SBF Summary Plan Handbook - CWA Local 1180

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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 56
SBF Summary Plan Description 06-11-12 Oral Surgery Routine Extractions – per tooth Surgical extractions Soft tissue impactions Bony impactions Alveolectomy, per quadrant Root Canal Therapy Pulp Capping, Direct Pulpotomy Root Therapy – anterior Root Therapy – bicuspid Root Therapy – molar No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge Periodontics Scaling of teeth, per quad No Charge Pedicle Soft Tissue Graft $150.00 Free Soft Tissue Graft $150.00 Gingivectomy, per quad No Charge Osseous surgery, per quad No Charge Prosthetics – Crowns Acrylic with metal crowns No Charge Porcelain crowns No Charge Porcelain with metal crown $50.00 Post No Charge Recementation, per crown No Charge Prosthetics – Fixed Bridges Acrylic w/ metal bridge crown or pontic $50.00 Porcelain w/ metal bridge crown or pontic $50.00 Recementation, bridge No Charge Prosthetics – Removable Full upper denture, w/ adjustments $50.00 Full lower denture, w/ adjustments $50.00 57
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COMMUNICATIONS WORKERS OF AMERICA
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CWA LOCAL 1180 SECURITY BENEFITS FU
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What If I Elect Coverage Under Anot
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What Happens When I Retire 86 How D
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SBF Summary Plan Handbook - CWA Local 1180

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