||Major Restorative Services
||Each Calendar Year
||Each Calendar Year
|Financial Limit Per
|Financial Limit Per
Member of Spouse
||Covered from birth to age 21, or age 25 if
in full-time attendance at a school or university, or any age if
handicapped. See General Information for more details.
means the Canadian Provincial/Territorial Dental Fee Guide that
contains Dental services and fees in effect on the date the Dental
services are performed.
means Schedule 2 of the Fee Schedule that contains eligible Dental
services, financial limits, treatment frequencies, and fees in effect on the
date the Dental services are performed.
Payment of Benefits
- The Plan will pay benefits based on Dental services, financial limits
and treatment frequencies in the Fee Schedule.
- The Plan will apply the reimbursement percentage shown on the
previous page to the fees shown in the Fee Schedule/Fee Guide as
- For services performed in British Columbia or outside
Canada, if your province of residence is British Columbia the
fees in the Fee Schedule.
- For services performed in Canada but outside British
Columbia - the fees in the Fee Guide in the province/territory
- For services performed outside Canada if your province of
residence is not British Columbia - the fees in the Fee Guide
in your province/territory of residence.
- Fees in excess of the amount shown in the applicable Fee
Schedule/Fee Guide will be your responsibility.
Plan A Basic Preventive & Restorative Services
Plan A covers services for the care and maintenance of teeth, including
procedures to restore teeth to natural or normal function. Eligible
Expenses per person include, but are not limited to, the Basic Services
- complete provided the Plan has not paid for any other exam
by the same dentist in the past 6 months - 1 per 3-year period;
- recall 2 per calendar year;
- specific provided the Plan has not paid for any other exam
by the same dentist in the past 60 days; and
- panoramic 1 per 2-year period; and
- complete mouth series 1 per 3-year period.
All x-rays combined shall not exceed the dollar limit for a complete
- diagnostic models 1 set per calendar year
- polishing 2 per calendar year
- topical application of fluoride 2 per calendar year;
- fixed space maintainers; and
- preventive restorative resins and pit and fissure sealants
combined limit of 1 per tooth in a 2-year period. No age limit.
- Fillings to restore tooth surfaces broken down as a result of decay
limited to a dollar amount equal to a 5 surface filling per tooth in
a 2-year period for amalgam (silver coloured) fillings and or
composite (tooth coloured) fillings.
- Stainless steel crowns on primary and permanent teeth once per
tooth in a 2-year period.
- Inlays on onlays only 1 inlay, onlay, or another major restorative
service on the same tooth will be covered in a 5-year period. Where
other material would suffice, you will be responsible for the
difference between the cost of the chosen material and the cost of
Endodontics for the treatment of diseases of the pulp chamber and
pulp canal including but not limited to root canals 1 per tooth in a
Periodontics for the treatment of diseases of the soft tissue (gum)
and bone surrounding and supporting the teeth, excluding bone and
tissue grafts, but including the following:
- occlusal adjustment and recontouring a combined yearly limit
shown in Fee Schedule;
- root planing;
- gingival curettage 1 per sextant in a 5-year period; and
- osseous surgery 1 per sextant in a 5-year period
- removal, repairs and recementation of fixed appliances;
- rebase and reline of removable appliances a combined limit of
1 per upper and 1 per lower prosthesis in a 2-year period;
- tissue conditioning 2 per upper and 2 per lower prosthesis in a
5-year period; and
- gold foils only when used to repair existing gold restorations.
- other routine oral surgical procedures; and
- anaesthesia in conjunction with surgery shall not exceed the dollar
limit shown in Fee Schedule.
Plan B Major Restorative Services
You are eligible for Plan B Services when your dentist recommends
replacement of your missing teeth, or reconstruction of your teeth
(where Basic Restorative methods cannot be used satisfactorily).
Mounted x-rays and/or diagnostic casts may be required for approval.
Only 1 Major Restorative Service involving the same tooth will be
covered in a 5-year period.
Plan B Services include, but are not limited to, the following:
- complete upper and lower dentures;
- partial upper and lower dentures;
- fixed bridges.
- crowns and related services; and
- inlays and onlays involved in bridgework.
Bruxing guards 2 appliances in a 5-year period (no benefit is payable
for the replacement of lost, broken, or stolen bruxing guards).
- Only 1 inlay, onlay, or another Major Restorative Service on the
same tooth will be covered in a 5-year period.
- Crowns and fixed bridges on permanent posterior (molar) teeth are
limited to the cost of the gold restoration.
- Only 1 upper and 1 lower denture (complete or partial) is eligible in
a 5 year period.
- No benefit is payable for the replacement of lost, broken, or stolen
dentures. Broken dentures may be repaired under Plan A.
- Veneers, crowns, bridges, inlays, and onlays are subject to the
conditions outlined in the Fee Schedule. Where other material
would suffice, you will be responsible for the difference between
the cost of the chosen material and the cost of the alternative
Plan C Orthodontics
Benefits are payable for Orthodontic Services performed on or after the
effective date of your coverage.
- The lifetime benefit maximum under Plan C is $2,500.
- No benefit is payable for the replacement of appliances which are
lost or stolen.
- Services done for the correction of temporomandibular joint (TMJ)
dysfunction are not covered.
Emergency Treatment Outside Your Province of
You are entitled to the services of a dentist if, while travelling or on
vacation outside your province of residence, you require emergency
Dental care. You will be reimbursed according to the Fee Schedule.
The following are not Eligible Expenses under the Dental Plan:
- Items not listed in the Fee Schedule and fees in excess of those
listed in the Fee Schedule;
- Any item not specifically included as a benefit;
- Charges for broken appointments, oral hygiene or nutritional
instruction, completion of forms, written reports, communication
costs, or charges for translating documents into English;
- Procedures performed for congenital malformations or for purely
- Charges for drugs, pantographic tracings, and grafts;
- Charges for implants and/or services performed in conjunction
with implants, except as indicated in the Fee Schedule;
- Anaesthesia not done in conjunction with surgery, and charges for
facilities, equipment and supplies;
- Charges for services related to the functioning or structure of the
jaw, jaw muscles, or temporomandibular joint;
- Incomplete or temporary procedures;
- Recent duplication of services by the same or different dentist;
- Any extra procedure which would normally be included in the Basic
- Services or items which would not normally be provided, or for
which no charge would be made, in the absence of Dental benefits;
- Travel expenses incurred to obtain Dental treatment.
- Present your ID card to your dentist's office. It is important to ask
if your Dental benefits will cover the entire cost of your treatment.
To avoid any misunderstanding, we suggest that your dentist
submit an outline of the proposed services to the Plan before your
start treatment. This is important especially when your dentist is
recommending extensive Dental work. This will help you
understand what portion of the dentist's bill must be paid by you in
the event that you wish to proceed with the treatment
recommended by your dentist.
- We suggest that you submit claims within 90 days of the
completed date of services (earlier if possible). Failure to submit a
claim within the 90 day limit will not invalidate the claim if it is
submitted as soon as reasonably possible. However, in no event
will the Plan pay any claim or adjustment submitted later than 1
year from the date the service is performed.
- The Plan requires a separate claim form for each member of your
family who has received Dental services. Be sure to include the
following information on the claim form:
- Name of the dentist;
- Name and birthdate of the person receiving the Dental care
- Your group, social insurance, and Dependent(s) numbers (this
information is on your ID card;
- Your home mailing address; and
- Whether you have coverage through another plan. Claims
information regarding the other carrier is not retained on file. If
you or your Dependents are covered by two plans, your
dentist must complete two separate Dental claim forms (one
for each plan). Incomplete claims will be returned for
- Before your dentist starts treatment, please ask how billing is
made. The Plan may pay in either of two ways:
- The Plan will pay the dentist directly for services provided
under this Dental Plan when a claim form signed by the dentist
is received by the Plan, certifying these services were
performed and the fee charged.
- If you have paid your dentist directly, the Plan will reimburse
you the benefit amount when a claim form or receipts signed
by your dentist are received. You will receive a cheque when
the claim is processed.
- Orthodontic Claims Procedures
Because the Plan does not return original receipts,
photocopies will be accepted. Do not hold receipts until the
completion of treatment.
- Claiming Deadlines:
- It is suggested that you submit Orthodontic claims within
90 days of the date the payment was due to your
orthodontist (the due date).
- Reimbursement is made if the complete and correct
claims information is received within 1 year of the due
date. However, no benefit is payable for claims not
received within 1 year of the due date.
- Treatment Plan:
- Have your orthodontist complete the "Certified Specialist
in Orthodontics Standard Information Form" (the
treatment plan) before treatment starts.
- If the payment schedule or treatment changes, the Plan
requires a revised treatment plan for review.
- The Plan will retain your treatment plan on file. If your
treatment plan is not on file the Plan is unable to pay:
- your initial fee/down payment;
- your monthly/quarterly fees; or
- one time appliance fees;
- Claims for consultations, exams and records (x-rays,
study models, etc.) will be reimbursed without a
treatment plan on file.
- Monthly or Quarterly Fees:
- Submit receipts for the monthly or quarterly fees on a
regular basis as treatment progresses.
- The amount paid will be pro-rated over the estimated
months of active treatment. For example, when braces
are on the teeth, the estimated length of treatment will be
on the treatment plan.
- As long as your coverage is in effect, monthly or quarterly
reimbursements will be made to you until the dollar
maximum is reached or the treatment is complete,
whichever occurs first.