Building Trades Employers Insurance Fund
Insurance Forms
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BTEIF Prime Blue Dental Plan
(adminstered by EBS Benefit Solutions)
(updated for 2006)
Click here to print plan details.
Click here to print Prime Dental participating providers.
Class I - Preventative Services
There is no deductible for Class 1. Services are paid at 100% of Maximum Amount Payable (MAP) or charges, whichever is less, the amount paid is applied toward the calendar year maximum. Covered services with a sampling of 2005 payments at 100% of the MAP are shown below.
| Initial & periodic oral exams-2 every 12 consecutive months. | |
|---|---|
| Initial oral exam | $24.48 |
| Periodic oral exam | $24.48 |
| Dental X-Rays | |
| Intraoral complete series including bitewings-not more than one set of full mouth x-rays in any 36 months. | $57.88 |
| Bitewing X-rays/2 films-only 2 sets/12 months | $15.26 |
| Test & laboratory exams | |
| Pulp vitality tests | $15.07 |
| Prophylaxis (cleaning) 2 every 12 consecutive months | |
| Adult prophylaxis (age 12 & up) | $36.78 |
| Children's prophylaxis (age 11 & under) | $27.11 |
| Fluoride application | |
| 4 topical applicants of fluoride in 12 consecutive months for a covered dependent under 19 years. Topical application of fluoride-child | $16.34 |
| Emergency treatments for pain | |
| Palliative treatment emergency treatment of Dental pain, minor procedure | $29.73 |
| Sealants | |
| Topical application of sealant on a posterior tooth for a covered dependent under 19 years old - 1 tooth every 36 mos. | |
| Sealant - per tooth | $26.78 |
| Preventative periodontal prophylaxis | |
| $54.93 | |
Payments may vary from the above depending on the specific services rendered. Participating dentists will accept payment of Class I services as payments-in-full
Class II - Basic Dental Services
There is no deductible for Class II. Services are paid at 100% of Maximum Amount Payable (MAP) or charges, whichever is less. The amount paid is applied toward the $1,000 per person calendar year maximum. Covered services with a sampling of 2005 payments at 100% of the MAP are shown below.
| Space maintainers for covered dependents under 19 | |
|---|---|
| Fixed unilateral type | $127.90 |
| Removable bilateral type | $192.47 |
| Restorations | |
| Amalgam-2 surfaces, permanent tooth | $63.00 |
| Composite resin-2 surfaces, anterior | $64.52 |
| Extractions | |
| Simple extraction-single permanent tooth | $54.26 |
| Surgical extraction-complete bony impaction | $229.50 |
| Endodontics | |
| Root canal therapy-anterior tooth | $288.70 |
| Apicoectomy-per tooth, first root | $285.94 |
| Oral Surgery | |
| Alveoplasty-not in conjunction w/extract per quad. | $111.75 |
| Tooth replantation | $165.00 |
| Biopsy of oral tissue (hard) | $114.76 |
| General anesthesia when medically necessary-allowance depends on length of time anesthesia is administered. | |
Payments may vary from the above depending on specific services rendered. Participating dental providers must accept payment as payment-in-full.
Class III - Major Dental Services
There is no deductible for Class III. Services are paid at 50% of the Maximum Amount Payable (MAP) or charges whichever is less. The amount paid is applied toward the $1,000 per person calendar year maximum. Covered services with a sampling of 2005 payments at 100% are shown below. These allowances are reviewed yearly.
| Crowns (one per 12 month period) | |
|---|---|
| Porcelain with semi-precious metal | $418.80 |
| Cast post and core in addition to crown | $99.47 |
| Inlays and Onlays | |
| Inlay, metallic, two surfaces | $300.00 |
| Onlay, per tooth | $374.86 |
| Periodontics | |
| Gingivectomy or gingivoplasty per quadrant | $102.56 |
| Gingival curettage per quadrant | $73.29 |
| Periodontic Scaling & Root Planning per quadrant | $65.00 |
| Prosthetics | |
| Complete upper denture | $438.48 |
| Lower partial denture with lingual bar & 2 clasps acrylic base | $497.32 |
| Bridge pontic-porcelain fused semi precious metal | $410.00 |
| Bridge abutment-porcelain fused semi-precious metal | $425.00 |
Payments may vary from the above depending on the specific services rendered. Participating dentists may accept payments of Class III services as payment-in-full. Class I, II and III services are all inclusive with the Prime Blue Dental Plan.
Click here to print plan details.