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The UA Local 43 Benefits Office was created to manage the benefits for our members and their families. These benefits have long included a health plan, a Defined Contribution and Defined Benefit Pension Plan.

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Benefits Office News

Click here for a Summary of Dental and Vision Benefits

1/13/2009

All information pertaining to dental and vision coverage. Deductibles, covered services, etc.

SCHEDULE OF DENTAL BENEFITS
 
For Eligible Active Employees and their Eligible Dependents
 
 
DEDUCTIBLE PER CALENDAR YEAR
 
Type A, B & C combined per Individual                                             $50
Maximum Individual Deductibles per Family                                      Three (3)
 
BENEFITS PAYABLE          
The Plan will pay the following percentages of Eligible Charges which exceed the Individual Calendar Year Deductible:
 
Type A:                        80% of Reasonable and Customary Charges
 
Type B:                        80% of Reasonable and Customary Charges
 
Type C:                       50% of Reasonable and Customary Charges
 
Type D:                       N/A
 
MAXIMUM BENEFITS PAYABLE (Per Eligible Individual)
 
Types A, B & C combined per Calendar Year                                    $500
Type D                                                                                                N/A
 
PRE-TREATMENT REVIEW
If the course of dental treatment is expected to exceed $200, a request for a Pre-treatment Review must be filed by the Dentist with the Plan to determine the benefits which will be payable under the Dental Plan. Failure to comply             with the Pre-treatment Review requirement will result in the denial of all expenses related to such treatment.
 
The time limit for filing a claim is limited to 12 months from date of service.
 
 
Description of Dental Benefit
 
The Plan pays the applicable percentage for eligible Reasonable and Customary Dental Expense Charges in excess of the Calendar Year Deductible up to the maximum benefit payable set forth in the Schedule of Dental Benefits, subject to the Dental Exclusions and Limitations.
 
A Dental Eligible Charge or Expense will be deemed incurred as of the date the procedure or service is rendered or the supply is furnished, except that such charge will be deemed incurred:
 
(1)        with respect to fixed partial dentures, crowns, inlays, or onlays, on the first date of preparation of the tooth or teeth involved;
 
(2)        with respect to removable partial or complete dentures, on the date the first impression was taken; or
 
(3)        with respect to endodontics, on the date the tooth was opened for root canal.
 
Dental Calendar Year Deductible
The Individual Calendar Year Deductible, as shown in the Schedule of Dental Benefits, shall mean the amount for Eligible Charges each Employee and each of his Dependents shall pay each Calendar Year before each is entitled to Plan payment for Eligible Dental Charges. A separate Calendar Year Deductible shall apply to the Employee and to each of the Employee's Dependents. A limit of three Individual Calendar Year Deductibles shall be payable by each family per Calendar Year.
 
Dental Co-Insurance
For Types A (Preventive), B (Basic), and C (Major), the Plan shall pay the percentage shown in the Schedule of Dental Benefits of eligible Reasonable and Customary Charges incurred in a Calendar Year after the individual Calendar Year Deductible has been satisfied, up to the calendar year maximum as indicated in the Schedule of Dental Benefits.
 
Dental Calendar Year Maximum
The Calendar Year Maximum, as shown in the Schedule of Dental Benefits, is the maximum dental benefits payable in a Calendar Year for Types A, B, and C dental expenses combined.
 
Dental Pre-treatment Review
The term treatment plan means the written statement of a dentist on a form furnished by or satisfactory to the Plan in which the dentist sets out findings from an examination of the covered individual, the dentist’s suggested plan of treatment, and the approximate cost and duration of such treatment. A treatment plan which can reasonably be expected to involve covered dental charges in excess of $200 must be submitted to Administrative Services, Inc. prior to commencement of the course of treatment. The Plan will require as part of the proof of the claim, a complete dental chart showing any extractions, fillings, or other work, performed prior to the date of the loss for which a claim is being made; itemized bills of the dentist or other sources of service, supplies and treatment; x-rays, laboratory or hospital reports, casts, molds, or study models, or other similar evidence of the condition or treatment of the teeth or oral cavity. Pre-treatment review will determine in advance of services being rendered, what expenses will be covered by the Plan.
 
Failure to obtain a pre-treatment review will result in the denial of any expenses associated with a procedure that exceeds $200. If the patient obtains a pre-treatment review and elects to pursue a course of treatment other than the one authorized by the Plan, the patient will only be reimbursed up to the authorized allowance. The patient will be responsible for all charges incurred above the authorized amount.
 
Dental Examination by the Plan
The Plan, at its own expense, will have the right and opportunity to have a Dentist examine the Employee or eligible Dependent when, and as often, as it may reasonably require during the pendency of a claim under this Plan.
 
Alternate Course of Dental Treatment
If alternate services may be employed to treat a dental condition, covered dental expenses will be limited to those which are customarily employed in the treatment of the disease or injury and are recognized by the profession to be appropriate methods of treatment in accordance with broadly accepted national standards of dental practice, taking into account the total current oral condition of the insured dental patient.
 

Extension of Dental Benefits
Benefits are payable for services rendered following termination of coverage only as follows:
 
(1)        charges for removal of a partial or complete denture will be considered if the impressions were taken and abutment teeth fully prepared while the individual was covered for dental benefits under this Plan, provided the prosthetic device is installed or delivered to the covered individual within thirty (30) days following termination of such individual’s coverage under this Plan.
 
(2)        charges for a fixed partial denture, crown, inlay or onlay required for the restoration of a tooth will be considered if the tooth was prepared for the crown while the individual was covered for dental benefits under this Plan and fixed partial denture, crown, inlay or onlay is installed within thirty (30) days following termination of such individual’s coverage under this Plan.
 
(3)        charges for root canal therapy will be considered if the tooth was opened while the individual was covered for dental benefits under this Plan and treatment completed within thirty (30) days following termination of such individual’s coverage under this Plan.
 
Under no other circumstances will coverage be extended beyond the date of termination of dental benefits.
 
ELIGIBLE DENTAL CHARGES OR EXPENSES
 
Eligible Dental Charges or Expenses
Eligible Dental Charges included under the Plan are those Reasonable and Customary charges incurred for the following services, supplies and treatment when performed by a legally qualified dentist for dental treatment.
 
(1)        Type A - Preventive and Diagnostic
 
(A)       oral exams - routine oral examinations including diagnosis, but not more than one such examination with respect to the same covered individual within any six consecutive month period;
 
(B)       prophylaxis with or without oral examination, including cleaning, scaling and polishing, but no more than one dental prophylaxis with respect to the same covered individual within any six consecutive month period;
 
(C)       intra-oral x-rays - complete series with or without bitewings (only one series in any 36 consecutive month period);
 
(D)       bitewing (x-rays) - (no more than one charge in any six consecutive month period);
 
(E)       panoramic x-ray (panorex) and complete mouth survey (FMX) limited to one series within any 36 consecutive month period;
 
(F)       topical application of stannous fluoride for individuals under age 14 (no more than one application in any 12 consecutive month period); and
 
(G)       space maintainers (not made of precious metals) for individuals under age 19 and limited to initial appliance only (allowance includes all adjustments in the first six months of installation).
 
(2)        Type B - Basic Restorative, Endodontics, Periodontics, Maintenance of Prosthodontics and Oral Surgery
 
(A)       simple (routine) extractions;
 
(B)       oral Surgery;
 
(C)       alveolectomy;
 
(D)       anesthesia, including general anesthesia when Medically Necessary and rendered in connection with a covered oral or dental surgical procedure;
 
(E)       therapeutic injections.
 
(F)       restorations - fillings of amalgam or synthetic process, but specifically excluding posterior or anterior crowns or jackets and initial placement of full or partial dentures and replacement of dentures and fixed bridge units. Benefits for replacement of an existing amalgam restoration or silicate restoration are only payable if at least 24 months has passed since the existing amalgam was placed;
 
(G)       denture repair and bridge repair;
 
(H)       endodontics;
 
(I)         periodontic;
 
(J)        apicoectomy (considered a separate service if performed with root canal therapy);
 
(K)       gingivectomy or gingivoplasty, per quadrant, osseous surgery, per quadrant. If more than one periodontal surgical service is performed per quadrant, only the inclusive surgical service performed will be considered a Dental Service provided for in this Schedule. Flap entry and closure is considered part of the dental service for osseous surgery and osseous graft. Periodontal scaling - 12 or more teeth;
 
(L)        surgical extraction of impacted wisdom teeth, both partial and complete; and
 
(M)       emergency palliative treatment.
 
(3)        Type C - Major Restorative and Installation of Prosthodontics (Non-Orthodontic)
 
(A)       inlays;
 
(B)       onlays;
 
(C)       crowns, but only when regular fillings are not adequate to restore the tooth;
 
(D)       prosthetics - including bridges and dentures:
 
(i)         the initial installation of, or addition to full or partial dentures of fixed bridge work will be eligible provided:
 
(a)        that such installation or addition is required as a result of an extraction of one or more injured or diseased natural teeth on or after the effective date of coverage of the patient,
 
(b)        that the installation or addition referred to above includes the replacement of such an extracted tooth, and
 
(c)        that such denture or bridgework is completed within twelve (12) months following the date of the extraction.
 
Dentures and bridgework will be considered initially installed only if such dentures and bridgework do not replace any existing dentures or bridgework;
 
(ii)        The replacement or alteration of full or partial dentures or fixed bridgework will be considered for payment if the replacement or alteration is necessary, occurred on or after the effective date of the coverage of the patient under the Plan and is completed within twelve (12) months after one of the following:
 
(a)        an accidental injury which requires surgical treatment, or
 
(b)        oral surgical treatment which involves the reposition of muscle attachments, or the removal of a tumor, cyst, torus, or redundant tissue; and
 
(iii)       The replacement of a full or partial denture when the replacement is required as a result of structural change within the mouth provided:
 
(a)        the replacement is made more than five years after the date of the installation of such denture, and
 
(b)        any such replacement will in no event be made less than twelve months after the effective date of coverage of the patient under the Plan.
 
(4)        Type D - Orthodontics – Not Covered.
 
 
DENTAL BENEFITS’ EXCLUSIONS AND LIMITATIONS
 
No benefits will be paid for the following dental expense charges:
 
(1)        any services, for which no charge is made to the eligible Employee or eligible Dependent, or any charges for service or supplies which are, or may be, obtained without cost in accordance with the laws or regulations of any government or government agency, except to the extent, if any, that a charge is made which the Employee or eligible Dependent is legally required to pay; “government” being deemed to include any nation, state commonwealth, territorial or provincial government, or any political subdivision;
 
(2)        any charges for services received from the dental and medical department of any Employer, Union, Employee Benefit Association, Trust or similar organization, or for services of a Dentist or clinic contracted for or by any such organization;
 
(3)        any charges for dental services for cosmetic purposes;
 
(4)        any charges for replacement of teeth extracted prior to the effective date of the Employee or eligible Dependent’s coverage under the Plan;
 
(5)        any charges for dentures, crowns, inlays, onlays, bridgework or appliances or services for increasing vertical dimensions;
 
(6)        any charges for dentures or bridgework adjustments within six months of the placement or adjustment of bridgework;
 
(7)        any charges for replacement of a lost or stolen prosthesis, or for a duplicate prosthesis;
 
(8)        any charges for sealants, or any charges for oral hygiene, dietary, or plaque control instructions and programs;
 
(9)        any charges for injury or disease arising out of or in the course of any occupation or any employment for compensation, profit or gain;
 
(10)      any charges for athletic or night mouth guards of any kind;
 
(11)      any charges for a temporary denture or bridge that, when combined with the charge for the permanent denture or bridge, exceeds the Reasonable and Customary amount payable for the permanent denture or bridge;
 
(12)      any charges made by a Dentist for the patient’s failure to appear as scheduled for an appointment;
 
(13)      any charges for implantology, including surgical care and/or treatment of endosseous and/or subperiosteal implants or any complications thereof;
 
(14)      any charges for drugs, other than injectable antibiotics administered by a Dentist or Physician as a result of dental treatment;
 
(15)      any charges for procedures, services, or supplies, which do not meet accepted standards of dental practice, including charges for procedures, services or supplies which are experimental in nature;
 
(16)      any charges for treatment initiated while the Employee or Dependent were not eligible under the Plan;
 
(17)      personalization or characterization of dentures;
 
(18)      any changes associated with treatment of accidental injury to sound natural teeth (expenses that may be covered under Article III);
 
(19)      splints, braces and any other type of orthodontic appliance, for whatever reason prescribed or utilized;
 
(20)      treatment performed by anyone other than a Dentist except, scaling or cleaning of teeth and topical application of fluoride may be performed by a licensed dental hygienist under the supervision and guidance of a Dentist;
 
(21)      any dental services and supplies that are covered under the Comprehensive Medical Plan;
 
(22)      services and supplies related to the treatment of TMJ syndrome; or
 
(23)      any dental services or treatment rendered outside of the United States, except emergency treatment shall be limited to a maximum benefit of $100.
 


SCHEDULE OF VISION REIMBURSEMENT BENEFITS
 
For Eligible Active Employees and their Eligible Dependents
 
 
MAXIMUM BENEFIT
$200 every 24 months
 
COVERED EXPENSES
Exams by a licensed optometrist or ophthalmologist, lenses (including contacts), frames, special coatings, prescription sunglasses.
 
EXCLUSIONS AND LIMITATIONS
Charges for non-prescription or over-the-counter eyewear.
Occupational eye exams required by Employer.
 
FILING CLAIMS
The Eligible Individual may go to his choice of providers. The Eligible Individual will pay for his care at the time of service and then submit his claim to the Administrator for reimbursement of Covered Expenses up to the Maximum Benefit.
 
 
SUMMARY OF NEW VISION BENEFITS
 
All active Eligible Employees and Dependents as determined under the eligibility rules of the Plan, shall be eligible to receive vision benefits for any Covered Expenses, subject to the Exclusions and Limitations of the Plan set forth herein.
 
Maximum Benefit
The Maximum Benefit payable by the Plan is $200 every 24 months.
 
Covered Expenses
Covered Expenses include the following: exams by a licensed optometrist or ophthalmologist, lenses (including contacts), frames, special coatings and prescription sunglasses.
 
Exclusions and Limitations
Exclusions and Limitations include the following: charges for non-prescription or over-the-counter eyewear and occupational eye exams required by an Employer.
 
Filing Claims
Eligible Individuals may go to their choice of providers. Eligible Individuals pay for their care at the time of service and then submit their claim to the Administrator for reimbursement of Covered Expenses up to the Maximum Benefit.
 
 
 

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