Dental Eligibility

What An "Eligible Charge" Is

An "eligible charge" is one the dentist makes to you for a dental service furnished to you or a covered dependent, provided the service is included in the list of Covered Dental Expenses and not listed under Exclusions.

All expenses are assessed on a reasonable and customary basis.  Lab fees may be cut back accordingly. 
A charge is considered incurred on the date the service is received, rather than on the date the charge is made.  In the case of root canal therapy, crowns, dentures or bridgework, which may require multiple appointments, the date the expense is incurred will be the date the service is finally completed.  For dentures or bridgework, this date will be the date the prosthetic device is installed.  For crowns, this will be the date the permanent crown is installed and for root canal therapy, this will be the date the canal is closed.

Covered Dental Expenses

The percentage payable and the Calendar Year Maximum are specified in the “SUMMARY OF BENEFITS”.   Charges for reasonable and customary services and supplies specified below shall be considered covered expenses when incurred by you or a covered dependent.  Eligible expenses include Basic and Preventive Treatment, Endodontics, Periodontics, Oral Surgery, Major Restorative, limited Prosthodontics and Orthodontic treatment.  An expense is eligible to the extent that coverage is not prohibited by provincial health insurance plans or because of other limitations described below or in the “SUMMARY OF BENEFITS”.

Basic Procedures:

  1.  oral hygiene instruction to the limits specified in “SUMMARY OF BENEFITS”
  2.  oral examinations including scaling and cleaning of teeth to the limits specified in “SUMMARY OF BENEFITS”
  3. topical application of sodium or stannous fluoride to the limits specified in “SUMMARY OF BENEFITS”
  4. dental x-rays: single diagnostic x-rays; complete series or equivalent  to the limits specified in “SUMMARY OF BENEFITS”
  5. consultations
  6. extractions
  7. oral surgery including excision of impacted teeth
  8. amalgam, acrylic, silicate or composite fillings
  9. retentive pins
  10. anaesthesia where reasonably and customarily required in connection with other covered procedures
  11. occlusal equilibration is limited to the limits specified in “SUMMARY OF BENEFITS”
  12. treatment of periodontal and other diseases of gums and tissues of the mouth, (special periodontal appliances)
  13. emergency endodontic procedures and root canal therapy
  14. prefabricated full coverage restorations for primary teeth
  15. passive space maintainers, those that do not move the teeth, and pit and fissure sealants for dependent children under the age of 18 only
  16. study casts to the limits specified in “SUMMARY OF BENEFITS”

Major Procedures:

  1. Metal inlays and crowns, used to restore natural teeth to their normal functions where the tooth, as a result of extensive caries or fracture, cannot be restored with a filing.   When a tooth can be restored with silver amalgam, silicate or synthetic restorations, benefits will be determined based on the usual costs of such a restoration.
  2. denture adjustments
  3. repairing, relining and rebasing of dentures to the frequency specified in the “SUMMARY OF BENEFITS’
  4. initial installation of partial or full removable dentures when required to replace one or more teeth extracted while the individual was insured under this plan.
  5. replacement of existing partial or full removable denture(s) providing:
    • the existing appliance is at least 5 years old and cannot be made serviceable;
    • or, the existing appliance is replaced as a result of the  initial placement of an opposing denture.
  6. Please note: Replacement of lost or stolen dentures, the duplication of dentures and personalization or characterization of dentures is not covered.  A temporary appliance is considered to be permanent if not replaced within 12 months from the date the temporary appliance was inserted
  7. initial installation of fixed bridgework when required to replace one or more teeth extracted while the individual was insured under this plan.
  8. bridge repairs and recementation
  9. replacement of existing fixed bridgework providing:
    • the existing fixed prosthetic device is at least 5 years old and cannot be made serviceable; or,
    • the replacement is required because of extraction, loss or fracture of one or more sound natural teeth after the individual became insured under this plan; or
    • A temporary bridge is considered to be permanent if not replaced within 12 months from the date the temporary bridge was inserted.

Orthodontic Treatment

Orthodontic treatment includes the diagnosis or correction of teeth irregularities and malocclusion of jaws, by wire appliances, braces or other mechanical aids, commonly known as “straightening of the teeth”.  These include active space maintainers, or orthodontic appliances for the purpose of repositioning or moving the teeth.
Expenses are covered at the percentage and to the maximum shown in the “SUMMARY OF BENEFITS”.  This benefit is only available to Members who are under the age of 21 and eligible dependent children under the age of 21. 

A Pre-Treatment Plan is always required for this benefit.  Treatment will generally extend over a two or three year time span.   The Claims Office will respond to the Pre-Treatment Plan with an explanation of how the monthly reimbursement process will work for the duration of the Orthodontic treatment.   Claim payment is on a reimbursement basis, subject to the submission of paid receipts.