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Summary Plan Description (SPD)
Southern California IBEW-NECA Active Health Plan
Amendment # 27
To the Self-Funded IBEW-NECA Dental Plan as Contained
In the Active Health Plan Summary Plan Description
Dated June 1, 2004
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 an after October 1, 2007, pages 96 – 101 are deleted in their entirety and replaced with the Trust Dental Plan – Summary of Benefits for Active Employees as attached hereto.
APPROVED AND ADOPTED at the Board of Trustees’ meeting held on November 20, 2007.
Trust Dental Plan - Summary of Benefits for Active Employees
Effective for dental services received on and after October 1, 2007
ADA Procedure Code |
PROCEDURE OR SERVICE |
Maximum Benefit Payable Per Procedure |
Annual Maximum = $2,000 |
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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. |
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| 0120 | Periodic Oral Evaluation, Once Every 12 Months | $36 |
| 0140 | Limited Oral Evaluation, Problem Focused | $42 |
| 0145 | Oral Evaluation for a Patient < 3 Years of Age and Counseling with Primary Caregiver | $42 |
| 0150 | Comprehensive Oral Examination, Once Every 12 Months | $54 |
| 0160 | Extensive Oral Evaluation, Problem Focused | $42 |
| 0170 | Reevaluation, limited, Problem Focused | $42 |
| 0180 | Comprehensive Periodontal Evaluation | $42 |
| 0210 | Intraoral - Complete Series (Including Bitewings) | $84 |
| 0220 | Intraoral - Periapical - First Film/Single Film | $22 |
| 0230 | Intraoral - Periapical - Each Additional Film | $14 |
| 0240 | Intraoral - Occlusal Film | $36 |
| 0250 | Extra-Oral - First Film | $58 |
| 0260 | Extra-Oral - Each Additional Film | $54 |
| 0270 | Bitewing - Single Film | $24 |
| 0272 | Bitewings - Two Films | $30 |
| 0273 | Bitewings – Three Films | $36 |
| 0274 | Bitewings - Four Films | $42 |
| 0277 | Vertical Bitewings – Seven to Eight Films | $42 |
| 0321 | Temporomandibular Joint Film | Not Covered |
| 0330 | Panoramic Film | $66 |
| 0460 | Pulp Vitality Tests | Not Covered Individually but Covered When a Root Canal Is Performed. |
| 0470 | Study Models | $60 |
| 0472 | Accession of Tissue, Gross Examination, Preparation and Transmission of Written Report | $115 |
| 0473 | Accession of Tissue, Gross and Microscopic Examination, Preparation and Transmission of Written Report | $115 |
| 0474 | Accession of Tissue, Gross and Microscopic Examination, Including Assessment of Surgical Margins for Presence of Disease, Preparation and Transmission of Written Report | $115 |
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. |
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1110 |
Prophylaxis – Persons Age 14 and over – Each 6 Months and with a letter of medical necessity a cleaning is allowed every 3 months | $65 |
| 1120 | Prophylaxis – Persons Under Age 14 | $53 |
| 1203 | Topical Application of Fluoride - Child under Age 17, Without Prophylaxis | $15 |
| 1330 | Oral Hygiene Instruction | Not Covered |
| 1351 | Topical Application of Sealant Under Age 16 – per Tooth | $30 |
| 1510 | Fixed Space Maintainer – Band Type - Unilateral | $212 |
| 1515 | Fixed Space Maintainer - Bilateral | $300 |
| 1520/1525 | Removable Space Maintainer - 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. |
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| 2140 | Amalgam Filling - One Surface, Primary or Permanent | $70 |
| 2150 | Amalgam Filling - Two Surfaces, Primary or Permanent | $79 |
| 2160 | Amalgam Filling - Three Surfaces, Primary or Permanent | $91 |
| 2161 | Amalgam Filling - Four or More Surfaces, Primary or Permanent | $100 |
| 2330 | One Surface Composite Filling, Anterior | $77 |
| 2331 | Two Surface Composite Filing, Anterior | $115 |
| 2332 | Three Surface Composite Filling, Anterior | $130 |
| 2335 | Four or More Surface or Involving Incisal Angle, Composite Filling, Anterior | $134 |
| 2391 | Resin-Based Composite Filling – One Surface Posterior | $70 |
| 2392 | Resin-Based Composite Filling – Two Surface Posterior | $79 |
| 2393 | Resin-Based Composite Filling – Three Surface Posterior | $91 |
| 2394 | Resin-Based Composite Filling – Four or More Surfaces Posterior | $100 |
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 Allied Administrators in advance of service or procedure being performed. |
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| 2510 | Inlay - Metallic - One Surface | Not Covered |
| 2520 | Inlay - Metallic - Two Surfaces | Not Covered |
| 2530 | Inlay - Metallic - Three or More Surfaces | $336 |
| 2543 | Onlay - Metallic - Three Surfaces | $432 |
| 2544 | Onlay - Metallic - Four Surfaces | $504 |
2740 |
Crown – Porcelain/Ceramic Substrate |
Not Covered |
| 2750 | Crown - Porcelain Fused to High Noble Metal | $606 |
| 2751 | Crown - Porcelain Fused to Predominantly Base Metal | $606 |
| 2752 | Crown - Porcelain Fused to Noble Metal | $606 |
| 2780 | Crown – ¾ Cast High Noble Metal | $606 |
| 2781 | Crown – ¾ Cast Predominantly Base Metal | $606 |
| 2782 | Crown – ¾ Cast Noble Metal | $606 |
| 2790 | Crown – Full Cast High Noble Metal | $606 |
| 2791 | Crown - Full Cast Predominantly Base Metal | $606 |
| 2792 | Crown - Full Cast Noble Metal | $606 |
| 2794 | Crown - Titanium | $606 |
| 2910 | Recement Inlay | $40 |
| 2920 | Recement Crown | $38 |
| 2930 | Prefabricated Stainless Steel Crown – Primary Tooth | $108 |
| 2931 | Prefabricated Stainless Steel Crown – Permanent Tooth | $108 |
| 2932 | Prefabricated Resin Crown | $144 |
| 2933 | Crown - Prefabricated Stainless/Resin | Not Covered |
| 2940 | Sedative Filling | Not Covered |
| 2950 | Core Build-Up, Including Pins | $34 |
| 2951 | Pin Retention, in Addition to Restoration | Not Covered |
| 2952 | Post and Core, Indirectly Fabricated (in addition to Crown) | $130 |
| 2954 | Prefabricated Post and Core in Addition to Crown | $115 |
| 2960 | Labial Veneer – Resin Laminate, Chairside | $288 |
| 2980 | 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. |
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| 3110 | Pulp Cap - Direct (Excluding Final Restoration) | $38 |
| 3120 | Pulp Cap – Indirect (Excluding Final Restoration) | Not Covered |
| 3220 | Therapeutic Pulpotomy (Excluding Final Restoration) | $78 |
| 3230 | Pulpal Therapy, Anterior Primary Tooth | $78 |
| 3240 | Pulpal Therapy, Posterior Primary Tooth | $78 |
| 3310 | Root Canal - Anterior, Excluding Final Restoration | $370 |
| 3320 | Root Canal - Bicuspid, Excluding Final Restoration | $419 |
| 3330 | Root Canal – Molar, Excluding Final Restoration | $530 |
| 3346 | Retreatment of Previous Root Canal Therapy - Anterior, Prior Authorization Required* | $370* |
| 3347 | Retreatment of Previous Root Canal Therapy - Bicuspid, Prior Authorization Required* | $419* |
| 3348 | Retreatment of Previous Root Canal Therapy - Molar, Prior Authorization Required* | $530* |
| 3351 | Apexification/Recalcification - Initial Visit | $144 |
| 3352 | Apexification/Recalcification - Interim Medication Replacement | $144 |
| 3353 | Apexification/Recalcification - Final Visit | $144 |
| 3410 | Apicoectomy/Periradicular Surgery - Anterior | $444 |
3421 |
Apicoectomy/Periradicular Surgery - Bicuspid |
$444 |
| 3425 | Apicoectomy/Periradicular Surgery - Molar | $494 |
| 3426 | Apicoectomy/Periradicular Surgery - Each Additional Root | Not Covered |
| 3430 | Retrograde Filling, per Root | $134 |
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. |
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| 4210 | Gingivectomy, 4 or More Teeth in Quadrant | $226 |
| 4211 | Gingivectomy/Gingivoplasty – 1 to 3 Teeth in Quadrant | $134 |
| 4240 | Gingival Flap Procedure, Including Root Planning, 4 or More Teeth. | Not Covered |
| 4249 | Clinical Crown Lengthening - Hard Tissue | $326 |
| 4260 | Osseous Surgery, 4 or More Teeth | $653 |
| 4261 | Osseous Surgery, 1 to 3 Teeth | $327 |
| 4271 | Free Soft Tissue Graft | Not Covered |
| 4320 | Provisional Splinting - Intracoronal | Not Covered |
| 4341 | Scaling/Root Planning, 4 or More Teeth (2 Quadrants Maximum per Visit) |
$120 |
| 4342 | Perio Scaling and Root Planing, 1 to 3 Teeth | $60 |
| 4355 | Full Mouth Debridement for Periodontal Evaluation and Diagnosis | $239 |
4910 |
Periodontal Maintenance Procedures (Following Active Therapy) |
$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. |
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5110 |
Complete Denture - Maxillary | $544 |
| 5120 | Complete Denture - Mandibular | $566 |
| 5130 | Immediate Denture – Maxillary | $566 |
| 5140 | Immediate Denture – Mandibular | $566 |
| 5211 | Maxillary Partial – Resin Base (including Clasps, Rests & Teeth) | $482 |
| 5212 | Mandibular Partial – Resin Base (including Clasps, Rests & Teeth) | $482 |
| 5213 | Maxillary Partial - including Clasps, Rests & Teeth | $870 |
| 5214 | Mandibular Partial - including Clasps, Rests & Teeth | $870 |
| 5225 | Maxillary Partial – Flex Base (including Clasps, Rests & Teeth) | $482 |
| 5226 | Mandibular Partial – Flex Base (including Clasps, Rests & Teeth) | $482 |
| 5410 | Adjust Complete Maxillary Denture | $18 |
| 5411 | Adjust Complete Mandibular Denture | $18 |
| 5421 | Adjust Maxillary Partial Denture | $18 |
| 5422 | Adjust Mandibular Partial Denture | $18 |
| 5510 | Repair Broken Complete Denture Base | $70 |
| 5520 | Replace Missing or Broken Teeth, Complete Denture, per Tooth | $65 |
| 5610 | Repair Resin Denture Base, Partial Denture | $70 |
| 5620 | Repair Cast Framework, Partial Denture | $130 |
5630 |
Repair or Replace Broken Clasp, Partial Denture |
$115 |
| 5640 | Replace Missing or Broken Teeth, Partial Denture, per Tooth | $65 |
| 5650 | Add Tooth to Existing Partial Denture, per Tooth | $94 |
| 5660 | Add Clasp to Existing Partial Denture | $151 |
| 5670 | Replace All Teeth and Acrylic on Cast Metal Framework (Maxillary) | $195 |
| 5671 | Replace All Teeth and Acrylic on Cast Metal Framework (Mandibular) | $195 |
| 5710 | Rebase Complete Maxillary Denture | $240 |
| 5711 | Rebase Complete Mandibular Denture | $240 |
| 5720 | Rebase Maxillary Partial Denture | $240 |
| 5721 | Rebase Mandibular Partial Denture | $240 |
| 5730 | Reline Complete Maxillary Denture (Chairside) | $101 |
| 5731 | Reline Complete Mandibular Denture (Chairside) | $101 |
| 5740 | Reline Maxillary Partial Denture (Chairside) | $101 |
| 5741 | Reline Mandibular Partial Denture (Chairside) | $101 |
| 5750 | Reline Complete Maxillary Denture (Laboratory) | $202 |
| 5751 | Reline Complete Mandibular Denture (Laboratory) | $202 |
| 5760 | Reline Maxillary Partial Denture (Laboratory) | $202 |
| 5761 | Reline Mandibular Partial Denture (Laboratory) | $202 |
| 5820 | Interim Partial Denture (Maxillary) | $218 |
| 5821 | Interim Partial Denture (Mandibular) | $218 |
| 5850/5851 | Tissue Conditioning, Maxillary/Mandibular | $58 |
| 5860 | Overdenture – Complete | $544 |
| 5861 | Overdenture - Partial | $566 |
| 6053 | Implant/Abutment Supported Removable Denture for Completely Edentulous Arch | $544 |
| 6054 | Implant/Abutment Supported Removable Denture for Partially Edentulous Arch | $870 |
| 6094 | Abutment Supported Crown – Titanium | $764 |
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. |
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| 6210 | Pontic - Cast High Noble Metal | $400 |
6211 |
Pontic - Cast Predominantly Base Metal | $400 |
| 6212 | Pontic - Cast Noble Metal | $400 |
| 6214 | Pontic - Titanium | $400 |
| 6240 | Pontic - Porcelain Fused to High Noble Metal | $403 |
| 6241 | Pontic - Porcelain Fused to Predominantly Base Metal | $400 |
| 6242 | Pontic - Porcelain Fused to Noble Metal | $426 |
| 6251 | Pontic - Resin with Predominantly Base Metal | Not Covered |
| 6252 | Pontic - Resin with Noble Metal | Not Covered |
| 6607 | Inlay – Cast Noble Metal, 3 or More Surfaces | $336 |
| 6608 | Onlay – Porcelain/Ceramic, 2 Surfaces | $432 |
| 6609 | Onlay – Porcelain/Ceramic, 3 or More Surfaces | $504 |
| 6610 | Onlay – Cast High Noble Metal, 2 Surfaces | $432 |
| 6611 | Onlay – Cast High Noble Metal, 3 or More Surfaces | $504 |
| 6612 | Onlay – Cast Predominantly Base Metal, 2 Surfaces | $432 |
| 6613 | Onlay – Cast Predominantly Base Metal, 3 or More Surfaces | $504 |
| 6614 | Onlay – Cast Noble Metal, 2 Surfaces | $432 |
| 6615 | Onlay – Cast Noble Metal, 3 or More Surfaces | $504 |
| 6634 | Onlay – Titanium | $504 |
| 6720 | Crown - Resin with High Noble Metal | Not Covered |
| 6721 | Crown - Resin with Predominantly Base Metal | Not Covered |
| 6722 | Crown - Resin with Noble Metal | Not Covered |
| 6750 | Crown - Porcelain Fused to High Noble Metal | $606 |
| 6751 | Crown - Porcelain Fused to Predominantly Base Metal | $606 |
| 6752 | Crown - Porcelain Fused to Noble Metal | $606 |
| 6780 | Crown - 3/4 Cast High Noble Metal | $606 |
| 6781 | Crown – 3/4 Cast Predominantly Base Metal | $606 |
| 6782 | Crown - 3/4 Cast Noble Metal | $606 |
| 6790 | Crown - Full Cast Noble Metal | $606 |
| 6791 | Crown - Full Cast Predominantly Base Metal | $606 |
| 6792 | Crown - Full Cast Noble Metal | $606 |
| 6794 | Crown - Titanium | $606 |
| 6930 | Recement Fixed Bridge | $59 |
| 6940 | Stress Breaker | $144 |
| 6970 | Post and Core, Indirectly Fabricated, in Addition to Fixed Partial Denture Retainer | $130 |
| 6972 | Prefabricated Post and Core in Addition to Fixed Partial Denture Retainer | Not Covered |
| 6973 | Core Buildup for Retainer, Including Any Pins | Not Covered |
| 6980 | Fixed Partial Denture Repair, By Report | $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. |
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| 7111 | Coronal Remnants – Deciduous Tooth | $50 |
| 7140 | Extraction, Erupted Tooth or Exposed Root | $52 |
| 7210 | Surgical Removal of Erupted Tooth | $91 |
| 7220 | Removal of Impacted Tooth - Soft Tissue | $113 |
| 7230 | Removal of Impacted Tooth - Partially Bony | $142 |
| 7240 | Removal of Impacted Tooth - Completely Bony | $173 |
| 7241 | Removal of Impacted Tooth - Completely Bony, with Unusual Surgical Complications | $209 |
| 7250 | Surgical Removal of Residual Tooth Roots | $91 |
| 7260 | Oroantral Fistula Closure | $403 |
| 7272 | Tooth Transplantation | $154 |
| 7280 | Surgical Exposure, Soft or Bony Tissue, of Impacted/Unerupted Tooth for Orthodontia | $173 |
| 7285 | Biopsy of Oral Tissue – Hard (Bone, Tooth) | $163 |
| 7286 | Biopsy of Oral Tissue – Soft (All Others) | $115 |
| 7310 | Alveoplasty in Conjunction with Extractions, Four or More Teeth Per Quad | Not Covered |
| 7320 | Alveoplasty Not in Conjunction with Extractions, Four or More Teeth Per Quad | $245 |
| 7321 | Alveoplasty Not in Conjunction with Extractions – 1 to 3 Teeth | $123 |
| 7440 | Excision of Malignant Tumor – Lesion Diameter Up To 1.25 cm, Prior Authorization Required* | See Note Above* |
| 7441 | Excision of Malignant Tumor – Lesion Diameter Greater than 1.25 cm, Prior Authorization Required* | See Note Above* |
| 7450 | Removal of Benign Odontogenic Cyst or Tumor – Lesion Diameter Up To 1.25 cm | $281 |
| 7451 | Removal of Benign Odontogenic Cyst or Tumor – Lesion Diameter Greater Than 1.25 cm | $281 |
| 7471 | Removal of Lateral Exostosis | $281 |
| 7472 | Removal of Torus Palatines | $281 |
| 7473 | Removal of Torus Mandibularis | $281 |
| 7490 | Radical Resection of Mandible with Bone Graft, Prior Authorization Required* | See Note Above* |
| 7510 | Incision and Drainage of Abscess – Intraoral Soft Tissue | $68 |
| 7511 | Incision and Drainage of Abscess – Intraoral Soft Tissue - Complicated | $68 |
| 7520 | Incision and Drainage of Abscess – Extraoral Soft Tissue | $90 |
| 7521 | Incision and Drainage of Abscess – Extraoral Soft Tissue - Complicated | $90 |
| 7530 | Removal of Foreign Body from Mucosa, Skin or Subcutaneous Alveolar Tissue, Prior Authorization Required* | See Note Above* |
| 7540 | Removal of Reaction-Producing Foreign Bodies, Musculoskeletal System, Prior Authorization Required* | See Note Above* |
| 7550 | Partial Ostectomy/Sequestrectomy for Removal of Non-Vital Bone, Prior Authorization Required* | See Note Above* |
| 7560 | Maxillary Sinusotomy for Removal of Tooth Fragment or Foreign Body | $612 |
| 7840 | Condylectomy (TMJ) | $842 |
| 7850 | Surgical Discectomy (TMJ) | $842 |
| 7910 | Suture of Recent Small Wounds Up To 5 cm, Prior Authorization Required* | See Note Above* |
| 7960 | Frenulectomy (Frenectomy or Frenotomy) – Separate Procedure | $170 |
| 7970 | Excision of Hyperplastic Tissue - per Arch | $148 |
| 7971 | Excision of Pericoronal Gingiva | $97 |
| 7980 | Sialolithotomy | $281 |
| 7981 | Excision of Salivary Gland, By Report | $612 |
| 7982 | Sialodochoplasty | Not Covered |
| 7983 | 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. |
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| 8210 | Minor Orthodontic Treatment | $336 |
| 8220 | Minor Orthodontic Treatment | $336 |
| 9110 | Palliative (Emergency) Treatment of Dental Pain – Minor Procedure | $72 |
| 9212 | Trigeminal Division Block Anesthesia | $77 |
| 9215 | Local Anesthesia | Not Covered |
| 9220 | Deep Sedation/General Anesthesia – First 30 Minutes | $192 |
| 9310 | Specialist Examination/Consultation | $58 |
| 9430 | Office Visit for Observation – No Other Services Performed | $38 |
| 9440 | Office Visit - after Regularly Scheduled Hours | $77 |
| 9610 | Therapeutic parenteral drug, Prior Authorization Required* | See Note Above* |
| 9940 | Occlusal Guard | $150 |
| 9951 | Occlusal Adjustment, Limited | $58 |
| 9952 | Occlusal Adjustment, Complete | Not Covered |
| 9999 | Broken Appointments - less than 24-Hour Notice, per 15 Min. Broken Appointment Maximums: |
Not Covered |
ORTHODONTIA |
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8070 |
Comprehensive Orthodontic Treatment - Transitional
|
50% of Treatment Schedule $1,400 Lifetime Benefit |
8080 |
Comprehensive Orthodontic Treatment – Adolescent to Age 19 |
Included in Above |
8090 |
Comprehensive Orthodontic Treatment - Adult |
Not Covered |
Note: Plus additional cost of noble metal (gold) when used.
* Included in benefit for root canal therapy.