Dental Benefits

Healthy teeth and gums are an important part of your overall health. That's why the Fund offers you and your eligible dependents a comprehensive Dental Plan. When you visit one of the Plan's participating dentists, most services are covered at no charge to you, up to Plan limits. You may also choose to visit a non-participating dentist; however you will most likely have out-of-pocket costs for your dental care.

Your Dental Benefits At-A-Glance

Your dental benefits provide for the care and treatment of the teeth and gums, up to the limits of the Plan, including:

•  preventive and diagnostic services such as cleaning, oral exams, and x-rays;
•  restorative services, extractions, oral surgery, bridgework and dentures; and
•  Orthodontia services and supplies.

Panel of Participating Dentists

The Fund as assembled a panel of participating Dentists. This list is available at the Fund Office. For assistance in finding a participating dentist, call the Fund Office at 914-592-9330.

Pretreatment Review

If charges for treatment are expected to be more than $350, you are required to get prior approval from the Fund Office before treatment begins—whether you use a participating provider or not. If approved, services are to be provided within 90 days of your receiving approval. Call the Fund Office at 914-592-9330 for information on how to file for pretreatment review.

Out-of-Network Care with a Non-Participating Dentist

If you visit a provider that does not participate in the Teamsters 456 panel, you must pay the provider's full charge and then submit a claim for reimbursement to the Fund Office. The Plan will reimburse you for up to what it would pay a participating dentist for the same service. You are responsible for any difference between what the dentist charged you and what the Fund reimbursed you. The annual limit of $1,550 is also reduced to $800 when an out of network provider is used.

To obtain a claim form, call the Fund Office at 914-592-9330.

Orthodontia

Benefits are payable for orthodontia treatment or services up to a lifetime maximum of $2,000 per covered person.

How Orthodontia Benefits are Paid In-Network

There is no charge to you for diagnosis and insertion of a dental appliance (your provider receives $1,000 for this service). Thereafter, you pay the provider $75 for each month of active treatment up to $1,250.00 (16 1 months). The provider than receives another $1,000 from the Fund for the completion of treatment and appliance removal.

Covered Dental Expenses

Covered expenses are the services or supplies listed in the charts below and on the following pages that are covered by the Plan when you visit a participating provider. Please note that benefits are provided up to the annual maximum of $1,550 per covered person for services excluding orthodontia. There is a lifetime maximum for orthodontia benefits of $2,000 per covered person. If you choose to visit a non-participating dentist, you must check with the Fund Office to find out what is covered and how much the Fund will reimburse you for out-of-network services. In no event will the Plan pay more than it pays a participating provider.

Diagnostic and Preventive Services

Note: A maximum of two emergency visits are payable per calendar year. A maximum of four quads of periodontic scaling is payable per year and is not covered on the same day as routine cleaning.

Restorative Dentistry

Oral Surgery

Root Canal Therapy

Periodontics – Treatment of Gums

Note: maximum of 4 quads of periodontal scaling per year and not covered on same day as prophylaxis.

Prosthetics – Fixed and Removable

Note: Denture relines and rebases are payable one year after insertion date.

Orthodontics

Implants

What's Not Covered

Sealants are not covered under the Plan. For additional plan limitations and exclusions, contact the Fund Office at 914-592-9330.