The Western States Health & Welfare Trust Fund of the OPEIU makes the Trust Dental Plan available to you as an option for dental coverage.  Click on the tabs below for additional information

**Refer to your specific Labor Contract for YOUR Dental Plan**

1. Orthodontics.
   50% of reasonable and customary charges.
   
   
2. Basic Services.
   80% of usual and customary and reasonable charges (UCR).
   Basic Services include:
   1. Oral examination, including treatment plan, if necessary.
   2. Periapical and bitewing X‑rays as required.
   3. Topical fluoride application for family members under the age of 15.
   4. Prophylaxis, including cleaning, scaling and polishing.
   5. Repair of dentures and bridges.
   6. Palliative emergency treatment.
   7. Fillings consisting of silver amalgam, silicate and plastic restoration.
   8. Extractions.
   9. Endodontics, including pulpotomy, pulp capping and root canal treatment.
   10. Space maintainer.
   11. Oral surgery consisting of fracture and dislocation treatment, diagnosis and treatment of cyst and abscess.
   12. Apicoectomy.
       
       
3. Prosthetic Services. 50% of usual and customary and reasonable charges (UCR). Prosthetic services include:
   1. Inlays / Onlays;
   2. Crowns;
   3. Bridges, fixed and removable;
   4. Dentures, full and partial except that dental expense benefits for full denture replacement shall not be provided for any denture replacement made less than five years after a denture placement or replacement covered under this plan shall be limited to the standard procedures for prosthetic services.

Usual, customary and reasonable charges for dental service, in the area where the services are rendered, are determined by the Plan subject to the following considerations:

1. The usual fee is the fee which the individual dentist most frequently charge to the majority of his patients for a similar service;
   
2. The customary fees are those fees which fall within the customary range of fees charged in a given area by most dentists of similar training and experience for the performance of similar service;
   
3. A charge is reasonable when it meets the usual and customary criteria, or it may be reasonable if, in the opinion of an appropriate professional review committee, it merits special consideration based on complexity of treatment of the particular case;
   
4. The determination of the actual amount payable for any given procedure is within the sole discretion of the Plan. Charges in excess of the usual, customary and reasonable fee, as determined by the Plan, shall be your responsibility.

The deductible amount for each covered person during each calendar year is $10.00.

The deductible applies only once in any calendar year. So that your dental claim will not be subjected to a deductible late in one calendar year and soon again in the following year, any expenses applied against the deductible in the last three months of a calendar year may also be applied against the deductible for the next calendar year.

A separate dental deductible will apply to each insured member of your family but the maximum deductible for all eligible family members is $30 per calendar year.

The maximum amount payable for all covered dental procedures for each covered person shall not exceed in the aggregate:

1. $1,000.00 for orthodontic treatment during the lifetime of each covered person.
2. $1,500.00 for all other dental procedures during each calendar year.

These dental benefits do not cover expenses incurred by reason of:

1. Accidental bodily injury or sickness which arises out of or occurs in the course of any occupation or employment for wage or profit, unless claim for such loss has been properly denied by the State Industrial Commission or a private industrial carrier;
2. Expenses incurred with respect to any person while he or she was not covered under the Plan;
3. Expenses incurred for prosthetic devices (including bridges and crowns) and the fitting thereof which were ordered while the person was not insured under the plan ,or which were offered while the person was insured under the plan but are finally installed or delivered to such a person more than thirty days after termination of coverage;
4. Expenses incurred for treatment by other than a duly licensed dentist or denturist, except that cleaning or scaling of teeth may be performed by a licensed dental hygienist, if treatment is rendered under the supervision and direction of the dentist;
5. Expenses incurred for any replacement of an existing partial or full removable denture of fixed bridgework, or the addition of teeth to an existing partial removable denture or bridgework unless evidence satisfactory to the plan is presented that:
   1. The replacement or addition of teeth is required to replace one or more additional natural teeth extracted while an individual is insured under the plan; or
   2. the existing denture, bridgework, crown or inlay was installed at least five years prior to its replacement and that the existing denture, bridgework, crown or inlay cannot be made serviceable; or
   3. the existing denture is an immediate temporary denture and replacement by a permanent denture is required, and takes place within twelve months from the date of installation of the immediate temporary denture;
6. Expenses incurred for services and supplies that are partially or wholly cosmetic in nature, including charge for personalization or characterization of dentures;
7. Expenses incurred for replacement of a lost, stolen or broken prosthetic device;
8. Services, supplies or treatments provided by or covered under any governmental plan or law, or required or provided by any statute, or provided by any hospital or institution which does not require payment for such expenses in the absence of such group coverage.
9. Expenses incurred for care, treatment, services or supplies which are not necessary for the treatment of disease concerned nor to the extent that any charge for care, treatment, services or supplies are unreasonable;
10. War or act of war (declared or undeclared) or service in the armed forces of any country.

The charge for a dental procedure is considered to have been incurred on the day of performance of the procedure (except for certain Orthodontic procedures). If a procedure is not completed in one day, the day upon which the procedure is completed is deemed to be the incurred date for any charges in connection with such procedure.