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2021 SMM #3 Dental Change Effective 5.1.2021

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2021 SMM #3 Dental Change Effective 5.1.2021 PLEASE KEEP THIS IN YOUR FUND BOOKLET Local 485 Health and Welfare Fund 7130 Columbia Gateway Drive, Suite A, Columbia, MD 21046 Summary of Material Modifications #3 To: ALL PLAN PARTICIPANTS April 2021 This Notice, called a “Summary of Material Modification” (SMM), advises you of a change in the information presented in the Fund’s Summary Plan Description (SPD) that was previously provided to you. Please read this SMM and keep it with your 2020 Summary Plan Description and if you have any questions, contact the Fund Office at (410) 872-9500. NEW DENTAL NETWORK PANEL Effective May 1, 2021, the Trustees have hired a new company to provide Dental services to members, spouses, and dependents of the Plan. If you need Dental Services starting May 1, 2021, contact DDS, Inc. DDS, Inc. can be reached at (800)-255-5681 or www.ddsinc.net. You must use a DDS, Inc. participating panel dentist for dental services. A list of panel dentists is attached. Please visit www.ddsinc.net for the most up-to-date list of panel dentists (click on “Patients Only” and “Find a Provider” and enter “485” under “Union Number”). Through DDS, Inc., you will have access to a much larger network of dentists. A list of covered services is attached. Each member, spouse, and dependent has an annual individual maximum benefit of $1,250 for covered services during the Fund’s Plan Year, May 1 to April 30 of each year. Copayments will only apply for certain services, including crowns and dentures. Please note that certain services are not covered; a list of these exclusions is attached. DDS, Inc. will be provided an up-to-date record of your eligibility and will use that information to confirm that you or your family members are eligible for services on the date(s) of your appointments. Enclosed is an identification card. This card is not proof of eligibility, please contact DDS for current eligibility. You should carry a photo ID. No dental services will be provided by AMERICAN DENTAL after April 30, 2021; as of May 1, 2021, all dental services must be provided by a DDS, Inc. panel dentist. You may request a copy of your dental records from your prior dentist who must provide them to you. Please see the attached information and visit DDS, Inc.’s website, www.ddsinc.net, for more information. The Trustees are confident that you will enjoy better access to coverage. In the meantime, if you have any questions regarding the information contained in this notice, please contact the Fund Office above. Sincerely, BOARD OF TRUSTEES Plan of Benefits and Exclusions • Annual Maximum Benefit Payments You have an annual per patient maximum benefit of $1,250 for general dentistry during the Fund’s Plan Year, May 1 to April 30 of each year. No benefits will be paid by the Fund in excess of $1,250 per Plan Year. You will be responsible for all benefit expenses in excess of $1,250 during the Fund’s Plan Year. Those additional expenses for each covered service provided by a Participating Dentist are as follows: the amount that the Fund would pay for the service as well as any copayment you would normally be charged for the service. These amounts are shown on the “List of Covered Dental Services,” below. • Basic Services o Panoramic and full series x-rays covered once a year. o Fluoride and sealants for dependents under the age of nineteen (19) only. o Only four (4) quads of perio scalings can be done in twelve (12) months and are not covered if done on the same day as prophylaxis. • Prosthetics Prosthetic devices, crowns, bridges, and dentures are eligible for replacement three (3) years after the date of insertion. • Orthodontics You must make 100% Copayment; participating panel dentists are required to charge you only the copayments for orthodontic services shown in the “List of Covered Dental Services” below. EXCLUSIONS All services not listed “List of Covered Dental Services” below are excluded from coverage under this plan. The following are also not covered: services or supplies that are not medically necessary for treatment of any injury, illness, or condition. Only services and supplies that are necessary to identify or treat a condition that has been diagnosed or is reasonably expected to exist, and are (1) consistent with the diagnosis and treatment of the condition; (2) in accordance with standards of good dental practice; (3) required for reasons other than convenience to the Participant, the dentist, or another provider of service; and (4) the most appropriate level of service or supplies that can safely be provided. The fact that a service or supply is prescribed by a dentist or other provider does not necessarily mean that it is medically necessary. List of Covered Dental Services Services not listed below are excluded from coverage under this plan. What the Fund pays towards CODE DESCRIPTION Copay your $1,250 annual maximum D0120 PERIODIC ORAL EVALUATION-ESTABLISHED PATIENT $18.00 $0.00 D0140 LIMITED ORAL EVALUATION-PROBLEM FOCUSED $18.00 $0.00 D0150 COMPREHENSIVE ORAL EXAM $18.00 $0.00 D0160 DETAILED AND EXTENSIVE ORAL EVALUATION-PROBLEM $18.00 $0.00 D0180 COMPREHENSIVE PERIODONTAL EVALUATION- $18.00 $0.00 D0210 X-RAYS-COMPLETE SERIES $30.00 $0.00 D0220 X-RAYS-PERIAPICAL 1ST FILM $4.00 $0.00 D0230 X-RAYS-PERIAPICAL EACH ADDL $3.00 $0.00 D0240 X-RAYS-OCCLUSAL FILM $11.00 $0.00 D0250 EXTRA-ORAL 2D PROJECTION RADIOGRAPHIC IMAGE $25.00 $0.00 D0270 X-RAYS-1 BITEWING $10.00 $0.00 D0272 X-RAYS-2 BITEWINGS $12.00 $0.00 D0274 X-RAYS-4 BITEWINGS $16.00 $0.00 D0320 TEMPOROMANDIBULAR JOINT ANTHROGRAM, INCLUDING $29.00 $0.00 D0330 X-RAYS-PANORAMIC FILM $30.00 $0.00 D0340 2D CEPHALOMETRIC RADIOGRAPHIC IMAGE-ACQUISITION, $35.00 $0.00 D0431 BACTERIOLOGIC EXAM/TESTS $24.00 $0.00 D0460 PULP VITALITY TESTS $17.00 $0.00 D0470 DIAGNOSTIC CASTS $17.00 $0.00 D1110 DENTAL PROPHYLAXIS-ADULT $25.00 $0.00 D1120 DENTAL PROPHYLAXIS-CHILD $25.00 $0.00 D1208 FLUORIDE TREATMENT $15.00 $0.00 D1351 SEALANT-PER TOOTH $16.00 $0.00 D1510 SPACE MAINTAINER-FIXED UNILAT $117.00 $0.00 D1516 SPACE MAINTAINER-FIXED-BILATERAL,MAXILLARY $117.00 $0.00 D1517 SPACE MAINTAINER-FIXED-BILATERAL,MANDIBULAR $117.00 $0.00 D1520 SPACE MAINTAINER-REMOV.UNILAT $117.00 $0.00 D1526 SPACE MAINTAINER-REMOVABLE-BILATERAL,MAXILLARY $117.00 $0.00 D1527 SPACE MAINTAINER-REMOVABLE-BILATERAL,MANDIBULAR $117.00 $0.00 D1551 RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER- MAX $55.00 $0.00 D1552 RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER- MAN $55.00 $0.00 D1553 RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER- MAN $55.00 $0.00 D1556 REMOVAL OF FIXED SPACE MAINTAINER-PROCEDURE MAX $30.00 $0.00 D1557 REMOVAL OF FIXED SPACE MAINTAINER-PROCEDURE MAND $30.00 $0.00 D1558 REMOVAL OF FIXED BILATERAL SPACE MAINTAINER $30.00 $0.00 D2140 AMALGAM-1 SURFACE,PRIM.,PERM. $15.00 $0.00 D2150 AMALGAM-2 SURFACES,PRIM.,PERM. $27.00 $0.00 D2160 AMALGAM-3 SURFACES,PRIM.,PERM. $38.00 $0.00 D2161 AMALGAM-4+SURFACES,PRIM.,PERM. $66.00 $0.00 D2330 COMPOSITE-1 SURFACE,ANTERIOR $22.00 $0.00 D2331 COMPOSITE-2 SURFACES,ANTERIOR $32.00 $0.00 D2332 COMPOSITE-3 SURFACES,ANTERIOR $53.00 $0.00 D2335 COMPOSITE-4+SURF/INCISAL,ANT. $75.00 $0.00 D2391 COMPOSITE-1 SURFACE,POSTERIOR $22.00 $0.00 D2392 COMPOSITE-2 SURFACES,POSTERIOR $32.00 $0.00 D2393 COMPOSITE-3 SURFACES,POSTERIOR $53.00 $0.00 D2394 COMPOSITE-4 SURFACES,POSTERIOR $67.00 $0.00 D2720 CROWN-RESIN/HIGH NOBLE METAL $292.50 $157.50 D2722 CROWN - RESIN NOBLE METAL $292.50 $157.50 D2740 CROWN-PORCELAIN/CERAMIC $325.00 $175.00 D2751 CROWN-PORCE PREDOM BASE METAL $325.00 $175.00 D2752 CROWN - PORCELAIN NOBLE METAL $325.00 $175.00 D2915 RE-CEMENT OR RE-BOND POST $22.00 $0.00 D2920 RECEMENT CROWN $22.00 $0.00 D2930 PREFABRICATED STAINLESS STEEL CROWN-PRIMARY TOOTH $71.50 $38.50 D2931 STAINLESS STEEL CROWN-PERM. $71.50 $38.50 D2932 PREFABRICATED RESIN CROWN $71.50 $38.50 D2940 PROTECTIVE RESTORATION $45.00 $0.00 D2950 CORE BUILDUP - INC PINS $75.00 $0.00 D2952 CAST POST AND CORE $125.00 $0.00 D2954 PREFABRICATED POST AND CORE $125.00 $0.00 D3110 PULP CAP-DIRECT $15.00 $0.00 D3120 PULP CAP-INDIRECT $15.00 $0.00 D3220 THERAPEUTIC PULPOTOMY $80.00 $0.00 D3221 PULPAL DEBRIDEMENT, PRIMARY AND PERM TTH $80.00 $0.00 D3310 ROOT CANAL-ANTERIOR $180.00 $0.00 D3320 ROOT CANAL-BICUSPID $300.00 $0.00 D3330 ROOT CANAL-MOLAR $400.00 $0.00 D3331 TREATMENT OF ROOT CANAL OBSTRUCTION NON-SURGICAL $130.00 $0.00 D3346 RETREATMENT OF ROOT CANAL-ANTERIOR TTH $475.00 $0.00 D3347 RETREATMENT OF ROOT CANAL-BICUSPID TTH $575.00 $0.00 D3348 RETREATMENT OF ROOT CANAL-MOLAR TOOTH $625.00 $0.00 D3430 RETROGRADE FILLING $65.00 $0.00 D3450 ROOT AMPUTATION-PER ROOT $125.00 $0.00 D3920 HEMISECTION (INCLUDING ANY ROOT REMOVAL),NOT $110.00 $0.00 D4341 PERIODONTAL SCALING/ROOT PLANING-QUAD $27.00 $0.00 D4355 FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE $70.00 $0.00 D4381 LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS VIA A $30.00 $0.00 D5110 COMPLETE DENTURE-MAXILLARY $375.00 $125.00 D5120 COMPLETE DENTURE-MANDIBULAR $375.00 $125.00 D5130 IMMEDIATE DENTURE-MAXILLARY $375.00 $125.00 D5140 IMMEDIATE DENTURE-MANDIBULAR $375.00 $125.00 D5211 MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING $315.00 $105.00 D5212 MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING $315.00 $105.00 D5213 MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK $315.00 $105.00 D5214 MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK $315.00 $105.00 D6210 PONTIC-CAST HIGH NOBLE METAL $292.50 $157.50 D6211 PONTIC-CAST PREDOMINATELY BASE METAL $292.50 $157.50 D6212 PONTIC-CAST NOBLE METAL $292.50 $157.50 D6241 PONTIC-PORCE PREDOM BASE METAL $325.00 $175.00 D6242 PONTIC - PORCELAIN NOBLE METAL $325.00
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