The Dental
Plan is an indemnity plan. Under this program, covered
services are reimbursed as a percentage of the
"Usual and Customary" charges for that
service in the state where the charge is incurred.
|
|
| Obtain
Services From Any Dentist |
| Coverage
Schedule |
| Benefits
Schedule |
| Eligibility |
| Deductible
Amount |
| Calendar
Year Maximum |
| Usual
& Customary |
| Waiting
Period |
| Eligible
Expenses |
| Effective
Date |
| Exclusions |
| Expenses
Incurred |
| It's
Easy To Apply |
| Any
Questions? |
| Please
Note |
| Administered
By |
| Underwritten
By |
|
| Obtain
Services From Any Dentist |
Under
this program, insured members may use any dentist they
choose. If you were previously a member of a dental
plan requiring the use of a specific dentist, you may
continue to use that dentist if you so choose, but it
is not a requirement of the Dental Plan.
|
| Coverage
Schedule |
| Calendar
Year Deductible |
$50
per person - Type I Benefits
$100 per person - Type II and Type III
benefits, combined |
| Calendar
Year Maximum |
$1,000
per person for all covered services
$500 per person for all eligible Orthodontic
services, if Optional Orthodontic Coverage is
selected |
| Lifetime
Maximum |
$1000
for Orthodontic services, if Optional
Orthodontic Coverage is selected |
|
| Benefits
Schedule |
| BENEFITS
SCHEDULE |
AFTER
THE ANNUAL DEDUCTIBLE THIS PLAN WILL PAY: |
TYPE
I BENEFITS
Preventive Services
|
100%
of the Usual and Customary
charges |
100%
of the Usual and Customary
charges |
TYPE
II BENEFITS
Basic Services
- Fillings
- Oral
Surgery
- Extractions
|
80%
of the Usual and Customary
charges (After 6 months of
continuous coverage) |
50%
of the Usual and Customary
charges (After 6 months of
continuous coverage) |
TYPE
III BENEFITS
Major Services
- Crowns
- Bridges
- Dentures
- Periodontics
|
50%
of the Usual and Customary
charges (After 12 months of
continuous coverage) |
50%
of the Usual and Customary
charges (After 18 months of
continuous coverage) |
TYPE
IV BENEFITS
(Optional Coverage)
Applies only to insured dependent children
under 19
|
| 50%
of the Usual and Customary
charges (After 24 months of
continuous coverage) |
50%
of the Usual and Customary
charges (After 24 months of
continuous coverage) |
|
| Eligibility |
All eligible
members of APWU who are actively at work, or
Retirees able to perform normal duties of a person
of same age and sex (including dependents) are
eligible to enroll. An eligible dependent is the
member's spouse and unmarried children from birth to
age 19 - extended to age 25 if a full time student.
|
| Deductible
Amount |
The
Deductible is shown in the coverage Schedule. The
Deductible is an amount of covered dental charges
incurred by an insured person for which no benefits
will be paid. The deductible amount will apply to
each insured person.
|
| Calendar
Year Maximum |
The
maximum amount payable for all Eligible Dental
Expenses in any calendar year is shown in the
Coverage Schedule. The Calendar year maximum will
apply to each insured person.
|
| Usual
& Customary |
This
means a charge that does not exceed the general
level of charges being made by other providers of
dental services in the same geographic area.
|
| Waiting
Period |
The
period of time the insured person must be
continuously covered under the group policy before
the insured is entitled to be reimbursed for covered
dental charges. (see Coverage Schedule)
|
| Eligible
Expenses |
Expenses
must be incurred while the Policy is in force and
the person is covered by the Policy. To be an
Eligible Expense, the dental service must be
performed by a licensed Dentist acting within the
scope of this license to: (1) render dental
services; (2) perform dental surgery (3) administer
anesthetics for dental surgery.
|
| Effective
Date |
Coverage
will become effective on the day your first premium
is received and accepted.
|
| Exclusions |
We
will not pay benefits for:
- Any dental care
or supply not listed as a Covered Expense shown
in the SCHEDULE.
- Dental care or
supplies furnished in a facility operated under
the direction or at the expense of the U.S.
Government (or its Agency) or by a Physician
employed by such a facility.
- Dental care and
supplies for which:
- no charge
is made
- no payment
is required when the Insured has no
coverage. This does not apply for care and
supplies covered by the Medical Assistance
Act of 1967, as amended.
- Dental care or
supplies resulting from taking part in the
commission of an assault or felony.
- Dental care or
supplies due to an injury during the course of
employment for pay, profit or gain.
- Dental care as
a result of:
- an act of
war (declared or undeclared)
- insurrection
- atomic
explosion or other release of nuclear energy
- Charges
incurred after the Insured's coverage ends.
- Personal
supplies for care and instructions in dental
hygiene, unless used in a Physician's office.
- Services or
materials of a cosmetic nature or repair of
congenital malformation solely for cosmetic
purposes, unless:
- as a result
of, and within 24 months of an accident
while insured, or
- treatment
of congenital defects of a newborn baby.
- Sealants.
- Dental
procedures performed by a licensed dental
hygienist, unless under the supervision and
direction of a licensed dentist.
- Prescriptions
drugs, unless a Covered Expense shown in the
SCHEDULE.
- Orthodontic
care, treatment or supplies, unless covered by
rider.
A complete list of limitations and exclusions is
provided in the certificate of insurance.
|
| Expenses
Incurred |
All
covered dental services must be provided by, or
under the direct supervision of a dentist.
Charges must be incurred by an insured person while
he is insured in order to be covered charges:
- For a crown,
bridge, or cast restoration, the charge is
incurred on the date the tooth is prepared.
- For any other
prosthetic device, the charge is incurred on the
date the master impression is made.
- For root canal,
the charge is incurred on the date the pulp
chamber is opened.
- For all other
services, the charge is incurred on the date the
services are given.
|
| It's
Easy To Apply |
- Simply complete
the Enrollment Form. Please make sure you
complete all the information requested. An
incomplete application will be returned,
resulting in a delay in processing your
application. Click
here for Enrollment Form.
- Send no
money.
- Return your
application to: The Voluntary Benefits Plan,
P.O. Box 1471, Waterbury, CT 06721
Once you receive your certificate of insurance, if
you're not 100% satisfied within the first 30 days,
we'll send you a full refund of any premiums paid
during that period and your certificate will be
considered never issued. You will be under no
further obligation.
|
| Any
Questions? |
Call
the following toll-free number
1-800-422-4492
(Within Connecticut, 1-800-237-5536) • TDD
1-203-754-4410
|
| Please
Note |
You
must notify the Voluntary Benefits Plan of any
address change, life status change (i.e., marriage,
divorce, or name change) or benefit changes
requested. Notice must be in writing.
This is a summary of benefits only and is subject
to the terms, conditions and limitations of group
policy no. G-224,540, form no. G-19000 / 19001.
Coverage may vary or may not be available in all
states.
|
| Administered
By |
The
Voluntary Benefits Plan
P.O. Box 1471
Waterbury, CT 06721
(California License #: 0791700)
|
| Underwritten
By |
The
United States Life Insurance Company In the City of
New York
A+ rating from A.M. Best reflects United States
Life's superior overall financial strength and
operating performance when compared to A.M. Best's
standards. This is A.M. Best's second highest
rating.
|
This
page reprinted from the APWU.org
website.
|
