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Basic Plan SPD >> Dental Benefits
How the Plan Works
The Plan provides coverage for necessary dental care received through
the 32BJ Dental Center at 101 Avenue of the Americas, New York,
NY 10013, or from dentist center referred you to.
Necessary dental care is a service or supply that is required to identify
or treat a dental condition, disease or injury. The fact that a dentist
prescribes or orders a treatment does not make it dentally necessary. The service or
supply must be all of the following:
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provided by a dentist, or solely in the case of cleaning or scaling of
teeth, performed by a licensed, registered dental hygienist under the
supervision and direction of a dentist
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consistent with the symptoms, diagnosis or treatment of the condition, disease
or injury
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consistent with standards of good dental practice
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not solely for the patient’s or the dentist’s convenience, and
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the most appropriate supply or level of service that can safely be
provided to the patient.
Covered services are listed in the “Schedule of Covered Dental Services”, subject to frequency limitations that are
stated in that schedule. The Plan does not cover procedures that are not
on the schedule, but may provide an alternate benefit if approved by the
Fund.
The 32BJ Dental Center
The 32BJ Dental Center is equipped to provide a broad range of dental
services. If you receive your dental care from the 32BJ Dental Center, or a
dentist center referred you to, you
will not have to pay for any of that care. Call 1-212-388-2099 to make an
appointment at the 32BJ Dental Center.
Participating Dental Providers
The Fund has a network of participating dental providers (PDPs). You
have the privilege of accessing this network of PDPs at a discounted rate.
Should you choose to secure dental services from a network PDP you will
pay to the PDP the same rate that the Fund pays for these services based
on its contract with the PDP. You will pay the PDP directly for services
received from the network PDP.
What Dental Services Are Covered
The Plan covers a wide range of dental services, including:
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preventive and diagnostic services such as routine oral exams,
cleanings, X-rays, topical fluoride applications and sealants
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basic therapeutic services such as extractions and oral surgery,
intravenous conscious sedation when for oral surgery, gum treatment,
fillings and root canal therapy, and
- major services such as fixed bridgework, crowns, dentures, and gum
surgery.
See the "Schedule of Covered Dental Services" section for details.
Frequency Limitations
Benefits are subject to the frequency limits shown in the "Schedule of Covered Dental Services" section.
Schedule of Covered Dental Services
Alternate Benefit
There is often more than one way to treat a given dental problem. For example, a tooth could be repaired with an amalgam filling, a resin composite or a crown. If this is the case, the Plan will generally limit benefits to the least expensive method of treatment that is appropriate and that meets acceptable dental standards.
Access to Discounted Services from Network Dentists
The Plan has over 1,000 dentists who are participating dental providers (PDPs)
located throughout the metropolitan New York area. If you choose to get dental
services from one of these PDPs instead of the Dental Center, you will need to
pay the PDP directly for dental services. You will pay the PDP the full amount
of the Plan’s contracted fee. Although the Plan pays nothing, you will receive a
significant discount off the PDP’s regular charges.
To find a PDP simply call Member Services at the Fund and we will mail you
a Dental Directory that lists all PDPs, or you can stop in at the Walk-In Center
and pick up a Directory. If you need help selecting a dentist, call our Provider
Selection Service department at 1-212-388-2174.
You can also obtain the fee schedule for each dental procedure from our Member
Services department. This schedule will clearly identify the specific fee that a
PDP will charge you for each dental service. This way, you will know exactly
what your dental care will cost you if you use a PDP.
What Is Not Covered
The Plan’s dental coverage excludes the following:
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any service performed outside the 32BJ Dental Center unless referred by the
Dental Center
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any services performed before a patient becomes eligible for benefits
or after a patient’s eligibility terminates, even if a treatment plan has
been approved
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any services in excess of the frequency limitations specified in the
Schedule of Covered Dental Services
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orthodontic services
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treatment for accidental injury to natural teeth that is provided more
than 12 months after the date of the accident
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services or supplies that the Plan determines are experimental or investigative
in nature
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services or treatments that the Plan determines do not have a reasonably
favorable prognosis
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any treatment performed principally for cosmetic reasons, including,
but not limited to, laminate, veneers and tooth bleaching
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special techniques, including precision dentures, overdenture, characterization
or personalization of crowns, dentures, fillings or any other
service (This includes, but is not limited to, precision attachments and
stress-breakers. Full or partial dentures that require special techniques
and time due to special problems, such as loss of supporting
bone structure, are also excluded.)
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any procedures, appliances or restorations that alter the “bite,” or the
way the teeth meet (also referred to as occlusion and vertical dimension)
and/or restore or maintain the bite, except as provided under orthodontic
benefits (Such procedures include, but are not limited to, equilibration,
periodontal splinting, full-mouth rehabilitation, restoration of tooth structure
lost from attrition, and restoration for misalignment of teeth.)
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any procedures involving full-mouth reconstruction, or any services
related to dental implants, including any surgical implant with a prosthetic
device attached to it
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diagnosis and/or treatment of jaw joint problems, including temporomandibular
joint disorder (TMJ) syndrome, craniomandibular disorders,
or other conditions of the joint linking the jaw bone and skull or
the complex of muscles, nerves, and other tissue related to that joint
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multiple abutments
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treatment for self-inflicted injury or illness
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treatment to correct harmful habits, including, but not limited to,
smoking and myofunctional therapy
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habit-breaking appliances
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services for plaque-control programs, oral hygiene instruction, and
dietary counseling
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services related to the replacement or repair of appliances or devices,
including:
- duplicate dentures, appliances or devices
- the replacement of lost, missing or stolen dentures and appliances
less than five years from the date of insertion
- replacement of existing dentures, bridges or appliances that can be
made useable according to dental standards
- adjustments to a prosthetic device within the first six months of its
placement that were not included in the device’s original price
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drugs or medications (any prescriptions that are required may be
covered by the Plan’s prescription drug benefits – see the "Prescription Drug Benefits" section..)
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services for which a participant has contractual rights to recover cost,
whether a claim is asserted or not, under Workers’ Compensation, or
automobile, medical, personal injury protection, homeowners or other
no-fault insurance
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treatment of conditions caused by war or any act of war, whether
declared or undeclared, or a condition contracted or accident occurring
while on full-time active duty in the armed forces of any country or
combination of countries
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any portion of the charges for which benefits are payable under any
other part of the Plan
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if a participant transfers from the care of one dentist to another dentist
during the course of treatment, or if more than one dentist renders
services for the same procedure, the Plan will not pay benefits greater
than what it would have paid if the service had been rendered by one
dentist
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transportation to or from treatment
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fees for completing reports or for providing records, or
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any procedures not listed under the Schedule of Covered Dental
Services.
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