PIPE TRADES PPO PLUS SELF-FUNDED DENTAL PLAN

The dental benefit is self-funded by the Plan and is available for all active plan participants. (Coverage for self-pay participants may be different.) Please see the "Extended Coverage" section of this booklet.

Your program provides the benefits shown in the following table when services are performed by a dentist and when necessary and customary according to standards of generally accepted dental practice as determined by the Plan. However, there are limitations and exclusions that apply to your dental benefits; they are discussed starting on page 38.

Payment will be made for the covered dental charges incurred in excess of the deductible and multiplied by the benefit amount shown in the Schedule of Benefits below. In no event will the benefit exceed the maximum per person per calendar year or, for orthodontia, the lifetime maximum as shown in the Schedule of Benefits.

Deductible

The deductible is the out-of-pocket expense shown in the Schedule of Benefits that you pay before you are entitled to dental benefits. The deductible applies only once in a calendar year, and it is waived for routine prophylaxis (cleanings). If you receive two cleanings per year, your per-person deductible will be waived on all covered dental services in the next year.

SCHEDULE OF BENEFITS – 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

¹ The $50 deductible will be waived for routine prophylaxis (teeth cleaning). If you obtain two cleanings per year, your per-person deductible will be waived on all dental covered services in the following year.

² A third prophylaxis in a twelve month period may be covered if approved in advance by the Plan.

Preferred Provider Dentists

Under this plan you are free to use any dentist. However, the Trustees have negotiated lower charges with certain dentists, called “contract dentists.” Because the Plan saves money when you use a preferred provider dentist, your out-ofpocket costs are less when you use contract dentists.

For your free copy of the listing of contracted dentists, call the Administrative Office or visit the Plan’s website at www.pipetradesbenefits.org.

Obtaining services from a contracted dentist does not necessarily mean the services will be covered. Services that are not covered by the Plan are excluded regardless of where or by whom services are provided.

Pre-Certification Requirement

Treatments expected to cost more than $500 need Pre-Certification from the Plan. To obtain Pre-Certification, your dentist must send the proposed treatment plan to the Administrative Office for approval before treatment begins. Benefits will not be paid if you fail to obtain Pre-Certification for treatments of $500 or more. In some cases, the Plan will require a second opinion before a treatment plan is approved. In such cases, the Plan will refer you to a network dentist and pay the dentist's charges associated with the second opinion visit.

Covered Dental Charges

Covered dental charges are charges for the procedures described below when they are: prescribed, performed, or ordered by a dentist; reasonable and customary charges; incurred while you are covered by this Plan; and not excluded (see “Exclusions” on page 38).

1. Preventive Procedures
1. two oral examinations, including prophylaxis (per calendar year, deductible waived). A third prophylaxis treatment may be covered if determined by the Plan to be clinically appropriate;
2. topical application of sodium fluoride or stannous fluoride for dependent(s) up to age 19;
3. sealants to age 19 (once per tooth every 3 years, permanent molars only);
4. nutrition and oral hygiene counseling; and
5. space maintainers to age 19.
2. Diagnostic Procedures
1. 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,
2. tests and laboratory exams related to dental procedures; and
3. oral pathology.
3. Basic Dental Procedures
1. amalgam and composite restorations (fillings);
2. extractions and other oral surgery including pre and post-operative care;
3. space maintainers for dependent(s) up to age 19;
4. general anesthesia when administered by a dentist for a covered oral surgery procedure;
5. emergency palliative services;
6. periodontal treatment (treatment of gums and bones supporting teeth); and
7. endodontic treatment and related endodontic surgery including root canal therapy.
4. Major Dental Procedures
1. repair or recementing of crowns, inlays or bridges;
2. repair or relining of dentures (not more than one relining in 12 months);
3. installing removable partial denture or full dentures for the first time due to the extraction of one or more natural teeth extracted while covered by the Plan. (This includes adjustments made within 6 months following the installation);
4. replacement of an existing removable partial denture or full dentures, crown, or fixed partial denture by a new denture, crown, or fixed partial denture , or the addition of teeth to an existing denture or fixed partial denture to replace extracted natural teeth. These are covered only if:
1. the existing denture or fixed partial denture cannot be made serviceable and was installed at least 5 years before it is replaced,
2. the existing denture is an immediate (temporary) denture and must be replaced by a permanent denture, and the replacement is made within 12 months from the date the immediate (temporary) denture was installed, or
3. the replacement or addition of teeth is required to replace one or more natural teeth extracted while insured and after the existing removable partial denture or fixed partial denture was installed.
Benefits for replacement will not be more than the amount that would be payable for the same type of denture, crown or fixed bridge that is being replaced.
5. inlays, onlays, gold fillings, crowns, and installation of fixed partial dentures for the first time. Fixed partial dentures are covered only if they are for replacement of one or more natural teeth extracted while insured.

The Plan at its discretion may request clinical reports, charts and x-rays supporting the need for treatment.

If you are transferred from one dentist to another in the course of treatment, or if more than one dentist renders service on one dental procedure, the benefits will be determined as though one dentist had furnished all treatment.

Optional Services

If you select a more expensive plan of treatment than is customarily provided, the Plan will pay the applicable percentage of the lesser fee and you will be responsible for the remainder of the dentist’s fee. For example: a gold crown where a silver filling could restore the tooth or a precision denture where a standard denture would suffice.

Orthodontia

Benefits will be payable for the necessary orthodontic treatment and services rendered by a dentist to your eligible dependent under age 19, as shown in the Schedule of Benefits.

Covered orthodontic treatment charges will be deemed to be incurred as follows:

1. If the treatment plan allots a single charge to the entire treatment period or first phase of treatment, all of the charges will be deemed to have been incurred on the date of the initial banding. The first payment will be equal to 70% of total UCR charges for non-PPO providers or 90% of total contract charges for PPO providers up to the lifetime maximum of $5,000 after the annual deductible has been met.
2. If the treatment plan allots a single charge for further orthodontic services or second phase of treatment, all of the charges will be deemed to have been incurred on the date that the second phase of treatment begins. The second payment will be equal to 70% of total UCR charges for non-PPO providers or 90% of total contract charges for PPO providers up to the balance of the unused lifetime maximum of $5,000 after the annual deductible has been met.

Payments will be made upon submission of proof that treatments were rendered for the complete quarter.

EXCLUSIONS

No benefits will be payable for:

1. services or supplies for which an individual is not legally obligated to pay;
2. an illness or injury arising out of and in the course of the participant’s employment;
3. an illness or injury due to occupational disease; for the purposes of this Plan, “occupational disease” shall mean a disease for which the participant is entitled to benefits under the applicable Worker’s Compensation Law, Occupational Disease Law, or similar legislation;
4. the replacement of a lost or stolen prosthetic device;
5. charges that are made by someone who is not a dentist or for treatment not performed by a dentist. The cleaning and scaling of teeth may be performed by a licensed dental hygienist who works under the supervision of a dentist;
6. the first installation of denture or fixed/removable partial dentures if all teeth that will be replaced were extracted prior to the date the participant became covered. (Fixed partial dentures include crowns and inlays that form the abutments);
7. prosthetic devices and their fitting, for which treatment began prior to the date the participant became covered. (This includes fixed and removable partial dentures and crowns);
8. charges incurred as a result of an act of war, whether declared or not, or any related act; charges incurred as the result of participation in a riot or civil disorder;
9. extra sets of dentures or other appliances;
10. implants or the removal of implants. However, if implants are provided along with a covered prosthodontic appliance, the Plan will allow the cost of a standard partial or complete denture toward the cost of the implants and the prosthodontic appliances when the prosthetic appliance is completed. If the Plan makes such an allowance, the Plan will not pay for any replacement for five years following the completion of service;
11. educational or training programs (including oral hygiene or plaque control programs);
12. experimental procedures;
13. broken appointments;
14. completion of claim forms;
15. claims received more than twelve months after the services were received;
16. orthodontic treatment, except as provided for eligible dependent children under age 19;
17. charges that a participant is not legally obliged to pay; or treatment that he or she obtains, or is entitled to obtain, under any plan or program without charge, except Medicaid or Medi-Cal. This will include charges for treatment that is provided or paid by the federal government at a Veteran’s Administration facility:
1. an injury or illness related to the participant’s military service,
2. you or your dependents, if you are retired from the armed services,
3. provided or paid for by any governmental plan or law not restricted to its own civilian employees and their dependents, and
4. for which benefits are payable under other provisions of: (1) this dental Plan, or (2) the Self-Funded Indemnity Medical Plan.
18. full mouth reconstruction or rehabilitation, which is defined by the Plan as treatment involving 20 or more teeth;
19. treatment for the purpose of increasing vertical dimension;
20. any portion of a charge that is in excess of the reasonable and customary charge for the treatment;
21. charges for services that are cosmetic, not necessary, or are not recommended and approved by the Plan, or for care or treatment that is deemed inappropriate, or of a luxury nature;
22. extra oral grafts (grafting of tissue from outside the mouth to oral tissue);
23. services for restoring tooth structure lost from wear; for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion; or for stabilizing the teeth. Such services include but are not limited to equilibration and periodontal splinting;
24. prescribed drugs, premedication or analgesia (these may be covered under the Self-Funded Drug Plan or Kaiser);
25. prophylaxis, if the participant has received two prophylaxes covered under the Plan in the preceding 12 months, unless Pre-Certified by the Plan;
26. all hospital costs and any additional fees charged by the dentist for hospital treatment;
27. charges for anesthesia, other than general anesthesia administered by a dentist in connection with covered oral surgery services;
28. surgical procedures for correction of malalignment of teeth and/or jaws;
29. orthognathic surgery;
30. charges for diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joint or associated musculature, nerves and other tissues; or
31. services in excess of $500, unless Pre-Certification from the Plan is obtained.

Extended Benefits

If your coverage is terminated while you are receiving dental treatment (other than orthodontic procedures) that began while you were covered and for which services were performed by a dentist within the 31 days prior to the date of termination, benefits will be extended for that specific condition only, if further treatment for the condition is required. This is subject to the same terms that would have applied if the coverage had remained in force. Coverage will be extended only for necessary treatment received for the condition within the three months after the date the Plan terminates.

This provision will no longer apply as of the date the individual receiving extended coverage becomes insured under any other group policy for benefits that are like those provided by this Plan.