procedure started before coverage becomes effective. This includes any appliance, or modification of one, where an impression was made before the patient was covered under the Dental Plan; a crown, bridge or gold restoration for which the tooth was prepared before the patient was covered under the Dental Plan; 10. Dental expense incurred in connection with any dental procedure started after termination of eligibility for coverage; 11. Claims submitted by Dentists who are not licensed in the United States of America or services rendered outside of the United States; 12. Any dental treatment for strictly cosmetic or aesthetic purposes (including congenital abnormalities and abrasions), or due to attrition; 13. Other General Exclusions: a) Replacement of lost, stolen, or destroyed appliances; b) Appliances or restoration for the purpose of splinting; and to increase dimension and to restore occlusion. 14. Exclusions relating to Crowns, Dentures and Bridges: a) Veneer crowns (porcelain fused to metal) posterior to: Upper Arch - Second Bicuspid Lower Arch First Bicuspid (Pontic type of metal allowance will be made) Page 6 of 8
b) Partial Denture and Fixed Bridges on the same arch; c) Fixed bridges and crowns for a patient under the age of 16 years; d) Distal extension (cantilever) fixed bridges; e) Fixed bridge where space is more than half closed; f) Replacement of second molars only. The Trust Consultant may consider, by report, the replacement of a second molar (pontic) as part of a fixed bridge with a mesial and distal abutment(s), providing there is the potential for good occlusion with the opposing teeth. A Second Molar may only be replaced as a part of a removable partial denture, providing other edentulous areas anterior to the second molar are the reason for the partial construction; g) Stayplates Does not include replacement of teeth posterior to: Upper Arch Second Bicuspid Lower Arch First Bicuspid 15. The removal of asymptomatic third molars without adequate evidence of pathology in patients less than 15 years of age; 16. Procedures relating to Temporomandibular Joint Dysfunction rendered by a Dentist (D.D.S.). Coverage for necessary treatment of TMJ rendered by a Medical Doctor (M.D.) will be provided under the Indemnity Medical Plan (PPO) and will only be provided for those Employees and Dependents enrolled in that Medical Plan; 17. Plaque control; 18. The use of general anesthesia unless Medically Necessary; 19. Tissue graft surgery for periodontal disease; 20. Bleaching limited to endodontically treated teeth; 21. Root canal fillings involving the use of Sargenti Paste (N2) or a similar formulation. Claim forms shall specify the filling material, including sealers, for all 22. root canal procedures; 23. Any charges incurred for missing or failing to cancel an appointment; Prepaid Dental Plan Participant by a Dentist outside of the Dental Center in which that Participant is enrolled, unless by prior approval of the Trust Administrative Office; 24. Dental services performed by a Prepaid Dental Center and/or Office which was previously but is no longer under contract with either the Trust Fund or the Prepaid Dental Plan to provide prepaid dental services to Participants of the Trust. This exclusion shall remain in effect for a period of two (2) years from the date of termination the Prepaid Dental Center and/or Officeʼs contract with the Trust Fund or the Prepaid Dental Plan; 25. Retainers or any treatment covered under Orthodontic Care. Orthodontic: No payment will be made under this Orthodontic Care Program for expenses incurred for any of the following: 1. Any orthodontic procedure which has not been approved by the Board of Trustees in advance; 2. Any charges made by the Dentist for the replacement or repair of an appliance furnished to the patient that is lost or broken; 3. Any orthodontic service provided on or after the date of termination of the treatment plan if the treatment plan is terminated before completion for any reason; 4. Additional orthodontic benefits to any Dependent child for a period of five (5) years following the first (1st) day of Orthodontic Care under this program; 5. Any orthodontic treatment plan started after termination of eligibility for coverage. Orthodontic treatment is not considered to have been started until the first banding is performed; 6. Myofunctional therapy; 7. Surgical procedures incidental to orthodontic treatment; Page 7 of 8
8. Treatment related to temporomandibular joint disturbance and/or hormonal imbalances; 9. General anesthetics including intravenous and inhalation sedation; 10. Cephalometric x-rays, dental x-rays, tracings and photographs, and study models; 11. Retreatment of orthodontic cases; 12. Changes in treatment necessitated by an accident of any kind; 13. Surgical procedures incidental to orthodontic treatment (including extraction of teeth, procedures related to cleft micrognathia or macrognathia and orthodontic 14. treatment of cleft palate patients); 15. Dispensing drugs in the office, except as a written prescription; 16. Dental services of any kind performed in a hospital; 17. Any dental procedures considered within the field of General Dentistry, e.g., fillings, extractions, etc.; 18. Services which are compensable under Workers Compensation or Employer Liability Laws; 19. Patients with severe medical disabilities which may prevent the desired result 20. Treatment plans which in the opinion of the Orthodontic Specialist are unlikely to produce acceptable correction of the existing malocclusion; 21. Special types of appliances or braces, e.g., mini braces, sapphire or clear braces, ceramic braces, lingual or invisible braces; 22. Extra treatment, orthodontic, surgical and dental, beyond the usual and customary orthodontic treatment. Page 8 of 8