SBF Summary Plan Handbook - CWA Local 1180

SBF Summary Plan Description 06-11-12
What Dental Services Will You Receive
Covered Services Provided By Dentcare Dentists:
‣ Covered benefits include a large variety of typical dental services. For a list of
covered dental services, please see “Covered Dental Services” on the next page.
‣ If you require the services of a specialist, your Dentcare dentist will refer you to a
participating specialist.
‣ In cases of emergency, Dentcare covers a maximum of two visits to a Dentcare
dentist per member per contract year. However, if the member has had regular
checkups or is undergoing treatment, there is no limitation on emergency coverage.
‣ If the emergency occurs out of the Greater New York City area or if you are unable
to visit a Dentcare dentist, Dentcare will reimburse up to $25 per eligible family
member per contract year if you submit copies of the bills for emergency treatment.
‣ In the event you are unable to reach your own participating dentist, DENTCARE
provides 24 hour emergency service operators at: (800)-468-0600
Dentcare Benefit Plan
Covered Dental Services
Procedure
Diagnostic & Preventive Services
Full month x-ray
Single Films (periapical or bitewing)
Bitewing Series
Oral Examination
Specialty Consultation
Cleaning of Teeth (prophylaxis & polishing)
Fluoride Treatment
Treatment in case of dental emergency
Restorative Dentistry
Silver amalgam, one surface
Silver amalgam, two surfaces
Silver amalgam, three surfaces or more
Composite filling, one surface
Composite filling, two surfaces
Composite filling, three surfaces or more
Patient Co-payment
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
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