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Summary Plan Description (SPD)
AMENDMENT NO. 19
TO THE SOUTHERN CALIFORNIA IBEW-NECA
ACTIVE HEALTH PLAN
TO THE SOUTHERN CALIFORNIA IBEW-NECA
ACTIVE HEALTH PLAN
The Self-Funded IBEW-NECA Dental Plan as contained in the Southern California IBEW-NECA Health Plan Summary Plan Description dated June 1, 2004 is amended as follows:
Effective for dental claims incurred on and after November 1, 2006, pages 96 through 101 are deleted in their entirety and replaced with Summary of Benefits as attached hereto.
Approved and adopted at the Board meeting held on January 16, 2006
BY: _____________________
Chairman
BY: _____________________
Secretary
SELF FUNDED IBEW-NECA DENTAL PLAN
Effective with services incurred on and after November 1, 2006
|
ADA Procedure Code
|
PROCEDURE OR SERVICE
|
Maximum Benefit Payable Per Procedure
|
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
|
Annual Maximum = $2,000
|
|||||||||||
|
DIAGNOSTIC TREATMENT
*Note: Items with Prior Authorization Required: Service or procedure must be reviewed and approved by Allied
Administrators in advance of service or procedure being performed.
|
|||||||||||
00120 |
Periodic Oral Examination, once every 12 months | $36 | |||||||||
00140 |
Limited Oral Evaluation, once every 12 months | $42 | |||||||||
00150 |
Comprehensive Oral Examination, once every 12 months | $54 | |||||||||
00210 |
Intraoral - Complete Series (Including Bitewings) | $84 | |||||||||
00220 |
Intraoral - Periapical - First Film/Single Film | $22 | |||||||||
00230 |
Intraoral - Periapical - Each Additional Film | $14 | |||||||||
00240 |
Intraoral - Occlusal Film | $36 | |||||||||
00250 |
Extra-Oral - First Film | $58 | |||||||||
00260 |
Extra-Oral - Each Additional Film | $54 | |||||||||
00270 |
Bitewings - Single Film | $24 | |||||||||
00272 |
Bitewings - Two Films | $30 | |||||||||
00274 |
Bitewings - Four Films | $42 | |||||||||
00321 |
Temporomandibular Joint Film | Not Covered | |||||||||
00330 |
Panorex | $66 | |||||||||
00460 |
Pulp Vitality Tests | Not Covered Individually but Covered When a Root Canal Is Performed. | |||||||||
00470 |
Diagnostic Casts (Study Models) |
$60 | |||||||||
|
By Report |
Exam - 4 Bitewings & 2 PA |
$82 |
|||||||||
|
This section added by: Amendment 23.
|
|||||||||||
|
PREVENTIVE SERVICES *Note: Items with Prior Authorization Required:Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed. |
|||||||||||
01110 |
Prophylaxis - Adult – Each 6 Months and with a letter of medical necessity a cleaning is allowed every 3 months |
$65 | |||||||||
01120 |
Prophylaxis - Children to Age 14 | $53 | |||||||||
01201 |
Topical Application of Fluoride (Including Prophylaxis) under Age 17 | $60 | |||||||||
01203 |
Topical Application of Fluoride (Excluding Prophylaxis) Child | Not Covered | |||||||||
01330 |
Oral Hygiene Instructions | Not Covered | |||||||||
01351 |
Sealant per Tooth, Under Age 16 | $30 | |||||||||
01510 |
Space Maintainer - Fixed Unilateral | $212 | |||||||||
01515 |
Space Maintainer - Fixed Bilateral | $300 | |||||||||
|
01520/01525 |
Space Maintainer - Removable - Unilateral, Bilateral |
$212/$300 |
|||||||||
|
RESTORATIVE TREATMENT *Note: Items with Prior Authorization Required:Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed. |
|||||||||||
02110 |
Amalgam - One Surface, Primary | $54 | |||||||||
02120 |
Amalgam - Two Surfaces, Primary |
$68 | |||||||||
02130 |
Amalgam - Three Surfaces, Primary | $77 | |||||||||
02131 |
Amalgam - Four or More Surfaces, Primary | $82 | |||||||||
02140 |
Amalgam - One Surface, Permanent | $70 | |||||||||
02150 |
Amalgam - Two Surfaces, Permanent | $79 | |||||||||
02160 |
Amalgam - Three Surfaces, Permanent | $91 | |||||||||
02161 |
Amalgam - Four or More Surfaces, Permanent | $100 | |||||||||
02330 |
Resin - One Surface, Anterior | $77 | |||||||||
02331 |
Resin - Two Surfaces, Anterior | $115 | |||||||||
02332 |
Resin - Three Surfaces, Anterior | $130 | |||||||||
02335 |
Resin - Four or More Surfaces or Involving Incisal Angle (Anterior) | $134 | |||||||||
02336 |
Composite Resin Crown - Anterior - Primary | Not Covered | |||||||||
02380 |
Resin - One Surface - Posterior Primary |
Not Covered |
|||||||||
|
CROWNS Plus additional cost of noble metal (gold) when used. *Note: Items with Prior Authorization Required:Service or procedure must be reviewed and approved by the Allied Administrators in advance of service or procedure being performed. |
|||||||||||
02510 |
Inlay - Metallic - One Tooth Surface | Not Covered | |||||||||
02520 |
Inlay - Metallic - Two Tooth Surfaces | Not Covered | |||||||||
02530 |
Inlay - Metallic - Three or More Surfaces | $336 | |||||||||
02543 |
Onlays - Metallic 3 Surfaces | $432 | |||||||||
02544 |
Onlays - Metallic 4 or More Surfaces | $504 | |||||||||
02740 |
Porcelain, Ceramic Substrate | Not Covered | |||||||||
02750 |
Porcelain Fused to High Noble Metal |
$606 | |||||||||
02751 |
Porcelain Fused to Predominantly Base Metal | $606 | |||||||||
02752 |
Porcelain Fused to Noble Metal | $606 | |||||||||
02790 |
Full Cast Crown High Noble Metal | $606 | |||||||||
02791 |
Full Cast Predominantly Base Metal | $606 | |||||||||
02792 |
Full Cast Noble Metal | $606 | |||||||||
02780 |
3/4 Cast High Noble Metal | $606 | |||||||||
02910 |
Recement Inlay | $40 | |||||||||
02920 |
Recement Crown | $38 | |||||||||
02930 |
Prefabricated Stainless Steel (Primary) - Redo | $108 | |||||||||
02931 |
Prefabricated Stainless Steel (Permanent) - Redo | $108 | |||||||||
02932 |
Prefabricated Resin Crown | $144 | |||||||||
02933 |
Prefabricated Stainless Steel Crown with Resin Window | Not Covered | |||||||||
02940 |
Sedative Filling | Not Covered | |||||||||
02950 |
Core Buildup, Including Any Pins | $34 | |||||||||
02951 |
Pin Retention - per Tooth, in Addition to Restoration | Not Covered | |||||||||
02952 |
Cast Post and Core | $130 | |||||||||
02954 |
Prefabricated Post and Core in Addition to Crown | $115 | |||||||||
| 02960 |
Labial Veneer (Laminate) - Chairside | $288 | |||||||||
02980 |
Crown Repair, Prior Authorization Required* |
See Note Above* |
|||||||||
|
ENDODONTICS *Note: Items with Prior Authorization Required:Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed. |
|||||||||||
03110 |
Pulp Cap - Direct (Excluding Final Restoration) | $38 | |||||||||
03120 |
Pulp Cap - Indirect | Not Covered | |||||||||
03220 |
Therapeutic Pulpotomy (In Addition to Restoration) | $78 | |||||||||
03310 |
Anterior Root Canal (Excluding Final Restoration) | $370 | |||||||||
03320 |
Bicuspid Root Canal (Excluding Final Restoration) | $419 | |||||||||
03330 |
Molar Root Canal (Excluding Final Restoration) | $530 | |||||||||
03346 |
Retreatment - Anterior, Prior Authorization Required* | $370* | |||||||||
03347 |
Retreatment - Bicuspid, Prior Authorization Required* | $419* | |||||||||
03348 |
Retreatment - Molar, Prior Authorization Required* | $530* | |||||||||
03351 |
Apexification/Recalcification Initial Visit | $144 | |||||||||
03352 |
Apexification/Recalcification Each Interim Visit | $144 | |||||||||
03353 |
Apexification/Recalcification Final Visit | $144 | |||||||||
03410 |
Apicoectomy (Separate) - Anterior | $444 | |||||||||
03421 |
Apicoectomy/Peri Surgery - Bicuspid (1st Root) | $444 | |||||||||
03425 |
Apicoectomy/Peri Surgery - Molar (1st Root) | $494 | |||||||||
03426 |
Apicoectomy/Peri Surgery - Each Additional Root | Not Covered | |||||||||
03430 |
Retrograde Filling - per Root | $134 | |||||||||
|
03940 |
Recalcification (Caoh, Temp. Restoration) per Tooth (not a
procedure) |
Not Covered |
|||||||||
|
PERIODONTICS *Note: Items with Prior Authorization Required:Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed. |
|||||||||||
04210 |
Gingivectomy or Gingivoplasty - per Quadrant | $226 | |||||||||
04211 |
Gingivectomy/Gingivoplasty - per Tooth (Less than 6 Teeth) | $134 | |||||||||
04220 |
Gingival Curettage, per Quad (2 Quadrants Maximum per Visit) |
$125 | |||||||||
04240 |
Gingival Flap Procedure, Including Root Planning per Quad. | Not Covered | |||||||||
04249 |
Clinical Crown Lengthening - Hard Tissue | $326 | |||||||||
04260 |
Osseous or Muco-Gingival Surgery per Quad | $653 | |||||||||
04271 |
Gingival Graft (Per Procedure) |
Not Covered |
|||||||||
04320 |
Provisional Splinting |
Not Covered |
|||||||||
04341 |
Scaling and Root Planning per Quadrant (2 Quadrants Maximum per Visit) |
$120 |
|||||||||
04355 |
Full Mouth Debridement to enable Comprehensive Period Evaluation |
$239 |
|||||||||
04910 |
Periodontal Maintenance Procedure |
$82 |
|||||||||
|
PROSTHODONTICS *Note: Items with Prior Authorization Required:Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed. |
|||||||||||
05110 |
Complete Maxillary Denture | $544 | |||||||||
05120 |
Complete Mandibular Denture | $566 | |||||||||
05130/05140 |
Immediate Denture Upper/Lower | $566 | |||||||||
05211/05212 |
Partial Acrylic Upper or Lower with Chrome Cobalt Alloy Clasps |
$482 | |||||||||
05213 |
Partial Upper - Cast Metal Framework | $870 | |||||||||
05214 |
Partial Lower - Cast Metal Framework | $870 | |||||||||
05410-05422 |
Denture Adjustments (Upper or Lower) | $18 | |||||||||
05510 |
Complete Denture Repair (No Teeth Involved) | $70 | |||||||||
05520 |
Complete Denture Repair, Replace Missing or Broken Teeth | $65 | |||||||||
05610 |
Partial Repair Resin Denture Base | $70 | |||||||||
05620 |
Denture Repair - Replace Teeth | $130 | |||||||||
05630 |
Partial Denture Repair, Replace Broken Clasps - Extra (Maximum 2) | $115 | |||||||||
05640 |
Replace Broken Teeth per Tooth - Partial Denture | $65 | |||||||||
05650 |
Add Tooth to Existing Partial Denture | $94 | |||||||||
05660 |
Add Clasp to Existing Partial Denture | $151 | |||||||||
05710 |
Rebase Complete Maxillary Denture | $240 | |||||||||
05711 |
Rebase Complete Mandibular Denture | $240 | |||||||||
05720 |
Rebase Maxillary Partial Denture | $240 | |||||||||
05721 |
Rebase Mandibular Partial Denture | $240 | |||||||||
05730 |
Reline Complete Maxillary Denture, Chairside | $101 | |||||||||
05731 |
Reline Complete Mandibular Denture, Chairside | $101 |
|||||||||
05740 |
Reline Maxillary Partial Denture, Chairside | $101 | |||||||||
05741 |
Reline Mandibular Partial Denture, Chairside | $101 | |||||||||
05750 |
Maxillary Denture Reline, Laboratory | $202 | |||||||||
05751 |
Mandibular Denture Reline, Laboratory | $202 | |||||||||
05760 |
Reline Maxillary Partial Denture (Lab) | $202 | |||||||||
05761 |
Reline Mandibular Partial Denture (Lab) | $202 | |||||||||
05820 |
Stayplate, Including Teeth and Clasps | $218 | |||||||||
05850/05851 |
Special Tissue Conditioning, per Denture Unit Upper/Lower | $58 | |||||||||
05976 |
Implant |
Not Covered |
|||||||||
|
BRIDGES AND PONTICS Plus additional cost of noble metal (gold) when used. *Note: Items with Prior Authorization Required:Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed. |
|||||||||||
06210 |
Pontic - Cast High Noble Metal | $403 | |||||||||
06211 |
Pontic - Cast Predominantly Base Metal | $400 |
|||||||||
06212 |
Pontic - Cast Noble Metal | $400 | |||||||||
06240 |
Pontic - Porcelain Fused to High Noble Metal |
$403 | |||||||||
06241 |
Pontic - Porcelain Fused to Predominantly Base Metal |
$400 | |||||||||
06242 |
Pontic - Porcelain Fused to Noble Metal |
$426 | |||||||||
06251 |
Pontic - Resin with Predominantly Base Metal | Not Covered | |||||||||
06252 |
Pontic - Resin with Noble Metal | Not Covered | |||||||||
06720 |
Crown - Resin with High Noble Metal | Not Covered | |||||||||
06721 |
Crown - Resin with Predominantly Base Metal | Not Covered | |||||||||
06722 |
Crown - Resin with Noble Metal | Not Covered | |||||||||
06750 |
Crown - Porcelain Fused to High Noble Metal | $606 | |||||||||
06751 |
Crown - Porcelain Fused to Predominantly Base Metal | $606 | |||||||||
06752 |
Crown - Porcelain Fused to Noble Metal | $606 | |||||||||
06780 |
Crown - 3/4 Cast High Noble Metal | $606 | |||||||||
06790 |
Crown - Full Cast High Noble Metal | $606 | |||||||||
06791 |
Crown - Full Cast Predominantly Base Metal | $606 | |||||||||
06792 |
Crown - Full Cast Noble Metal | $606 | |||||||||
06930 |
Recement Bridge | $59 | |||||||||
06940 |
Simple Stress Breaker | $144 | |||||||||
06970 |
Cast Post and Core in Addition to Bridge Retainer | $130 | |||||||||
06971 |
Cast Post as Part of Bridge Retainer | Not Covered | |||||||||
06972 |
Prefab. Post and Core in Addition to Bridge Retainer | Not Covered | |||||||||
06973 |
Core Buildup for Retainer Including Any Pins | Not Covered | |||||||||
06980 |
Bridge Repairs |
$137 |
|||||||||
|
ORAL SURGERY *Note: Items with Prior Authorization Required:Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed. |
|||||||||||
07110 |
Single Tooth Extraction, Uncomplicated | $52 | |||||||||
07120 |
Each Additional Tooth Extracted | $48 | |||||||||
07130 |
Root Removal - Exposed Roots | $90 | |||||||||
07210 |
Surgical Removal of Erupted Tooth (Flap & Sut.) |
$91 | |||||||||
07220 |
Removal of Impacted Tooth - Soft Tissue | $113 | |||||||||
07230 |
Removal of Impacted Tooth - Partially Bony | $142 | |||||||||
07240 |
Removal of Impacted Tooth - Completely Bony | $173 | |||||||||
07241 |
Removal of Impacted Tooth - Completely Bony with Unusual Surgical Complications |
$209 | |||||||||
| 07250 |
Surgical Removal of Residual Tooth Roots | $91 | |||||||||
| 07260 |
Closure of Oral Fistula of Maxillary Sinus | $403 | |||||||||
07272 |
Transplantation of Tooth or Tooth Bud | $154 | |||||||||
07280 |
Crown Exposure for Orthodontia | $173 |
|||||||||
07285 |
Biopsy of Oral Tissue - Hard | $163 | |||||||||
07286 |
Biopsy of Oral Tissue - Soft | $115 | |||||||||
07310 |
Alveoplasty in Conjunction with Extractions - Per Quad | Not Covered | |||||||||
07320 |
Alveoplasty Not in Conjunction with Extractions | $245 | |||||||||
07440 |
Excision of Malignant Tumor, Prior Authorization Required* | See Note Above* | |||||||||
07451 |
Excision of Cyst or Tumor Greater than 1.25 cm Diameter | $281 | |||||||||
07471 |
Removal of Exostosis, Maxillary or Mandibular | $281 | |||||||||
07490 |
Radical Resection of Bone for Tumor with Bone Graft, Prior Authorization Required* | See Note Above* | |||||||||
07510 |
Intra-Oral Incision and Drainage of Abscess | $68 | |||||||||
07520 |
Extra-Oral Incision and Drainage of Abscess | $90 | |||||||||
07530 |
Incision and Removal of Foreign Body from Soft Tissue, Prior Authorization Required* | See Note Above* | |||||||||
07540 |
Removal of Foreign Body from Musculoskeletal System, Prior Authorization Required* | See Note Above* | |||||||||
07550 |
Sequestomy for Osteomyletitis, Prior Authorization Required* | See Note Above* | |||||||||
07560 |
Maxillary Sinusotomy for Removal of Tooth Fragment | $612 | |||||||||
07840 |
Condylectomy of Temporomandibular Joint | $842 | |||||||||
07850 |
Meniscectomy of Temporomandibular Joint | $842 | |||||||||
07910 |
Suture of Soft Tissue Wound or Injury, Prior Authorization Required* | See Note Above* | |||||||||
07960 |
Frenectomy | $170 | |||||||||
07970 |
Excision of Hyper Plastic Tissue per Arch | $148 | |||||||||
07971 |
Excision of Pericoronal Gingiva | $97 | |||||||||
07980 |
Sialolithotomy | $281 | |||||||||
07981 |
Removal of Salivary Gland | $612 | |||||||||
07982 |
Dilation of Salivary Duct | Not Covered | |||||||||
07983 |
Closure of Salivary Fistula | $252 | |||||||||
|
ADJUNCTIVE GENERAL SERVICES/MISCELLANEOUS *Note: Items with Prior Authorization Required:Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed. |
|||||||||||
08210 |
Removable Appliance Therapy | $336 | |||||||||
08220 |
Fixed or Cemented Appliance Therapy | $336 | |||||||||
09110 |
Emergency Treatment Palliative per Visit | $72 | |||||||||
08212 |
Trigeminal Division Block Anesthesia | $77 | |||||||||
09215 |
Local Anesthesia | Not Covered | |||||||||
09220 |
Anesthesia General | $192 | |||||||||
09310 |
Consultation (Diagnostic Service Provided by Dentist Other than Practitioner Providing Treatment) | $58 | |||||||||
09430 |
Post Operative Visit |
$38 |
|||||||||
09440 |
Office Visit after Regularly Scheduled Hours |
$77 |
|||||||||
09610 |
General Dentists/Specialists |
See Note Above* |
|||||||||
09940 |
Therapeutic Drug Injection, Prior Authorization Required* |
$150 |
|||||||||
09951 |
Occlusal Guard |
$58 |
|||||||||
09952 |
Correction of Occlusion, Limited - Per Quad (Maximum 2) |
Not Covered |
|||||||||
09999 |
Correction of Occlusion, Complete Broken Appointments - less than 24-Hour Notice, per 15 Min. Broken Appointment Maximums: Sealant Prophylaxis Any Other Appointment |
Not Covered |
|||||||||
|
ORTHODONTIA |
|||||||||||
|
8000 |
Full Banded Case – Adult |
Not Covered |
|||||||||
|
8001 |
Full Banded Case – Child Note: $1400 lifetime maximum if using Preferred Provider Organization |
50% of Treatment Schedule$1,000 Lifetime Benefit |
|||||||||
|
8004 |
Ortho Treatment Plan |
Included Above |
|||||||||
Note: Plus additional cost of noble metal (gold) when used.
* Included in benefit for root canal therapy.
BY: Signature on File
Chairman
BY: Signature on File
Secretary