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Dental Benefits Summary: The Building Trades Plan

Benefit	Coverage
Calendar Year Deductible	$75 per person; $225 per family
Calendar Year Maximum	In-Network: Plan pays up to $900 per person per calendar year toward all covered expenses. Out-of-Network: Plan pays up to $750 per person per calendar toward all covered expenses. Note: The calendar year maximum does not apply to pediatric oral care.
Preventive Care Services
Oral exams and routine cleanings: twice in a calendar year Bitewing x-rays and fluoride applications for children under 19: once per calendar year Sealants for dependent children younger than age 19: once every three consecutive calendar years Full mouth x-rays: once every three consecutive calendar years Brush biopsy to detect oral cancer Emergency treatment to relieve pain Cleanings following periodontal therapy	In- and Out-of-Network: Plan pays 100% of covered expenses, up to the *reasonable and customary charge*. There is no deductible.
Non-Preventive Services (below are some examples; for a complete list refer to the Summary Plan Description posted to the Forms & Documents page)
Space maintainers: once per lifetime Extractions and oral surgery services Fillings and crowns, repairs Root canal therapy Metallic inlays Bridges, implants and dentures: once per tooth in any five-year period Periodontic services to treat gum disease	In- and Out-of-Network: Plan pays 75% of covered expenses, after the deductible, up to the reasonable and customary charge.
Orthodontic treatments are not covered by the Plan.

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