Health and Welfare

Summary Plan Description Table of Contents

  1. Important Contact Information
  2. Introduction
  3. Table of Contents
  4. Plan A Schedule of Benefits
  5. Plan B Schedule of Benefits
  6. Plan C Schedule of Benefits
  7. Plan 11 Schedule of Benefits
  8. Plan 11-C Schedule of Benefits
  9. Eligibility for Active Participants
  10. Eligibility for Retiree Coverage
  11. Insurance Coverage
  12. Weekly Loss of Time Benefit
  13. Medical Benefits
  14. Prescription Drug Program
  15. Medicare Part D Prescription Drug Plan (PDP) for Retirees
  16. Members Assistance Program (MAP)
  17. Dental Benefit
  18. Vision Benefit
  19. Hearing Benefit
  20. Special Fund Program
  21. General Plan Exclusions and Limitations
  22. Other Limitations on Your Benefits
  23. Definitions
  24. Claim and Appeal Procedures
  25. General Plan Provisions
  26. Information About the Plan
  27. Board of Trustees

Dental Benefit

Dental Network of America (DNoA)

The Fund has an agreement with Dental Network of America (DNoA), who is a dental preferred provider (PPO) network administrator, an affiliate of Blue Cross Blue Shield of Illinois. DNoA offers the DNoA Preferred Network, which is a large network of participating dentists who have agreed to charge negotiated fees that are lower than what these dentists normally charge.

You will save money on your family’s dental bills when you use DNoA dentists.

This is a voluntary program—you are not required to use a DNoA dentist, and your benefits won’t be reduced if you use a non-participating dentist.

How Dental Benefits Are Determined

When you or any of your dependents have expenses for covered dental charges, the Plan will pay a specific percentage of such covered charges up to the calendar year maximum shown in your Schedule of Benefits. The annual maximum does not apply to preventive and routine services (those paid at 100%) for children under age 19.

Preventive and Routine (100%)

  1. Prophylaxis, or cleaning, which may be done by a dental hygienist, twice per calendar year.
  2. Oral examination and diagnosis which may be done twice per calendar year.
  3. X-rays, if necessary (full mouth x-rays once every three calendar years).
  4. Topical fluoride applications for dependent children under age 19 once per calendar year.
  5. Sealants for dependent children under age 19.
  6. Periodontal prophylaxis, up to four per calendar year. (Periodontal cleanings will count toward the two regular cleanings that are allowed per year.)

Minor Restorative (80%)

  1. Emergency treatment for relief of pain.
  2. Restorative services, including amalgam, synthetic, porcelain and plastic fillings.
  3. Endodontics, including pulpal therapy and root canal filling.
  4. Oral surgery, including extractions. Note: Covered charges for surgical removal of partially or completely bony impacted teeth are covered under the Major Medical Benefit. Tissue-only impactions are covered under the Dental Benefit.
  5. Periodontics, including treatment for disease of gums. DENTAL BENEFIT

Major Restorative (50%)

  1. Gold restorations when the teeth cannot be restored with another filling material.
  2. Crowns, inlays, onlays and jackets when the teeth cannot be restored with a filling material.
  3. Prosthetics such as bridges, partial dentures and complete dentures.
  4. Implants.
  5. Replacement prosthetics, such as crowns, bridges, dentures and implants, are covered if dentally necessary, provided the original prosthetic is at least five years (60 months) old.

Orthodontia

If your Schedule of Benefits includes orthodontia coverage, the Plan will pay 50% of the necessary treatment up to the maximum benefit on your schedule. Orthodontia benefits are only payable for dependent children, and only if the treatment begins while the child is under the age of 19.

Date of Incurral

For payment purposes, treatment is considered to have been incurred on the date the service is rendered. However, for the following services that require more than one visit, the incurral date is considered to be: 1) for full or partial dentures, when the impression is taken for the appliances; 2) for root canal therapy, when the tooth is opened; and 3) for fixed bridgework, crowns and other gold restorations, when the tooth is first prepared.

Dental Benefit Exclusions

Covered dental charges do not include charges for:

  1. Any treatment or service not prescribed by a dentist or oral surgeon.
  2. Services and supplies that are cosmetic in nature, including charges for bleaching or whitening of teeth, or personalization or characterization of dentures.
  3. Services, supplies or appliances provided in connection with the jaw, any jaw implant or the joint of the jaw (the temporo-mandibular joint).
  4. Periodontal splinting.
  5. Replacement of a removable prosthetic due to loss or damage.
  6. Adjunctive tests for oral cancer screening (for example, Vizilite).
  7. Any treatment or service excluded under the provisions of “General Plan Exclusions and Limitations,” beginning on page 64.