| Trust Dental Plan |
| The Active Employee Plan makes the Trust Dental Plan available to you as an option for dental coverage. |
| The Following Dental Charges (If Reasonable and Customary) Are Covered |
1. Charges for any accidental injury:
2. Charges for any sickness not entitling you to benefits under any Workers' Compensation or Occupational Disease law. 3. Charges that are necessary for the care and treatment of such accidental bodily injury or such sickness and are incurred on the recommendation of and performed by or under the direct supervision of a legally qualified dentist. 4. Charges that do not exceed the reasonable and customary charges for the procedure performed or the materials furnished. The excess, if any, will not be considered as eligible dental charges under the Plan. 5. Charges that are incurred for dental services, supplies and x-ray examinations. 6. Charges that are not excluded dental charges and are not otherwise excluded from coverage by the terms of the Plan. 7. Fluoride treatments are allowed twice per calendar year. 8. Sealants for dependents under the age of 19. This benefits applies
only to the following numbered teeth on the dental claim form: 1 through
5, 12 through 16, 17 through 21 and 28 through 32. This benefit renews
every calendar year and the maximum annual payment is $100. |
| All information provided on this web site is in summary and intended to provide highlights of your plans. We strongly recommend referring to the Plan booklet for complete details before making any decisions related to your eligibility, benefits and coverage. |