PLEASE NOTE: These plans
are NOT available for negotiation after December 31,
2002!
These
Plans may remain in effect under a collective bargaining
agreement until it expires on or after December 31, 2002
at which time Dental Plans A, B or C must be negotiated.
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. |
CONTRIBUTION RATES
AND
SCHEDULE OF DENTAL BENEFITS*
|
| Dental
Plans H and RC have been merged into Dental
Plan A. |
| |
Prod Code |
PLAN E |
PLAN F |
PLAN G |
PLAN 2000 |
CONTRIBUTION RATES |
|
$49.20 |
$61.50 |
$68.20 |
$119.60 |
MAXIMUM ANNUAL BENEFIT |
|
$1,800 per person per calendar year |
$1,500 per person per calendar year |
$1,800 per person per calendar year |
$1,800 per person per calendar year |
ORTHODONTIC BENEFIT AND LIFETIME MAXIMUM |
|
Dependent
children under 19 only. Plan pays 70% of eligible expenses up to a $1,700
lifetime maximum. |
Dependent
children under 19 only. Plan pays 70% of eligible expenses up to a $1,500
lifetime maximum. |
Dependent
children under 19 only. Plan pays 70% of eligible expenses up to a $1,800
lifetime maximum. |
Dependent
children under 19 only. Plan pays 70% of eligible expenses up to a $1,800
lifetime maximum. |
|
CLASS 1
DIAGNOSTIC
and
PREVENTIVE
|
Prod Code |
PLAN E |
PLAN F |
PLAN G |
PLAN 2000 |
Periodic Oral Exam |
00120 |
$16.00 |
$24.00 |
$24.00 |
$38.00 |
X-Ray & Pathology
• Single Fil |
00220 |
$9.00 |
$11.00 |
$11.00 |
$17.00 |
| • Each additional Film |
00230 |
$6.00 |
$9.00 |
$9.00 |
$13.00 |
Adult Prophylaxis
(teeth cleaning) |
0110 |
$34.00 |
$51.00 |
$51.00 |
$75.00 |
|
CLASS II
GENERAL
RESTORATIVE |
Prod Code |
PLAN E |
PLAN F |
PLAN G |
PLAN 2000 |
Amalgam Resoration (one surface) |
02140 |
$38.00 |
$50.00 |
$50.00 |
$81.00 |
Root Canal Therapy
(single root canal) |
|
$214.00 |
$286.00 |
$286.00 |
$452.00 |
Extractions
•Single Tooth
•Additional Tooth |
07110
07120 |
$42.00
$38.00 |
$56.00
$50.00 |
$56.00
$50.00 |
|
Surgical
Extractions
•Surgical removal of erupted tooth |
07210 |
$90.00 |
$120.00 |
$120.00 |
$174.00 |
•Removal of tooth (partially bony) |
07230 |
$138.00 |
$184.00 |
$184.00 |
$290.00 |
Anesthesia - General |
09220 |
1st 30 minutes $154.00 |
1st 30 minutes $206.00 |
1st 30 minutes $206.00 |
1st 30 minutes $304.00 |
|
CLASS III
PROSTHETIC & MAJOR |
Prod Code |
PLAN E |
PLAN F |
PLAN G |
PLAN 2000 |
Crowns
Single restoration only
•Porcelain w/metal |
02751 |
$289.00 |
$336.00 |
$336.00 |
$460.00 |
Complete Dentures
•Complete upper
• Complete lower
• Replacement |
05110
05120 |
$424.00
$424.00
3 years
|
$520.00
$491.00
3 years
|
$520.00
$491.00
3 years
|
$719.00
$719.00
3 years
|
*This is not a complete listing
of covered services, procedure codes, or allowances. It is a partial
list for illustrative purposes only.
|
