PFT Health & Welfare Fund Retiree Dental Plan

Retirees and eligible dependents may enroll.

 

Rates:

 

Individual       $20.69 per month – billed by United Concordia quarterly ($62.07)

 

Two People     $40.04 per month – billed by United Concordia quarterly ($120.12)

 

Family             $53.04 per month – billed by United Concordia quarterly ($159.12)

 

Here’s how the benefits of your Retiree Dental Program compare to Active Plan:

Benefit Category Basic Dental Program for Retiree Members Dental Program for Active Members
Diagnostic and Preventative Services
Routine Examinations 80% - once in any 6 consecutive month period. 100% of the total allowable fee or the amount
charged (whichever is lower)
Oral Prophylaxis (Teeth Cleaning) 80% - once in any 6 consecutive month period. 100% of the total allowable fee or the amount
charged (whichever is lower)
Fluoride Application 80% - once in any 6 consecutive month period. 100% of the total allowable fee or the amount
charged (whichever is lower)
Pit & Fissure Sealants Not Covered.
Not Covered. 80% - once in any 36 consecutive month period,
unless special need is shown.
100%- once in any 36 consecutive month period,
unless special need is shown
Bitewing X-ray 80% - once in any 6 consecutive month period. 100% of the total allowable fee or the amount
charged (whichever is lower)
Endodontic Services
(under local anesthesia)
Root Canal Treatment 50%. 100% of the total allowable fee or the amount
charged (whichever is lower)
Apicoectomy (Root surgery) 50%. 50% of the total allowable fee or the amount
charged (whichever is lower)
Restorative Services
Restorative Services 50%. 100%.
Single unconnected inlays, onlays and crowns 50%. 80%.
Oral Surgery
(under local anesthesia)
Removal of impacted teeth
(partially or completely covered by bone)
50%. 80%.
Most other Oral Surgery 50%. 80%.
Periodontics (Gum
Treatment) (Under local anesthesia)
NonSurgical 50%. 50%.
Surgical 50%. 50%.
Fixed Prosthetics
Fixed Bridgework including abutment inlays,
onlays and crowns, and pontics
50%. 50%.
Replacement 50% - if at least 5 years since initial installation date under this program. 60% without limitation, as required.
Repairs to fixed bridges 50% - 100%. 50%.
Removable Prosthetics
Full or Partial Dentures 50%. 50%.
Replacement 50% - if at least 5 years since initial
installation date under this program.
50% - Covered only five years since the date of
the insertion of the existing inlay, onlay, or crown and only if the inlay,
onlay, or crown is unserviceable and cannot be made serviceable
Orthodontic Services Not covered 50% of the total allowable charges or the amount
charged (whichever is lower) with a maximum allowance of $1,200.00. This is a
lifetime maximum
Repairs to Removable Prosthetics 50% - 100%. 60% - 100%.
Deductibles No Deductible. No Deductible.
Maximum Benefits $1500 per person per year. No annual cap.
Out-of-Area Emergency Services Covered as specified above.