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DENTAL PLAN

Good dental care is an extension of good health care. My Choice offers the following coverage options:

	Expenses	Co-Insurance	Maximum Benefit
Bronze Current Fee Schedule	Preventative / Diagnostic Dental Accident Basic Services Endodontic Periodontic Major Restorative Orthodontics	100% 100% 80% 80% 80% Not Covered Not Covered	Combined maximum of $1,500/plan year* " " " n/a n/a
Silver Current Fee Schedule	Preventative / Diagnostic Dental Accident Basic Services Endodontic Periodontic Major Restorative Orthodontics	100% 100% 80% 80% 80% 50% Not Covered	Combined maximum of $2,000/plan year* " " " " n/a
Gold Current Fee Schedule	Preventative / Diagnostic Dental Accident Basic Services Endodontic Periodontic Major Restorative Orthodontics (children only)	100% 100% 80% 80% 80% 50% 50%	Combined maximum of $2,000/plan year* " " " " $2,000/lifetime*

* Dollar limits and other restrictions apply per eligible person insured (see the Dental Plan Details in the following pages).

DENTAL PLAN DETAILS

The following is a further description of some of the specific elements of your dental plan.

g Current Fee Schedule	■ This refers to the provincial dental fee guide published annually by your provincial dental association. The guide provides your dentist with the suggested price for all dental procedures.
g Maximum Benefit	■ Annual or lifetime maximums as described in the Options are per insured member (i.e. Orthodontics is $2,000 per child lifetime maximum).
g Alternate Benefits and Submission of Treatment Plan	■ Where there exists more than one customarily employed and professionally adequate method of treating injury or disease to the teeth, Great-West Life reserves the right to determine eligible expenses on the basis of an alternate benefit. Great-West Life will advise you in advance of the amount of its liability when a proposed course of treatment includes major restorative dentistry or orthodontics. Have your dentist complete a treatment plan on a form you can obtain from the Human Resources department, including pre-treatment x-rays if the proposed treatment involves crowns or bridgework.
g Diagnostic and Preventative Services	■ Examinations and Diagnosis - oral examinations, - recall oral examinations are limited to once every 6 months, - emergency oral examination, - specific oral examination, - limited periodontal examinations twice a year, - radiographs, - tests and laboratory examinations, - topical fluoride, - oral hygiene instruction (initial instruction), - finishing restorations, - pit and fissure sealant, - space maintainers, - periodontal appliances
g Accidental Dental	■ Necessary dental treatment required as a result of an accidental injury to natural teeth provided by a dentist or specialist in accordance with the normal suggested fee for a general practitioner. ■ The dental work must be completed within 12 months of the accident to be considered. All other dental expenses are excluded.
g Basic Services (including Endodontic and Periodontic Services)	■ Basic Restorative - amalgam restorations, - acrylic or composite resin restorations, - recement inlay or crown, - removal of inlay or crown, - oral surgery, - anesthesia (only in relation to surgery). ■ Endodontic - conservative root canal therapy. ■ Periodontic - scaling/root planing (combined limit of twelve units per plan year), periodontal splinting, and surgical services. ■ Dentures - adjustments, repairs, relining and rebasing
g Major Services	■ Prosthetics - removable prosthetic devices - the initial installation of full or partial dentures, subject to the pre-existing condition (see ‘exclusions’). - replacement of existing dentures is not covered except if a) the replacement is required because of extraction, loss or fracture of one or more sound natural teeth after becoming insured under this benefit or, b) the replacement is more than 12 months after becoming insured under this coverage, and the existing denture is at least 5 years old and no longer serviceable. - extensive restorative dentistry - covered procedures include inlays, onlays and crowns, used to restore the natural teeth to their normal functions where the tooth, as a result of extensive caries or fracture, cannot be restored with a filling. The replacement of inlays, onlays and crowns are covered only if the replacement is more than 12 months after becoming effective under this benefit, and the existing inlay, onlay, or crown is at least 5 years old and no longer serviceable. 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 (refer to ‘exclusions’). - fixed prosthetic devices - the initial installation subject to pre-existing conditions (see ‘exclusions’). Recementing and replacement of the facing or veneer of the fixed prosthetic device. - replacement of the fixed prosthetic device is not covered except if a) the replacement is required because of extraction, loss or fracture of one or more sound natural teeth after becoming insured under this benefit or b) the replacement is more than 12 months after becoming insured under this benefit, and the existing fixed prosthetic device is at least 5 years old and no longer serviceable. - Whenever laboratory fees are incurred, they shall be limited to 60% of the fixed fee determined for the procedure. - a pre-treatment plan should be submitted to Great-West Life prior to Major Dental treatment. Confirmation of all eligible expenses and the amount will be provided.
g Orthodontics	■ Diagnosis or correction of teeth irregularities and malocclusion of jaws for dependent children (under age 19).
g Extension of Coverage	■ Upon your death, eligible dependents’ Dental insurance is extended, without premium payment, for twenty-four months from the date of death or to the date the policy or benefit terminates, whichever is earlier.
g Exclusions	■ No payment will be made for any procedure required due to any injury or dental disease for which treatment was advised or began before the effective date for that procedure. Payments will not be made for any procedure required due to teeth extracted, missing or fractured before the effective date of coverage for that procedure, except as specifically stated for appliance replacement under covered expenses. ■ Treatment or appliance, related directly or indirectly to full mouth reconstruction, to correct vertical dimension and temporomandibular joint dysfunction. ■ Services rendered by a dental hygienist and not administered under supervision of a dentist. ■ Dental services covered under the health insurance benefit, if such benefit is part of this plan, or under any other group insurance contract. ■ Services and supplies relating to any appliance worn in the practice of a sport. ■ Expenses which are or would normally be payable or reimbursable under a private or public insurance plan. ■ Self-inflicted injury, while sane or insane. ■ Injury or illness resulting from civil unrest, insurrection or war, whether war be declared or not, or participation in a riot. ■ Services which are not medically required, which are given for cosmetic purposes or which exceed ordinary services given in accordance with current therapeutic practice. ■ Care or services rendered free of charge or which would be free of charge were not for insurance coverage or which are not chargeable to the insured person.
g Termination of Benefit	■ Age 70 or earlier retirement.

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