CUPE Local 3902 (Unit 5): Dental Benefit Plan

The benefits shown below will be eligible, if based on the licensed dental practitioner’s reasonable and customary charge in accordance with the Fee Guide and the maximum shown in the Schedule of Benefits

Basic Services

  1. Basic Diagnostic and Preventive Services:
    • Complete oral examinations once every 3 years
    • emergency and specific oral examinations
    • full series x-rays and panoramic x-rays once every 3 years
    • bitewing x-rays once per calendar year (twice per calendar year for covered persons 19 years of age and under)
    • recall examinations once per calendar year (twice per calendar year for covered persons 19 years of age and under)
    • cleaning of teeth (up to 1 unit of polishing plus up to 1 unit of scaling) once per recall period
    • topical application of fluoride once per recall period
    • denture cleaning once per recall period
    • pit and fissure sealants on molars only, for covered person 14 years of age and under
      space maintainers
    • mouth guards once every 12 month
  2. Basic Diagnostic and Preventive Services:Complete oral examinations once every 3 years:
    • amalgam, tooth coloured filling restorations (paid to full metal on molar) and temporary sedative fillings
    • inlay restorations – these are considered basic restorations and will be paid to the equivalent non-bonded amalgam
  3. Basic Oral Surgery:
    • extractions of teeth and/or residual roots
  4. General anaesthesia, deep sedation, and intravenous sedation in conjunction with eligible oral surgery only
  5. Standard denture services:
    • denture repairs and/or tooth/teeth additions
    • standard relining and rebasing of dentures, once every 3 years, only after 6 months  have elapsed from the installation of a denture
    • denture adjustments and remount and equilibration procedures, only after 3 months have elapsed from the installation of a denture
    • soft tissue conditioning linings for the gums to promote healing
    • remake of a partial denture using existing framework once every 5 years
  6. Comprehensive oral surgery:
    • surgical exposure, repositioning, transplantation or enucleation of teeth
    • remodeling and recontouring – shaping or restructuring of bone or gum
    • excision – removal of cysts and tumors
    • incision –  drainage and/or exploration of soft or hard tissue
    • fractures including the treatment of the dislocation and/or fracture of the lower or upper jaw and repair of soft tissue lacerations
    • maxilofacial deformities – frenectomy – surgery on the fold of the tissue connecting the lip to the gum or the tongue to the floor of the mouth

Comprehensive Basic Services

  1. Endodontic treatment including:
    • root canal therapy
    • pulpotomy (removal of the pulp from the crown portion of the tooth)
    • pulpectomy (removal of the pulp from the crown and root portion of the tooth)
    • apexification (assistance of root tip closure)
    • apical curettage, root resections and retrograde fillings (cleaning and removing diseased tissue of the root tip)
    • root amputation and hemisection
    • bleaching of non-vital tooth/teeth
    • emergency procedures including opening or draining of the gum/tooth
  2. Periodontal treatment of diseased bone and gums including:
    • periodontal scaling and/or root planing, 2 time units per calendar year
    • occlusal equilibration – selective grinding of tooth surfaces to adjust a bite 2 time units every 12 months

The fees for periodontal treatment are based on units of time (15 minutes per unit) and/or number of teeth in a surgical site in accordance with the General Practitioners Fee Guide

  • bruxism appliance once every 12 months

Alternate Treatment
The group benefit plan will reimburse the amount shown in the Fee Guide for the least expensive service or supply, provided that both courses of treatment are a benefit under the plan.

Predetermination
Before your treatment begins, if the total cost of any proposed treatment is expected to exceed $300, it is recommended that you submit an estimate completed by your dental practitioner

Limitations
1. Laboratory services must be completed in conjunction with other services and will be limited to the co-pay of such services.  Laboratory services that are in excess of 40% of the dentist’s fee in the applicable Fee Guide shown in the Schedule of Benefits will be reduced accordingly; co-pay is then applied;

2. Reimbursement will be made according to standard and/or basic services, supplies or treatment. Related expenses beyond the standard and/or basic services, supplies or treatment will remain your responsibility;

3. Reimbursement will be pro-rated and reduced accordingly, when time spent by the dentist is less than the average time assigned to a dental service procedure code in the applicable Fee Guide shown in the Schedule of Benefits

4. Reimbursement for root canal therapy will be limited to payment once only per tooth.  Extra charges for difficult access, exceptional anatomy, calcified canals and retreatments are not included.  The total fee for root canal includes all pulpotomies and pulpectomies performed on the same tooth;

5. Common surfaces on the same tooth/same day will be assessed as one surface. If individual surfaces are restored on the same tooth/same day, payment will be assessed according to the procedure code representing the combined surface.  Payment will be limited to a maximum of 5 surfaces in any 36 month period;

6. When more than one surgical procedure, including multiple periodontal surgical procedures, is performed during the same appointment in the same area of the mouth, only the most comprehensive procedure will be eligible for reimbursement, as the fee for each procedure is based on complete, comprehensive treatment, and is deemed part of the multiple services factor;

7. The multiple services factor occurs when a minimum of 6 or more restorations (fillings) or multiple periodontal services are performed at the same appointment and the full fee guide price is charged for each restoration or periodontal service, the first service will be paid in full and all remaining services will be reduced by 20%;;

8. Root planing is not eligible if done at the same time as gingival curettage;

9. In the event of a dental accident, claims should be submitted under the health benefits plan before submitting them under the dental plan.

Dental Exclusions

Eligible benefits do not include and reimbursement will not be made for:

    1. Services Services or supplies received as a result of disease, illness or injury due to:
      1. an act of war, declared or undeclared;
      2. participation in a riot or civil commotion; or
      3. committing a criminal offence;
    2. Services or supplies provided while serving in the armed forces of any country;
    3. Failure to keep a scheduled appointment with a legally qualified dental practitioner;
    4. The completion of any claim forms and/or insurance reports;
    5. any dental service that is not contained in the procedure codes developed and maintained by the Canadian Dental Association, adopted by the provincial or territorial dental association of the province or territory in which the service is provided (or your province of residence if any dental service is provided outside Canada) and in effect at the time the service is provided;
    6. Implants;
    7. Restorations necessary for wear, acid erosion, vertical dimension and/or restoring occlusion;
    8. Appliances related to treatment of myofascial pain syndrome including all diagnostic models, gnathological determinants, maintenance, adjustments, repairs and relines;
    9. Posterior cantilever pontics/teeth and extra pontics/teeth to fill in diastemas/spaces;
    10. Service and charges for sleep dentistry;
    11. Diagnostic and/or intraoral repositioning appliances including maintenance, adjustments, repairs and relines related to treatment of temporomandibular joint dysfunction;
    12. Any specific treatment or drug which:
      1. does not meet accepted standards of medical, dental or ophthalmic practice, including charges for services or supplies which are experimental in nature, or is not considered to be effective (either medically or from a cost perspective, based on Health Canada’s approved indication for use);
      2. is an adjunctive drug prescribed in connection with any treatment or drug that is not an eligible service;
      3. is administered in a hospital or is required to be administered in a hospital in accordance with Health Canada’s approved indication for use;
      4. is not dispensed by the pharmacist in accordance with the payment method shown under the Health Benefit Plan Prescription Drugs benefit;
      5. is not being used and/or administered in accordance with Health Canada’s approved indication for use, even though such drug or procedure may customarily be used in the treatment of other illnesses or injuries;
    13. Services or supplies that:
      1. are not recommended, provided by or approved by the attending legally qualified (in the opinion of GSC) medical practitioner or dental practitioner as permitted by law;
      2. are legally prohibited by the government from coverage;
      3. you are not obligated to pay for or for which no charge would be made in the absence of benefit coverage; or for which payment is made on your behalf by a not-for-profit prepayment association, insurance carrier, third party administrator, like agency or a party other than GSC, your plan sponsor or you;
      4. are provided by a health practitioner whose license by the relevant provincial regulatory and/or professional association has been suspended or revoked;
      5. are not provided by a designated provider of service in response to a prescription issued by a legally qualified health practitioner;
      6. are used solely for recreational or sporting activities and which are not medically necessary for regular activities;
      7. are primarily for cosmetic or aesthetic purposes, or are to correct congenital malformations;
      8. are provided by an immediate family member related to you by birth, adoption, or by marriage and/or a practitioner who normally resides in your home. An immediate family member includes a parent, spouse, child or sibling;
      9. are provided by your plan sponsor and/or a practitioner employed by your plan sponsor, other than as part of an employee assistance plan;
      10. are a replacement of lost, missing or stolen items, or items that are damaged due to negligence. Replacements are eligible when required due to natural wear, growth or relevant change in your medical condition but only when the equipment/prostheses cannot be adjusted or repaired at a lesser cost and the item is still medically required;
      11. are video instructional kits, informational manuals or pamphlets;
      12. are delivery and transportation charges;
      13. are a duplicate prosthetic device or appliance;
      14. are from any governmental agency which are obtained without cost by compliance with laws or regulations enacted by a federal, provincial, municipal or other governmental body;
      15. would normally be paid through any provincial health insurance plan, Workplace Safety and Insurance Board or tribunal, or any other government agency, or which would have been payable under such a plan had proper application for coverage been made, or had proper and timely claims submission been made;
      16. relates to treatment of injuries arising out of a motor vehicle accident;
        Note: Payment of benefits for claims relating to automobile accidents for which coverage is available under a motor vehicle liability policy providing no-fault benefits will be considered only if-
        i)    the service or supplies being claimed is not eligible; orA letter from your automobile insurance carrier will be required;
        ii)   the financial commitment is complete;
      17. are cognitive or administrative services or other fees charged by a provider of service for services other than those directly relating to the delivery of the service or supply.