Restorative. (1) Gold, baked porcelain restorations, crowns and jackets. If a tooth can be restored with a material such as amalgam, payment of the applicable percentage for that procedure will be made toward the charge for another type of restoration selected by the patient and the dentist. The balance of the treatment charge will remain the responsibility of the patient.
Restorative fillings made of amalgams, silicates, plastics and synthetic porcelains. Includes temporary stainless steel crowns. Prosthetic: - repair of damaged dentures. Adding teeth to existing dentures, or relining or rebasing the dentures. Each procedure limited to once every 3 years. Accidental injury: - Major dental services as a result of an accident up to a maximum of $1,000.00 per year per person. In addition to the "Basic" services listed, all eligible employees and eligible dependents shall be entitled to receive 50% of eligible charges for the "Major" dental services listed below: Endodontics: - the usual procedures required for pulpal therapy and root canal filling. Periodontics: - the usual procedures for treatment of the disease of the tissues and bones supporting the teeth. Extensive Restorations: - gold inlays and onlays. - jackets, crowns and bridges to rebuild and replace missing teeth. - each procedure except crowns limited to once in a 5 year period. Crowns will not be replaced within 5 years of placement. Anesthesia: - nitrous oxide analgesia, administered in the dentist's office. Prosthetic: - partial or complete upper and lower dentures, provided by a dentist or licensed denturist. Each procedure limited to once every 5 years. Allowances include all adjustments. Orthodontic: - The correction of malposed teeth. Annual maximum for the dental plan is $1500.00 per person. Lifetime maximum for orthodontic coverage is $1500.00 per person. The dental plan is based on the prevailing Dental Fee Guide. Any charges over and above those listed on this guide shall be the responsibility of the employee. Appendix B-3 Hourly employees will be given a Health Spending Account each January 1, in the amount of $500 per year. APPENDIX “C” WESTERN GLOVE WORKS
Restorative. Filling teeth with amalgams, composites (including white fillings on all permanent teeth) and stainless steel crowns to restore surfaces that have broken as a result of decay. Gold Foil Fold foil can be used to repair teeth with existing gold restorations. Prosthetic repairs Repair of fixed appliances (only by a dentist) or repair of removable appliances (either by a dentist or a denturist). Reline of fixed or removable appliances by a dentist or a denturist is allowed once every 6 months. Endodontics Pulpal therapy and filling of root canals. Periodontics Treatment of diseases of the soft tissue and the bone surrounding and supporting the teeth. Major Restorative Services (Part B) The benefits under this section are those services required for major reconstruction of teeth that have deteriorated and for replacement teeth. Eligible expenses in this category will be reimbursed at the rate of 75% of with an unlimited maximum. The following services are covered; Crowns and Bridges To replace missing teeth with a fixed prosthetic. Crowns and/or bridges may be replaced once every 60 months.
Restorative. Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures. - Replacement of crowns, inlays and onlays requires the existing restoration to be 60+ months old. - Cost Share for Benefits in this category is subject to the Plan Deductible described in your <EOC NAME>. You pay the Charges shown below until you have met the Plan Deductible. After you meet the Plan Deductible, the Services are covered at no charge for the remainder of the year. D2140 Amalgam - one surface, primary or permanent $68 D2150 Amalgam - two surfaces, primary or permanent $84 D2160 Amalgam - three surfaces, primary or permanent $104 D2161 Amalgam - four or more surfaces, primary or permanent $121 D2330 Resin-based composite - one surface, anterior $81 D2331 Resin-based composite - two surfaces, anterior $100 D2332 Resin-based composite - three surfaces, anterior $124 D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) $147 D2510 Inlay - metallic - one surface $413 Base metal is the benefit; 1 per 60 months D2520 Inlay - metallic - two surfaces $482 Base metal is the benefit; 1 per 60 months D2530 Inlay - metallic - three or more surfaces $502 Base metal is the benefit; 1 per 60 months Code Description Pediatric Enrollee Cost Share Clarification/Limitations for Pediatric Enrollees D2542 Onlay - metallic - two surfaces $544 Base metal is the benefit; 1 per 60 months D2543 Onlay - metallic - three surfaces $570 Base metal is the benefit; 1 per 60 months D2544 Onlay - metallic - four or more surfaces $687 Base metal is the benefit; 1 per 60 months D2740 Crown - porcelain/ceramic $785 1 per 60 months D2750 Crown - porcelain fused to high noble metal $753 1 per 60 months D2751 Crown - porcelain fused to predominantly base metal $625 1 per 60 months D2752 Crown - porcelain fused to noble metal $673 1 per 60 months D2753 Crown - porcelain fused to titanium and titanium alloys $753 1 per 60 months D2780 Crown - 3/4 cast high noble metal $606 1 per 60 months D2781 Crown - 3/4 cast predominantly base metal $567 1 per 60 months D2782 Crown - 3/4 cast noble metal $588 1 per 60 months D2783 Crown - 3/4 porcelain/ceramic $619 1 per 60 months D2790 Crown - full cast high noble metal $665 1 per 60 months D2791 Crown - full cast predominantly base metal $577 1 per 60 months D2792 Crown - full cast noble metal $620 1 per 60 months D2794 Crown - titanium and titanium alloys $683 1 per 60 months D2910 Re-cement or...
Restorative. Provides all the necessary procedures to rebuild, repair, or reform the teeth. Within this benefit are included amalgam, synthetic porcelain and plastic fillings, gold fillings and crowns when the teeth cannot be restored with a filling material.
Restorative. 1. Gold Foil Restorations (if other substances are inappropriate)
Restorative. (5) Oral and maxillofacial surgery.
Restorative. All necessary procedures to restore natural teeth by composites (fillings) made of amalgams, silicates, plastics, and synthetic porcelains. Includes temporary stainless steel crowns.
Restorative. Fillings made of amalgams, silicates, plastics and synthetic porcelains. Repair of damaged dentures. Adding teeth to existing dentures. Relining or rebasing the dentures is limited to once every 3 calendar years. Endodontics: The usual procedures required for pulpal therapy and root canal filling. Periodontics: The usual procedures for treatment of the diseases of the tissues and bones supporting the teeth. Anesthesia: General anesthesia or nitrous oxide analgesia administered in the dentist's office. Consultations: Consultations required by attending dentist.
Restorative. Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures. - Replacement of crowns, inlays and onlays requires the existing restoration to be 60+ months old. D2140 Amalgam - one surface, primary or permanent No cost D2150 Amalgam - two surfaces, primary or permanent No cost D2160 Amalgam - three surfaces, primary or permanent No cost D2161 Amalgam - four or more surfaces, primary or permanent No cost D2330 Resin-based composite - one surface, anterior No cost D2331 Resin-based composite - two surfaces, anterior No cost D2332 Resin-based composite - three surfaces, anterior No cost D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) No cost D2510 Inlay - metallic - one surface No cost Base metal is the benefit; 1 per 60 months D2520 Inlay - metallic - two surfaces No cost Base metal is the benefit; 1 per 60 months D2530 Inlay - metallic - three or more surfaces No cost Base metal is the benefit; 1 per 60 months D2542 Onlay - metallic - two surfaces No cost Base metal is the benefit; 1 per 60 months D2543 Onlay - metallic - three surfaces No cost Base metal is the benefit; 1 per 60 months D2544 Onlay - metallic - four or more surfaces No cost Base metal is the benefit; 1 per 60 months D2740 Crown - porcelain/ceramic No cost 1 per 60 months Code Description Pediatric Enrollee Cost Share Clarification/Limitations for Pediatric Enrollees D2750 Crown - porcelain fused to high noble metal No cost 1 per 60 months D2751 Crown - porcelain fused to predominantly base metal No cost 1 per 60 months D2752 Crown - porcelain fused to noble metal No cost 1 per 60 months D2753 Crown - porcelain fused to titanium and titanium alloys No cost 1 per 60 months D2780 Crown - 3/4 cast high noble metal No cost 1 per 60 months D2781 Crown - 3/4 cast predominantly base metal No cost 1 per 60 months D2782 Crown - 3/4 cast noble metal No cost 1 per 60 months D2783 Crown - 3/4 porcelain/ceramic No cost 1 per 60 months D2790 Crown - full cast high noble metal No cost 1 per 60 months D2791 Crown - full cast predominantly base metal No cost 1 per 60 months D2792 Crown - full cast noble metal No cost 1 per 60 months D2794 Crown - titanium and titanium alloys No cost 1 per 60 months D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration No cost 1 per 6 months; included at no additional cost within 12 months of placement by the same Contract Dentist/office D2920 Re-cement o...
