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Dental Plan

Find a dental provider

The PBA Health and Welfare Fund Dental Plan provides comprehensive dental benefits, usually at no cost to members, through a network of participating dentists.  The Dental Plan covers the following categories of dental procedures:

Table 1: Coverage Summary

Category Examples
Basic Diagnostic and Preventive Procedures Routine Examinations, Cleanings, X-Rays
Restorative Procedures Fillings
Endodontic Procedures Root Canal
Prosthodontic Procedures Crowns, Bridges, Dentures
Periodontic Procedures Gingivectomy, Osseous Surgery
Orthodontia (Available until Age 23) Full Banding, Space Maintainers
Oral Surgery Extractions,  Dental Implants (Flat-dollar reimbursement)
Other Palliative (Emergency) Treatment


Participating Dental Providers

There is typically no cost to you for covered services provided by a participating dentist.The PBA Health and Welfare Fund Dental Plan maintains a network of participating dental providers. You may obtain a list of participating providers by contacting the PBA Funds Office, or on this website. If you are unable to access our website, please call the PBA Funds Office, and we can assist you in finding a provider. There is typically no cost to you for covered services provided by a participating dentist. You may incur out-of-pocket expenses if you have exhausted plan benefit limits or if non-covered services are provided.  You will not be required to complete claim forms when using a participating provider.

Non-participating dentists may charge more than the PBA Dental Plan’s fee schedule, resulting in out-of-pocket costs to you.Non-Participating Dental Providers

Covered services performed by non-participating dental providers are covered up to a maximum of the Dental Plan’s network fee schedule. You may file a claim form with the PBA Funds Office for reimbursement for out-of-network services. Claim forms can be obtained by contacting the PBA Funds Office, or you can print claim forms from this website. An American Dental Association Claim Form will also be accepted. All claims must be filed within twelve (12) months of the date of service. It is important to note that if you use a non-participating dental provider, you will likely have out-of-pocket costs for charges exceeding the Dental Plan’s network fee schedule. 

Benefit Limits

Some covered services and procedures are subject to dollar maximums and/or frequency limitations. Table 2, below, describes benefit limits for some of the most common covered services/procedures.  For a complete list of benefit limits, please refer to the Dental Plan Schedule of Allowances which is available on this website or at the PBA Funds Office.

Prior-Authorization

A number of dental procedures covered by the Dental Plan require prior-authorization. If a procedure is subject to prior-authorization, your dentist must obtain approval from the Plan before performing the procedure. In the event that more than one course of treatment is available, the Fund has the discretion to determine the procedure on which payment will be based. If you elect to proceed with an alternative course of treatment, you will be responsible for any cost in excess of the Plan’s payment for the procedure that the Fund authorized.

Table 2 below shows a summary of the benefit limits and prior-authorization requirements for the most common dental services covered by the PBA Health and Welfare Fund Dental Plan.  For a full list of benefit limits and prior-authorization requirements, please contact the PBA Funds Office to request a “Dental Plan Schedule of Allowances” which is also available on this website

 

Table 2:  Summary of Benefit Limits and Prior Authorization

Service/Procedure Benefit Limit Prior Authorization Required
Routine Examination One exam every six (6) months. No
X-Rays Dollar maximum per 12-month period based on Plan fee schedule. No
Dental Prophylaxis (Cleaning/Scaling/Root Planing) Once every six (6) months. No
Crowns, Bridges, Inlays, Onlays, and full or partial dentures Can only be replaced once every five (5) years. Yes
Orthodontia Benefits are only available to dependent children until the age of 23. Yes
Periodontics Only covered when performed by a periodontic specialist.Dollar maximums and frequency limits apply based on type of procedure. Yes
Fillings Dollar maximum per 12-month period per tooth based on Plan fee schedule. No
Dental Implants One implant per arch, per twelve (12) month period.  Benefits are limited to a flat-dollar reimbursement of $600.00.  Reimbursement is only available for implants performed by a board certified oral or maxillofacial surgeon or periodontist.  Implants can be replaced, if necessary, after 10 years. Yes
A full list of benefit limits and prior authorization requirements can be found in the “Dental Plan Schedule of Allowances.”

 Explanation of Benefits

Whenever the PBA Health and Welfare Fund Dental Plan makes a payment to your dentist or to you, you will receive an Explanation of Benefits (EOB).  The EOB is not a bill. The EOB describes the services that were performed and tells you how much the Plan paid.  It is important to review your EOB for accuracy.  If you receive an EOB for a service that was not performed, please contact the PBA Funds Office as soon as possible so that any discrepancies can be addressed.

Tips for Using Your Dental Coverage

The following tips will help you get the most out of your Dental Plan:

  • Try to use a participating provider whenever possible. Most dental work is covered in full when you use a participating provider.
  • Be aware of procedures that require prior-authorization. If you need dental work other than a routine exam and cleaning, ask your dentist if the procedure requires prior-authorization. If you or your dentist are unsure, please contact the PBA Funds Office.
  • If your dependent child requires braces, please consult a participating orthodontist regarding a treatment plan.
  • Review your Explanation of Benefits (EOB). Errors on your dental record can affect your eligibility for procedures that are subject to benefit limits.  It is important that any discrepancies are addressed as soon as possible.

Dental Implants

A fixed reimbursement for dental implants is available through the Dental Plan. The Plan will reimburse a flat dollar amount of $600.00 per implant, with a limit of one (1) implant per arch, per twelve (12) month period.  Please note that the mouth consists of two (2) arches, an upper arch and a lower arch.  Implant benefits are only available for implant procedures performed by a board certified oral or maxillofacial surgeon or periodonist. 

To obtain reimbursement for dental implants:

  • Choose a board certified oral/maxillofacial surgeon or periodontist.
  • Have the surgeon’s/periodontist’s office submit a treatment plan to the Fund with diagnostic x-rays.
  • Both you and the surgeon/periodontist will be notified of the Fund’s determination.
  • If the treatment plan and implant procedure are approved, you may schedule the implant procedure.
  • Submit treatment dates for services to the PBA Funds Office for processing of payment.
  • After the implant procedure has been completed, a post and crown may be placed. You may have the post and crown placed by the same provider who performed the implant procedure or by another dentist.  Reimbursement for the post and crown is limited to the Plan’s allowance for a post and crown placement on a natural tooth root (non-implant placement).

Please be aware that dental implants may result in out-of-pocket costs, including:

  1. The difference between the provider’s charges and the Plan’s fixed dollar-amount reimbursement.
  2. The cost of any other procedures not covered by the Plan, such as bone grafting, that may be necessary as a result of the implant procedure.
  3. The difference between the provider’s charges for the placement of the implant post and crown and the Plan’s allowance for a post and crown placed on a natural tooth root (non-implant post and crown placement).
  4. Any cost related to services that have not been approved through the Plan’s prior authorization process.

If your spouse or other dependents have coverage that is primary, use that coverage first and use your PBA H&W Fund benefits as secondary coverage in order to minimize your out of pocket costs.Coordination of Benefits

The Health and Welfare Fund coordination of benefits (COB) provision applies to the Dental Plan. Please refer to Section I (Eligibility) of this Plan Description for details regarding COB. If you or one of your dependents uses other dental coverage that is primary to this plan, you may apply for secondary benefits by completing a paper claim form and submitting it directly to the PBA Funds Office. Claim forms can be obtained by contacting the PBA Funds Office, or you can print claim forms from claim forms from this website. An American Dental Association Claim Form will also be accepted. As a secondary payer, the Fund will:

  • Calculate the amount it would have paid absent the primary coverage; and
  • Reimburse the member the amount it would have paid, limited to the member’s out-of pocket expense under the primary coverage.