The Active Plan will pay the Reasonable and Customary fees (for in-network providers) actually charged by a Dentist for covered dental services provided to you and your Eligible Dependents.
The Active Plan covers 100% of Preventive Services, including:
- Dental examinations, scaling and cleaning of teeth or gums, up to twice in a calendar year;
- Dental X-rays, but not more than one, whether bitewing or full mouth, in a calendar year;
- Topical application of sodium fluoride or stannous fluoride, but only for Eligible Dependents under 15 years of age; and
- Space maintainers used in place of prematurely lost teeth.
The Active Plan covers 80% of Basic Restorative Services, including:
- Fillings to diseased or broken teeth;
- Endodontic treatment, which includes root canal therapy;
- Anesthesia in connection with any Basic or Major Restorative Service; and
- Injection of antibiotic drugs in connection with a covered dental procedure.
The Active Plan covers 50% of Major Restorative Services, including:
- Treatment of periodontal and other diseases of the gums and tissues of the mouth, except periodontal prophylaxis;
- Crowns, inlays and gold fillings;
- Initial installation of either (I) a removable denture, including adjustments within six months of installation, or (II) a fixed bridgework; provided that, in either case, the denture or bridgework must replace natural teeth that were lost while the Eligible Individual was covered by the Active Plan;
- Replacement of, or the addition of teeth to, a removable denture or fixed bridgework; provided that, in each case, one of the following applies:
- the replacement or addition of teeth is due to the loss of teeth that occurred while the Eligible Individual was covered by the Active Plan; or
- the denture or bridgework being replaced, or to which teeth are being added, has been in use at least five years and cannot be made serviceable; or
- the denture being replaced is an immediate temporary denture installed within the past twelve months and is now being replaced by a permanent denture;
- Repairing, recementing or relining of dentures, crowns, inlays or bridgework; and
- Treatment of temporomandibular joint dysfunction other than by surgery.
The Basic Restorative Services and Major Restorative Services discussed above are subject to a deductible of $100 per individual or $300 per family per calendar year.
The Active Plan covers orthodontic treatment (including correction of malocclusion) up to a lifetime maximum per individual of $2,500. There is no Deductible for orthodontic treatment.
If your Eligible Dependent reaches his or her 26th birthday, and is in the process of a course of orthodontic treatment which began before he or she reached his or her 25th birthday, benefits for the course of orthodontic treatment will be payable under the following conditions:
- A description of the course of orthodontic treatment must be submitted to the Fund Office within 10 days after the date the child reaches his or her 25th birthday
- If that description confirms the need for continued treatment beyond the 26th birthday, benefits for the course of orthodontic treatment will be payable, but only until the date the child reaches his or her 27th birthday, subject to the lifetime maximum limit and the calendar year benefit maximum.
- See your SPD for more detailed information about dental benefits.
Related Forms & Documents