Joint Council #28 - Dental Benefits-Plan C

Washington Teamsters Welfare Trust Dental Benefits
BENEFIT HIGHLIGHTS—DENTAL PLAN C

Following are highlights of Dental Plan C.

Please note, the plan features a network of dentists who offer discounts not available outside the network. You can choose to use either in-network or out-of-network dentists, but you'll save money—for you and the Trust—when you use Washington Dental Service (WDS) member dentists. For questions about your dental benefits or dental claims or to find a WDS member dentist near you, call WDS toll-free at 800-554-1907. WDS also has a website at www.DeltaDentalWA.com where you can access certain information.

PLAN FEATURES	DENTAL PLAN C
BENEFIT MAXIMUMS
Calendar Year Maximum Benefit	$1,800 per eligible
Orthodontia Benefit for dependent children under age 19 only	Plan pays 70% of eligible expenses
Orthodontia Lifetime Maximum	$1,800 per eligible

CLASS 1—DIAGNOSTIC AND PREVENTIVE
PLAN COVERS UP TO %100 OF THE LISTED SCHEDULE:
Periodic Oral Exam	$21.00
Bitewing x-rays - two films	$17.00
Adult Prophylaxis (teeth cleaning)	$46.00
Child Prophylaxis (teeth cleaning)	$32.00
Topical application of fluoride (excluding cleaning) - child	$18.00
Sealants for Children - per tooth	$21.00

CLASS 2—GENERAL AND MINOR RESTORATIVE
PLAN COVERS UP TO %100 OF THE LISTED SCHEDULE:
Periodontal scaling and root planing - per quadrant	$77.00
Amalgam Restoration (one surface)	$42.00
Root Canal Therapy - molar	$395.00
Simple Extraction Single	$47.00
Surgical Extraction Erupted Tooth	$101.00
Surgical Extraction Impacted Teeth - Completely Bony	$188.00

CLASS 3 —PROSTHETIC AND MAJOR RESTORATIVE
PLAN COVERS UP TO %100 OF THE LISTED SCHEDULE:
Crowns - single restoration only
Porcelain fused to high noble metal	$254.00
Porcelain fused to noble metal	$251.00
Please note: this summary is provided to assist participants in understanding Dental Plan C. It is not intended to be an all-inclusive description of Plan benefits and does not cover all limitations or exclusions. This summary should not be used in lieu of a Plan booklet. While every effort has been made to ensure that the information provided here is accurate, if there are any discrepancies between this summary and the official Plan documents and booklets, the official Plan documents and booklets govern. Dental Plan A I Dental Plan B I Dental Plan C I Dental Plan Comparisons I Old Dental Plans Click here to see BENEFITS CONTACT INFORMATION AND PHONE NUMBERS.