C o n n e c t i c u t C a r p e n t e r s H e a l t h F u n d P l a n

Dental

The Health Fund provides you and your covered dependents with dental care to get — and keep — healthy teeth. Preventive services are encouraged — the Health Fund pays 100% of allowable charges for two checkups per year per person. For other services the Health Fund pays a percentage of allowable charges.

The Health Fund pays all or part of allowable charges for certain:

· preventive services

· orthodontics

· periodontics

· restorative services (Basic and Major)

There’s no deductible or copay — you only need to pay the coinsurance for restorative, periodontal or orthodontia services, plus any amount over allowable charges.

Only services given by a dentist are covered, except for cleaning and scaling done by a dental hygienist under the dentist’s supervision.

Work that is cosmetic, including personalization or characterization of dentures, isn’t covered. Dental charges for treatment of damages as a result of an accident are paid under your medical coverage.

You’re covered for devices such as bridges and crowns if they’re ordered while you’re eligible under the Health Fund. Should you lose your Health Fund eligibility, bridges and crowns ordered while you were covered must be installed within 60 days after you’re no longer eligible for the Health Fund.

If you become covered for the first time or have your coverage reinstated after an absence of a year or more and you received dental treatment in the six months before you became covered, that treatment is considered a pre-existing condition and won’t be covered under the Health Fund for the first 12 months of coverage. The Health Fund will use your creditable coverage under another group dental plan to reduce the 12-month pre-existing condition limitation period.

Maximum Coverage

The Health Fund will pay $1,500 of covered expenses per person per calendar year, including preventive and restorative expenses. For orthodontia and periodontic treatment, the limit is $1,000 per person per lifetime.

Dental

Full Spectrum

Full Health

Disabled Member

Retiree Full

A Bit of Information

Dental charges are paid for in the year a device was placed in the mouth, not when it was made. If the work begins in one year and finishes in the next, it is covered up to the maximum in the year it’s finished. Be careful — the Health Fund won’t pay to replace lost or stolen devices.

Preventive Services
Service	You Pay	Health Fund Pays
Examinations, cleaning and bitewing X-ray	Any amount over allowable charges	100% Two per calendar year
Full mouth X-ray	Any amount over allowable charges	100% One every three years
Sodium fluoride or stannous fluoride	Any amount over allowable charges	100% One per calendar year for under age 15


Restorative Services
Service	You Pay	Health Fund Pays
Sealants	40% plus any amount over allowable charges	60% Under age 16
Fillings	40% plus any amount over allowable charges	60%
Tooth extraction	40% plus any amount over allowable charges	60%
Oral surgery, including excision of impacted teeth	40% plus any amount over allowable charges	60%
Anesthesia	40% plus any amount over allowable charges	60%
Endodontic treatment, including root canal therapy	40% plus any amount over allowable charges	60%
Anesthesia for any restorative service	40% plus any amount over allowable charges	60%
Injection of antibiotic drugs in connection with a covered procedure	40% plus any amount over allowable charges	60%
Crowns, inlays and gold fillings	40% plus any amount over allowable charges	60%
Initial installation of a removable denture, including adjustments within 6 months of installation, or fixed bridgework	40% plus any amount over allowable charges	60%
Replacement of, or addition to, a removable denture or fixed bridgework	40% plus any amount over allowable charges	60% · The denture or bridgework must have been in use at least five years and can’t be repaired, or · The denture being replaced with a permanent denture is an immediate temporary denture installed within the past 12 months
Repairing, recementing or relining of dentures, crowns inlays or bridgework	40% plus any amount over allowable charges	60%
Treatment of temporomandibular joint dysfunction other than by surgery	40% plus any amount over allowable charges	60%

Periodontics

Service

You Pay

Health Fund Pays

Periodontal and other gum and tissue disease of the mouth

40% plus any amount over allowable charges

60%

Lifetime maximum $1,000

Orthodontia