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The Dental Plan is an indemnity plan. Under this program, covered services are reimbursed as a percentage of the "Usual and Customary" charges for that service in the state where the charge is incurred.
Obtain Services From Any Dentist |
Under this program, insured members may use any dentist they choose. If you were previously a member of a dental plan requiring the use of a specific dentist, you may continue to use that dentist if you so choose, but it is not a requirement of the Dental Plan.
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| Coverage Schedule |
| Calendar Year Deductible |
$50 per person - Type I Benefits
$100 per person - Type II and Type III benefits, combined |
| Calendar Year Maximum |
$1,500 Per person for all covered services
$500 per person for all eligible Orthodontic services, if Optional Orthodontic Coverage is selected |
| Lifetime Maximum |
$1000 for Orthodontic services, if Optional Orthodontic Coverage is selected |
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| Benefits Schedule |
| BENEFITS SCHEDULE |
AFTER THE ANNUAL DEDUCTIBLE THIS PLAN WILL PAY: |
TYPE I BENEFITS
Preventive Services
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100%
of the Reasonable and Customary
charges
(No Waiting Period) |
100%
of the Reasonable and Customary
charges
(No Waiting Period) |
TYPE II BENEFITS
Basic Services
- Fillings
- Oral Surgery
- Extractions
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80%
of the Reasonable and Customary
charges (After 6 month
waiting period) |
50%
of the Reasonable and Customary
charges (After 6 month
waiting period) |
TYPE III BENEFITS
Major Services
- Crowns
- Bridges
- Dentures
- Periodontics
|
50%
of the Reasonable and Customary
charges (After 12 month
waiting period) |
50%
of the Reasonable and Customary
charges (After 18 month
waiting period) |
TYPE IV BENEFITS
(Optional Coverage)
Applies only to insured dependent children under 19
|
50%
of the Reasonable and Customary
charges (After 24 month
waiting period) |
50%
of the Reasonable and Customary
charges (After 24 month
waiting period) |
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| What Is The Cost Of This Plan? |
Click here to view Dental Plan Bi-Weekly Rates.
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| Eligibility |
All eligible members of APWU who are actively at work, or Retirees able to perform normal duties of a person of same age and sex (including dependents) are eligible to enroll. An eligible dependent is the member's spouse and unmarried children from birth to age 19 - extended to age 25 if a full time student.
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| Deductible Amount |
The Deductible is shown in the coverage Schedule. The Deductible is an amount of covered dental charges incurred by an insured person for which no benefits will be paid.
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| Calendar Year Maximum |
The maximum amount payable for all Eligible Dental Expenses in any calendar year is shown in the Coverage Schedule. The Calendar year maximum will apply to each insured person.
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| Reasonable & Customary |
This means a charge that does not exceed the general level of charges being made by other providers of dental services in the same geographic area.
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| Waiting Period |
The period of time the insured person must be continuously covered under the group policy before the insured is entitled to be reimbursed for covered dental charges. (see Coverage Schedule)
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| Eligible Expenses |
Expenses must be incurred while the Policy is in force and the person is covered by the Policy. To be an Eligible Expense, the dental service must be performed by a licensed Dentist acting within the scope of this license to: (1) render dental services; (2) perform dental surgery (3) administer anesthetics for dental surgery.
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| Effective Date |
Coverage will become effective on the day your first premium is received and accepted.
DATE INSURANCE ENDS: This coverage will end on the earliest following date: when the group policy ends; when the premium is not paid when due; when the member leaves the union; with respect to the spouse, the date the spouse is no longer a legal spouse; or with respect to the children, the date the children are no longer dependent.
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| Exclusions |
The Plan will not pay benefits for:
- Any dental care or supply not listed as a Covered Expense shown in the SCHEDULE.
- Dental care or supplies furnished in a facility operated under the direction or at the expense of the U.S. Government (or its Agency) or by a Physician employed by such a facility.
- Dental care and supplies for which:
- no charge is made
- no payment is required when the Insured has no coverage. This does not apply for care and supplies covered by the Medical Assistance Act of 1967, as amended.
- Dental care or supplies resulting from taking part in the commission of an assault or felony.
- Dental care or supplies due to an injury during the course of employment for pay, profit or gain.
- Dental care as a result of:
- an act of war (declared or undeclared)
- insurrection
- atomic explosion or other release of nuclear energy
- Charges incurred after the Insured's coverage ends.
- Personal supplies for care and instructions in dental hygiene, unless used in a Physician's office.
- Services or materials of a cosmetic nature or repair of congenital malformation solely for cosmetic purposes, unless:
- as a result of, and within 24 months of an accident while insured, or
- treatment of congenital defects of a newborn baby.
- Sealants.
- Dental procedures performed by a licensed dental hygienist, unless under the supervision and direction of a licensed dentist.
- Prescriptions drugs, unless a Covered Expense shown in the SCHEDULE.
- Orthodontic care, treatment or supplies, unless covered by rider.
A complete list of limitations and exclusions is provided in the certificate of insurance.
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| Expenses Incurred |
All covered dental services must be provided by, or under the direct supervision of a dentist.
Charges must be incurred by an insured person while he is insured in order to be covered charges:
- For a crown, bridge, or cast restoration, the charge is incurred on the date the tooth is prepared.
- For any other prosthetic device, the charge is incurred on the date the master impression is made.
- For root canal, the charge is incurred on the date the pulp chamber is opened.
- For all other services, the charge is incurred on the date the services are given.
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| It's Easy To Enroll |
- Simply complete the Enrollment Form. Please make sure you complete all the information requested. An incomplete enrollment form will be returned, resulting in a delay in processing your enrollment form. Click here for Enrollment Form.
- Send no money.
- Return your enrollment form to: The Voluntary Benefits Plan, P.O. Box 1471, Waterbury, CT 06721 or fax to 1-203-754-7847.
Once you receive your certificate of insurance, if you're not 100% satisfied within the first 30 days, we'll send you a full refund of any premiums paid during that period and your certificate will be considered never issued. You will be under no further obligation.
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| Any Questions? |
Call the following toll-free number
1-800-422-4492
• TDD 1-203-754-4410
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| Please Note |
You must notify the Voluntary Benefits Plan of any address change, life status change (i.e., marriage, divorce, or name change) or benefit changes requested. Notice must be in writing.
This is a summary of benefits only and is subject to the terms, conditions, exclusions and limitations of group policy no. G-224,540, form no. G-19000 / 19001. Coverage may vary or may not be available in all states. (This plan is not available in PR, VI, GU & AS)
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| Administered By |
The Voluntary Benefits Plan
P.O. Box 1471
Waterbury, CT 06721
Phone: 1-800-422-4492
Fax: 1-203-754-7847
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| Underwritten By |
The United States Life Insurance Company In the City of New York
A member company of American International Group, Inc.
United States Life has been awarded an A+ (Superior) rating from A.M. Best. This rating reflects United States Life's superior overall financial strength and operating performance when compared to A.M. Best's standards. The rating is current as of May 5, 2007. For the latest A.M. Best's Ratings and A.M. Best's Company Reports, please visit the A.M. Best Web site at www.ambest.com.
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