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Summary Plan Description (SPD)
AMENDMENT NO. 38
TO THE
SOUTHERN CALIFORANI 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 or after October 1, 2007 and before January 1, 2009, benefits for procedure codes 4271 and 4273 under the heading “Periodontics” as set forth on page 98 are deleted in their entirety and replaced with the amended benefits for procedure codes 4271 and 4273 as set forth below:
PERIODONTICS |
||
| 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 | $327 |
| 4273 | Subepithelial Connective Tissue Graft Procedure | $327 |
| 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 |
Approved and adopted by the Board of Trustees meeting held on December 4, 2008.
BOARD OF TRUSTEES
SOUTHERN CALIFORNIA IBEW-NECA
HEALTH TRUST FUND
BY: Signature on File
Chairman
BY: Signature on File
Secretary