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Pipe Trades PPO Plus Self-Funded Indemnity Dental Plan For All Participants

Calendar Year Deductible: $50¹ per person, 3 per family
Calendar Year Maximum: $3,000 per person
Orthodontia Lifetime Maximum: $5,000 per child

Schedule of Dental Benefits
Dental Service	In-Network	Out-of-Network
Preventive and Diagnostic Services Cleaning (two per calendar year²)	90% of contract rate, no deductible.	70% of usual, customary & reasonable, no deductible.
Fluoride Treatments, Exams, X-Rays, Bitewings (once every six months to age 18; once every twelve months ages 18 and over), Panoramic/Full Mouth X-Rays (once every three years)	90% of contract rate, after deductible.	70% of usual, customary & reasonable, after deductible.
Basic Services Restorative: Amalgam, Synthetic Porcelain and Plastic Fillings for the Treatment of Cavities, Scaling and Root Planing, Repairs to Dentures, Partial Dentures and Bridgework, Simple Extractions and Extraction of Impacted Teeth, Oral Surgery	90% of contract rate, after deductible.	70% of usual, customary & reasonable, after deductible.
Major Services Crowns, Full or Partial Dentures, Fixed Bridges	90% of contract rate, after deductible.	70% of usual, customary & reasonable, after deductible.
Orthodontia (Children under age 19 ONLY) Cephalometic, X-Ray, Study Models, Orthodontic Treatment (braces)	90% of contract rate, after deductible.	70% of usual, customary & reasonable, after deductible.
Pre-certification is required by the Plan prior to work costing $500 or more. Benefits will not be paid unless Pre-Certification is obtained.

¹ The $50 deductible will be waived for prophylaxis (cleanings). If you obtain two cleanings per year, your per-person deductible will be waived on all covered dental services in the following year. ² A third prophylaxis in a twelve month period may be covered if approved in advance by the Plan.