Health and Welfare Plan BenefitTabs™

  • Dental Benefits

     

  • Benefits

    Category of
    Coverage

    Active Plan Pays

    In-Network
    Retiree DPO Plan Pays

    Out-Of-Network
    Retiree DPO Plan Pays
    Diagnostic &
    Preventive Benefit

    100%

    100%

    80%
    Basic Benefits
    (oral surgery,
    restorative treatment,
    Ondontics,
    periodontics)

    80%

    80%

    80%
    Implants

    80%

    80%

    80%
    Orthodontic Benefits

    80%

    80%

    80%
    Crowns, jackets
    & Cast Restorations

    80%

    80%

    60%
    Prosthodontic Benefits

    80%

    80%

    60%
    Maximum

    $4000

    Effective 8/1/2010: $4000
    Prior to 8/1/2010: N/A

    Effective 8/1/2010: $4000
    Prior to 8/1/2010: N/A
    Maximum Orthodontics

    $4000

    $1500

    $1500
     

  • Implant Coverage

    Effective 8/1/2010: Dental implant coverage has been added, subject to the existing $4000 calendar year maximum.
     

  • Group Numbers

    Active: #4874-0005
    Retiree: #4874-0015
     

  • Contact Info

    Mailing Address:
    P.O. Box 997330
    Sacramento, CA 95899-7330
    Online Customer Service
    Phone Number: 800-765-6003
    FAX: 800-749-2227