The following comparative data is
for illustrative purposes only. It is NOT intended
to be an all-inclusive description of the Plan benefits
or any limitations/exclusions that may apply. It is NOT to
be used for general distribution purposes or in lieu of
a Plan booklet.
Every effort has been made to insure
that the following information is accurate as of the date
of issue, however, in all cases the applicable Plan booklet
(inclusive of all revisions or modifications made subsequent
to the latest printed editions) shall govern the eligibility
for the benefits payable under all Washington Teamsters
Welfare Trust programs. The Board of Trustees retains the
right of final determination in questions of interpretation. |
SUMMARY
COMPARISON OF NEW DENTAL PLANS |
| PLAN
FEATURES |
PLAN A |
PLAN B |
PLAN C |
| PLAN
RATE |
$125.20 |
$89.20 |
$49.20 |
| |
BENEFIT MAXIMUMS |
|
|
|
| Calendar
Year Maximum Benefit |
$1,800
per eligible |
$1,800
per eligible |
$1,800
per eligible |
| Orthodontia
Benefit for dependent children under age 19 only |
Plan
pays 70% of eligible expenses |
Plan
pays 70% of eligible expenses |
Plan
pays 70% of eligible expenses |
| Orthodontia
Lifetime Maximum |
$1,800
per eligible |
$1,800
per eligible |
$1,800
per eligible |
|
|
|
|
CLASS 1—DIAGNOSTIC
AND PREVENTIVE |
PLAN A |
PLAN B |
PLAN C |
| Routine
oral exams, teeth cleaning, fluoride treatments for children,
routine x-rays, sealants for children |
Plan
pays 100% of WDS' negotiated fees for WDS dentists; if
services are provided by a non-WDS provider, plan pays
100% of WDS' allowed amount. |
|
|
| |
Plan
covers up to 100% of the listed schedule |
| Periodic
Oral Exam |
|
$33.00 |
$21.00 |
| Bitewing
x-rays-two films |
|
$26.00 |
$17.00 |
| Adult
Teeth Cleaning |
|
$65.00 |
$46.00 |
| Child
Teeth Cleaning |
|
$45.00 |
$32.00 |
| Topical
Applications of fluoride (excluding cleaning)-child |
|
$25.00 |
$18.00 |
| Sealants
for children-per tooth |
|
$28.00 |
$21.00 |
|
|
|
|
| |
PLAN A |
PLAN B |
PLAN C |
| CLASS
2—GENERAL & MINOR RESTORATIVE |
|
|
|
| Fillings,
extractions, periodontal treatment, root canal therapy,
oral surgery, anesthesia |
Plan pays 90% of WDS' negotiated
fees for WDS dentists; if services are provided by a
non-WDS provider, plan pays 90% of WDS' allowed amount.
General anesthesia is covered when
medically necessary for children through age 6 or a physically
or developmentally disabled person when in conjunction
with any covered dental procedure. |
|
|
| Periodontal
scaling and root planing-per quadrant |
|
$182.00 |
$77.00 |
Amalgam
Restoration
(one surface) |
|
$83.00 |
$42.00 |
| Root
Canal Therapy-molar |
|
$732.00 |
$395.00 |
| Simple
Extraction Single |
|
$88.00 |
$47.00 |
| Surgical
Extraction Erupted Tooth |
|
$179.00 |
$101.00 |
| Surgical
Extraction Impacted Teeth-Completely Bony |
|
$350.00 |
188.00 |
|
|
|
|
CLASS 3—PROSTHETIC & MAJOR
RESTORATIVE |
PLAN A |
PLAN B |
PLAN C |
| Crowns,
bridges and dentures |
Plan
pays 75% of WDS' negotiated fees for WDS dentists; if services
are provided by a non-WDS provider, plan pays 75% of WDS'
allowed amount. |
|
|
| Crowns-single
restoration only |
|
|
|
| Porcelain
fused to high noble metal |
|
$409.00 |
$254.00 |
| Porcelain
fused to noble metal |
|
$390.00 |
$251.00 |
|
*This is not a
complete listing of covered services, procedure codes,
or allowances. It is a partial list for illustrative
purposes only.
|
