health
benefits

Dental

• Plan Summary
• Definitions
• Payment of Benefits
• Plan A — Basic Preventive & Restorative Services
• Plan B — Major Restorative Services
• Plan C — Orthodontics
• Emergency Treatment Outside Your Province of Residence
• Exclusions
• Claims

Plan Summary

Definitions

Fee Guide
means the Canadian Provincial/Territorial Dental Fee Guide that contains Dental services and fees in effect on the date the Dental services are performed.

Fee Schedule
means Schedule 2 of the Fee Schedule that contains eligible Dental services, financial limits, treatment frequencies, and fees in effect on the date the Dental services are performed.

1. The Plan will pay benefits based on Dental services, financial limits and treatment frequencies in the Fee Schedule.
2. The Plan will apply the reimbursement percentage shown on the previous page to the fees shown in the Fee Schedule/Fee Guide as follows:
   1. For services performed in British Columbia or outside Canada, if your province of residence is British Columbia – the fees in the Fee Schedule.
   2. For services performed in Canada but outside British Columbia - the fees in the Fee Guide in the province/territory of service.
   3. For services performed outside Canada if your province of residence is not British Columbia - the fees in the Fee Guide in your province/territory of residence.
3. Fees in excess of the amount shown in the applicable Fee Schedule/Fee Guide will be your responsibility.

Plan A — Basic Preventive & Restorative Services
Plan A covers services for the care and maintenance of teeth, including procedures to restore teeth to natural or normal function. Eligible Expenses per person include, but are not limited to, the Basic Services shown below.

Diagnostic Services

1. examinations:
   1. complete — provided the Plan has not paid for any other exam by the same dentist in the past 6 months - 1 per 3-year period;
   2. recall — 2 per calendar year;
   3. specific — provided the Plan has not paid for any other exam by the same dentist in the past 60 days; and
2. x-rays
   1. diagnostic;
   2. panoramic — 1 per 2-year period; and
   3. complete mouth series — 1 per 3-year period.
      All x-rays combined shall not exceed the dollar limit for a complete mouth series.
3. diagnostic models — 1 set per calendar year

Preventive Services

1. scaling;
2. polishing — 2 per calendar year
3. topical application of fluoride — 2 per calendar year;
4. fixed space maintainers; and
5. preventive restorative resins and pit and fissure sealants — combined limit of 1 per tooth in a 2-year period. No age limit.

Restorative Services

1. Fillings to restore tooth surfaces broken down as a result of decay — limited to a dollar amount equal to a 5 surface filling per tooth in a 2-year period for amalgam (silver coloured) fillings and or composite (tooth coloured) fillings.
2. Stainless steel crowns on primary and permanent teeth — once per tooth in a 2-year period.
3. Inlays on onlays — only 1 inlay, onlay, or another major restorative service on the same tooth will be covered in a 5-year period. Where other material would suffice, you will be responsible for the difference between the cost of the chosen material and the cost of alternative material.

Endodontics — for the treatment of diseases of the pulp chamber and pulp canal including but not limited to root canals — 1 per tooth in a 5-year period.

Periodontics — for the treatment of diseases of the soft tissue (gum) and bone surrounding and supporting the teeth, excluding bone and tissue grafts, but including the following:

1. occlusal adjustment and recontouring — a combined yearly limit shown in Fee Schedule;
2. root planing;
3. gingival curettage — 1 per sextant in a 5-year period; and
4. osseous surgery — 1 per sextant in a 5-year period

Prosthetic Repairs

1. removal, repairs and recementation of fixed appliances;
2. rebase and reline of removable appliances — a combined limit of 1 per upper and 1 per lower prosthesis in a 2-year period;
3. tissue conditioning — 2 per upper and 2 per lower prosthesis in a 5-year period; and
4. gold foil – only when used to repair existing gold restorations.

Surgical Services

1. extractions;
2. other routine oral surgical procedures; and
3. anaesthesia in conjunction with surgery shall not exceed the dollar limit shown in Fee Schedule.

Plan B — Major Restorative Services
You are eligible for Plan B Services when your dentist recommends replacement of your missing teeth, or reconstruction of your teeth (where Basic Restorative methods cannot be used satisfactorily).

Mounted x-rays and/or diagnostic casts may be required for approval.

Only 1 Major Restorative Service involving the same tooth will be covered in a 5-year period.

Plan B Services include, but are not limited to, the following:

Prosthodontic Services

1. removable:
   1. complete upper and lower dentures;
   2. partial upper and lower dentures;
2. fixed bridges.

Restorative Services

1. veneers;
2. crowns and related services; and
3. inlays and onlays involved in bridgework.

Periodontal Appliances
Bruxing guards — 2 appliances in a 5-year period (no benefit is payable for the replacement of lost, broken, or stolen bruxing guards).

Limitations

1. Only 1 inlay, onlay, or another Major Restorative Service on the same tooth will be covered in a 5-year period.
2. Crowns and fixed bridges on permanent posterior (molar) teeth are limited to the cost of the gold restoration.
3. Only 1 upper and 1 lower denture (complete or partial) is eligible in a 5 year period.
4. No benefit is payable for the replacement of lost, broken, or stolen dentures. Broken dentures may be repaired under Plan A.
5. Veneers, crowns, bridges, inlays, and onlays are subject to the conditions outlined in the Fee Schedule. Where other material would suffice, you will be responsible for the difference between the cost of the chosen material and the cost of the alternative material.

Plan C — Orthodontics
Benefits are payable for Orthodontic Services performed on or after the effective date of your coverage.

Limitations:

1. The lifetime benefit maximum under Plan C is $2,500.
2. No benefit is payable for the replacement of appliances which are lost or stolen.
3. Services done for the correction of temporomandibular joint (TMJ) dysfunction are not covered.

Emergency Treatment Outside Your Province of Residence
You are entitled to the services of a dentist if, while travelling or on vacation outside your province of residence, you require emergency Dental care. You will be reimbursed according to the Fee Schedule.

Exclusions
The following are not Eligible Expenses under the Dental Plan:

1. Items not listed in the Fee Schedule and fees in excess of those listed in the Fee Schedule;
2. Any item not specifically included as a benefit;
3. Charges for broken appointments, oral hygiene or nutritional instruction, completion of forms, written reports, communication costs, or charges for translating documents into English;
4. Procedures performed for congenital malformations or for purely cosmetic reasons;
5. Charges for drugs, pantographic tracings, and grafts;
6. Charges for implants and/or services performed in conjunction with implants, except as indicated in the Fee Schedule;
7. Anaesthesia not done in conjunction with surgery, and charges for facilities, equipment and supplies;
8. Charges for services related to the functioning or structure of the jaw, jaw muscles, or temporomandibular joint;
9. Incomplete or temporary procedures;
10. Recent duplication of services by the same or different dentist;
11. Any extra procedure which would normally be included in the Basic Service performed;
12. Services or items which would not normally be provided, or for which no charge would be made, in the absence of Dental benefits; and
13. Travel expenses incurred to obtain Dental treatment.

Claims

1. Present your ID card to your dentist’s office. It is important to ask if your Dental benefits will cover the entire cost of your treatment. To avoid any misunderstanding, we suggest that your dentist submit an outline of the proposed services to the Plan before your start treatment. This is important especially when your dentist is recommending extensive Dental work. This will help you understand what portion of the dentist’s bill must be paid by you in the event that you wish to proceed with the treatment recommended by your dentist.
2. We suggest that you submit claims within 90 days of the completed date of services (earlier if possible). Failure to submit a claim within the 90 day limit will not invalidate the claim if it is submitted as soon as reasonably possible. However, in no event will the Plan pay any claim or adjustment submitted later than 1 year from the date the service is performed.
3. the Plan requires a separate claim form for each member of your family who has received Dental services. Be sure to include the following information on the claim form:
   1. Name of the dentist;
   2. Name and birthdate of the person receiving the Dental care
   3. Your group, social insurance, and Dependent(s) numbers (this information is on your ID card;
   4. Your home mailing address; and
   5. Whether you have coverage through another plan. Claims information regarding the other carrier is not retained on file. If you or your Dependents are covered by two plans, your dentist must complete two separate Dental claim forms (one for each plan). Incomplete claims will be returned for clarification.
4. Before your dentist starts treatment, please ask how billing is made. The Plan may pay in either of two ways:
   1. The Plan will pay the dentist directly for services provided under this Dental Plan when a claim form signed by the dentist is received by the Plan, certifying these services were performed and the fee charged.
   2. If you have paid your dentist directly, the Plan will reimburse you the benefit amount when a claim form or receipts signed by your dentist are received. You will receive a cheque when the claim is processed.
5. Orthodontic Claims Procedures
   1. Receipts:
      Because the Plan does not return original receipts, photocopies will be accepted. Do not hold receipts until the completion of treatment.
   2. Claiming Deadlines:
      1. It is suggested that you submit Orthodontic claims within 90 days of the date the payment was due to your orthodontist (the due date).
      2. Reimbursement is made if the complete and correct claims information is received within 1 year of the due date. However, no benefit is payable for claims not received within 1 year of the due date.
   3. Treatment Plan:
      1. Have your orthodontist complete the "Certified Specialist in Orthodontics Standard Information Form" (the treatment plan) before treatment starts.
      2. If the payment schedule or treatment changes, the Plan requires a revised treatment plan for review.
      3. The Plan will retain your treatment plan on file. If your treatment plan is not on file the Plan is unable to pay:
         • your initial fee/down payment;
         • your monthly/quarterly fees; or
         • one time appliance fees;
      4. Claims for consultations, exams and records (x-rays, study models, etc.) will be reimbursed without a treatment plan on file.
   4. Monthly or Quarterly Fees:
      1. Submit receipts for the monthly or quarterly fees on a regular basis — as treatment progresses.
      2. The amount paid will be pro-rated over the estimated months of active treatment. For example, when braces are on the teeth, the estimated length of treatment will be on the treatment plan.
      3. As long as your coverage is in effect, monthly or quarterly reimbursements will be made to you until the dollar maximum is reached or the treatment is complete, whichever occurs first.