If you or your Dependent incur Covered Dental Charges, this Plan will pay for the expenses actually incurred, but not to exceed the percentages of Usual, Customary and Reasonable Charges when performed by a legally qualified dentist for oral examinations and treatment of accidentally injured or diseased teeth and supporting bone or tissue.
Under this plan, you are free to use any dentist. However, the Trustees have negotiated lower charges with certain dentists through Anthem Blue Cross, called “preferred providers.” The network of preferred providers is called “Dental Preferred Provider Organization” or “Dental PPO”. Because the Plan saves money when you use a preferred provider dentist, you as a participant also save money when you use a preferred provider dentist.
Charges incurred at a PPO Dentist are paid at the In-Network level of 100% of the Contract Rate for Class I services, 80% of the Contract Rate for Class II services and 60% of the Contract Rate for Class III services. Class III Services are subject to a $25 per person per year deductible.
Obtaining services from a preferred provider dentist does not necessarily mean the services will be covered. Services that are not covered by the Plan are excluded regardless of where or by whom services are provided.
Charges incurred at a Non-PPO Dentist will be paid at the Out-of-Network benefit level of 100% of Usual, Customary and Reasonable Charges for Class I Services, 80% of Usual, Customary and Reasonable Charges for Class II Services and 60% of Usual, Customary and Reasonable Charges for Class III Services. Class III Services are subject to a $25 per person per year deductible.
Usual, Customary and Reasonable Charges are charges that the Fund Administrator determines fall within a range of those most frequently made for services, supplies, and treatments in our service area by those who provide them. If you receive a covered service that costs more than this Usual, Customary and Reasonable Charge, the Plan will pay benefits based only on the amount considered Usual, Customary, and Reasonable.
Alternate Courses of Treatment
If alternate procedures, services, or courses of treatment may be performed for the treatment of the injury or disease concerned or to accomplish the desired result, the amount included as Covered Dental Expense will not exceed the Usual, Customary and Reasonable Charge for the least expensive procedure, service, or course of treatment which, as determined by the Fund Administrator, will produce a professionally adequate result.
Pre-Estimation of Costs
Pre-estimation of treatment is requested for claims $300 and over.
After the attending Dentist’s statement with the pre-estimation of costs has been returned to your dentist, you should discuss the computations with him/her.
The Fund Administrator as a condition for payment for services may require that reasonable evidence of the extent or character of services is submitted or that you be examined by a dental consultant retained by the Fund Administrator in or near your community of residence.
Advantages To Members
- The use of participating dentists results in substantial savings in your out-of-pocket expenses.
- The use of participating dentists will reduce costs to your dental plan, lowering costs for both the Trust and employee alike. With reduced costs, more dental care is available within the plan benefits.
- Participating dentists are evaluated for standards of care.
If necessary, remind participating dentist billing offices of this procedure.
Remember to tell your dentist that treatment plans with proposed charges over $100 should be pre-authorized by the Trust’s Administrative Office for determination of allowable costs.
For emergencies requiring immediate care, use the most readily available qualified help.