It's Your Choice 2016
Uniform Dental Benefits (Certificate of Coverage)
Please read the following information carefully for your procedure frequencies and provisions.
This is a list of Uniform Dental Benefits and is based upon the Current Dental Terminology © American Dental Association. Codes are provided as a reference and may be subject to change; plans may substitute alternative codes to provide essentially equivalent coverage.
Dental Plan Administrator: The third party administrator responsible for providing the Uniform Dental Benefit plan under the Group Insurance Board’s program. Delta Dental of Wisconsin is the current Dental Plan Administrator for the Uniform Dental Benefit plan.
Dental Plan: Means all benefits, limitations, and exclusions included in the Uniform Dental Benefit Certificate.
Dental Provider: Means a dentist or any other person or entity licensed by the state of Wisconsin, or other applicable jurisdiction, to provide one or more Dental Plan benefits.
In-Network Dental Provider: A Dental Provider who has agreed in writing by executing a participation agreement to provide or direct dental care services, supplies, or other items covered under the policy to participants. The Dental Provider’s written participation agreement must be in force at the time of such services, supplies or other items covered under the policy are provided to the participant.
Note that there are no out-of-network benefits available under this Dental Plan.
No payment will be made for a benefit that is not listed.
**Special note on fillings: On anterior (front) teeth You will have 100% coverage subject to Your benefit maximum for both amalgam (silver) and composite/resin (tooth colored) fillings. On posterior (back) teeth, you have 100% coverage subject to your benefit maximum for amalgam (silver) fillings only. If you have a composite/resin (tooth colored) filling on a posterior tooth, you will be responsible for the difference between the amount your provider charges for an amalgam and a composite/resin filling.
Routine Oral Evaluation - exams are limited to two per year.
Limited Oral Evaluation
Complete Series or Panoramic Film: limited to one (either D0210 or D0330) once every 60 months.
Bitewing Films - limited to two sets per year.
Prophylaxis (Cleaning) and Fluoride:
Fluoride - limited to twice per year up to age 19.
Space Maintainers - limited to primary teeth lost prematurely
Orthodontic Services - limited to age 19, 50% coverage.
This page was last modified on: 9/28/2015 10:06:51 AM