Dental Benefits - UWOSA Staff

The plan provides payment towards reasonable and customary charges for necessary dental services up to the current Dental Association Suggested Fee Guide for General Practitioners, or any dental specialist’s fee guide approved by the dental association in effect in the province where treatment is rendered. For most dental expenses, the plan reimburses you 85% of the cost.

However, under the out-of-pocket maximum provision the maximum you will pay for accumulated health care and dental expenses which are subject to the 85% reimbursement provision in a calendar year is $450 for a member with single coverage and $900 for a member with family coverage. If you reach the maximum, you will be reimbursed at 100% of eligible expenses for the remainder of that year.

Payment of Benefit

You will be reimbursed provided eligible expenses are:

• For services or supplies ordered or provided by a Dentist or Denturist
• For services or supplies which are generally accepted by the dental profession as essential, effective, appropriate and customarily used in the diagnosis, care or treatment of a specific dental condition or injury; and
• For services or supplies specified below which are not performed or provided in connection with an ineligible service or supply
• Not in excess of
• Any maximum amount specified in the applicable fee guide; or
• Reasonable and customary charges, as determined by the insurance provider, for expenses not included in the applicable fee guide

The plan covers 85% of eligible expenses such as:

• Complete oral exams, once every three years
• Emergency examinations
• Recall exams, bitewing x-rays and fluoride treatments, once every nine months
• Full-mouth x-rays, once every five calendar years
• Panoramic x-rays, once every five calendar years
• Scaling and polishing, one unit of time, once every nine months
• Fillings, retentive pins and pit and fissure sealants
• Space maintainers (appliances placed for orthodontic purposes are not covered)
• Extractions
• Routine diagnostic tests and laboratory exams
• Minor surgical procedures and post-surgical care
• Anesthesia and conscious sedation
• Periodontal procedures
• Endodontic procedures – root canals and therapy
• Denture repairs and additions
• Denture remake, relines and rebases once every two calendar years

Once every 60 months, for natural teeth only:

• Full or partial removable dentures
• Crowns and bridges and onlays
• Metal inlays and onlays
• Fixed bridgework
• Gold foil restorations
• Veneers (laboratory processed)

There are various items not covered including, but not limited to:

• Any dental procedure which is not eligible
• Services or supplies performed or provided in connection with an ineligible procedure
• Dental care, services or supplies which are primarily for cosmetic purposes, as determined by the insurance provider
• Services performed by a dental hygienist in an independent private practice
• Services or supplies to which you or your eligible dependent are entitled to receive under any Government plan
• Services or supplies which would be available without charge if this benefit was not in effect
• Conditions arising from war (whether or not war is declared), participation in any civil commotion, insurrection or riot, or while serving in the armed forces
• Temporomandibular joint-related problems
• Laboratory fees which exceed Reasonable and Customary charges, as determined by the insurance provider.

The Health Care plan also includes coverage for dental care provided by a dentist to repair or replace natural teeth damaged as a result of a direct external accidental blow to the mouth. Coverage is based on rates in the Dental Association Suggested Fee Guide for General Practitioners. If a dental accident happens outside Canada, the plan does not cover any amount that is greater than it would pay for such expenses when incurred in the province of residence. Treatment must be reported and approved for payment within 12 months of the date of the accident.