What the Plans Cover

The Trust Early Retiree Voluntary Dental Plans cover the following services when performed by a licensed dentist and when determined to be necessary and customary by the standards of generally accepted dental practice for the prevention or treatment of oral disease or for accidental injury, including masticatory function. No benefits are payable for services or supplies for which the patient is not liable.


Covered Services	Basic Dental	Buy-up Dental
Class I Services Preventive services, including: Cleaning (prophylaxis) two times per calendar year, two additional cleanings per year with periodontic issues Fluoride application for dependents age 14 and under, two times per calendar year Sealants for dependents through age 18, once every five calendar years Space maintainers Diagnostic services, including: Routine examination, two times per calendar year Bitewing X-rays, two times per calendar year Full mouth X-rays or panoramic film, once every five calendar years	Plan pays 80% of UCR after deductible	Plan pays 100% of UCR
Class II Services Oral surgery: Surgical extractions and certain other minor surgical procedures, including general anesthesia when administered by a dentist in connection with a covered oral surgery and when given in a dental office Restorative: Treatment of tooth decay with amalgam, synthetic porcelain, and plastic materials (Refer to Class III Services for other restorations.) Endodontic: Procedures for pulpal therapy and root canal filling Periodontic: Treatment of tissues supporting the teeth, including scaling once every three years	Plan pays 80% of UCR after deductible	Plan pays 80% of UCR
Class III Services Restorative: Treatment of tooth decay with crowns, jackets and gold or cast restorations, including onlays and implants. Covered only when teeth cannot be restored with other materials (See "Limitations.")	Plan pays 50% of UCR after deductible	Plan pays 80% of UCR
Class IV Services Prosthodontic: Procedures for construction or repair of fixed bridges, partials and complete dentures (See "Limitations.")	Plan pays 50% of UCR after deductible	Plan pays 50% of UCR
Class V Services Orthodontic: Benefits will be provided to eligible early retirees and their covered dependents	Not covered	Plan pays 50% of UCR up to a lifetime maximum benefit of $1,250 per person