The Plan will pay 100% of eligible preventive care
dental expenses when you visit a PPO dental provider. Other services are covered at 80% of the allowance with a PPO provider.
You and your covered dependents are eligible for reimbursement of dental services of up to $3,000 per year.
Effective January 1, 2011 children through age 17 no longer have an annual maximum.
When you visit a PPO provider for dental care, the provider accepts the discounted rate for payment. You will need to pay your Patient’s Portion, if applicable.
If you do not visit a PPO provider, you are responsible for payment of the balance that the provider charges above the PPO rate in addition to your Patient’s Portion.
Orthodontics are only covered up to a lifetime maximum of $3,000 for dependent children up to age 26 under the Plan.
Note: This benefit provided for Standard Plan (full) coverage only; no provision for “H” Plan (limited) coverage.
Healthy teeth and gums are an important part of your overall health. That’s why the Plan will pay 100% of covered expenses for preventive dental services when you visit a CIGNA Dental PPO provider for dental care. Your dental benefits network is with CIGNA Dental. Of course, you are free to visit any dentist you wish, but you can save yourself, your covered dependents, and the Plan money if you visit a dentist who participates in the CIGNA Dental Network. You also may locate a participating dental provider by visiting
What You Need To Do
To find a participating provider, you may visit the CIGNA website (www.cigna.com). When you make your appointment, identify yourself as a member of the EWTF. Show the provider your EWTF ID card to be eligible for the PPO discounted rates. If you are having any dental service that is expected to cost more than $600, you must have your dentist complete a “treatment plan” form. These forms are available from the Fund Office.
Maximum Annual Benefit (Age 18 & Older)
The Plan pays for necessary dental care as described in this section, up to $3,000 per covered adult per calendar year. There is no dollar limitation for covered dental services rendered to an eligible patient under age 18.
For a list of preferred provider dentists convenient to you, please visit the CIGNA website at www.cigna.com or contact the Fund Office at 301-731-1050 or at 1-800-929-3983.
Please be sure to show your EWTF ID card when you go for your appointment. If you do not have the dental designation on your card, the participating dental providers do not have to honor the Plan’s discounted rates and you will be responsible for any balance after the Fund Office processes the claim.
Submitting your Dental Claims
When you use a CIGNA PPO provider, your dentist will submit your claims for you. All CIGNA dental claims should be electronically transmitted to EDI# 30506 or mailed directly to:
PO Box 21274
Eagan, MN 55121
EWTF Group Number
The dental group number is 3339689.
Non-PPO Dental Coverage
You are not required to visit a CIGNA PPO provider to receive dental care. If you visit a dentist who does not participate in the CIGNA PPO, you are responsible for payment of the amount the dentist charges above the PPO discounted rate in addition to your Patient’s Portion.
You may need to pay for services at the time you receive them and submit a claim form to apply for reimbursement. Send the completed claim form to:
Electrical Welfare Trust Fund
10003 Derekwood Lane, Suite 130
Lanham, MD 20706-4811
Covered Preventive Services
Preventive Services are payable at 100% of the allowance when you visit a PPO provider, or 80% of the allowance when you visit a non-PPO provider, up to an annual maximum of $2,000 (except for dependent children under age 18).
Covered Basic Dental Services
The schedule on page 12 shows the Basic Dental Services that are covered by this Plan. Most Basic Services are covered at 80% of the allowance, in or out of the network, up to an annual maximum of $2,000 (except for dependent children under age 18). Remember—if you visit a dentist who does not participate in the CIGNA Dental PPO, you are responsible for charges above the allowance, if any. Refer to the Schedule of Benefits for a list of how dental services are paid.
Covered Major Dental Services
The schedule on page 12 shows the Major Dental Services that are covered by this Plan. If you use a CIGNA PPO provider, Major Services are covered at 80% of the allowance up to an annual maximum of $2,000 (except for dependent children under age 18). If you do not use a PPO provider, Major Services are covered at 50% of the allowance.
Covered Orthodontia Services
The Plan provides orthodontia services for dependent children up to age 26 at 50% of the allowance up to a lifetime benefit of $3,000. No coverage is provided for the member or spouse.
When a Treatment Plan is Required
You are required to submit a “treatment plan” or pre-authorization for Major Services provided by your dentist to the Fund Office for prior approval when the cost of the treatment is expected to exceed $600. By submitting a proposed treatment plan in advance, both you and your dentist know what is covered under the Plan before the work is done. This also allows you to authorize direct payment to the dentist.
Continuing Treatment When Your Coverage Ends
If your dental care coverage terminates while you are undergoing certain treatments, your covered dental expenses for these treatments continue to be covered for up to 30 days. The types of treatments that are included under this provision are:
- An appliance or its modification for which an impression was taken prior to termination of dental benefits;
- A crown, bridge or gold restoration for which the tooth was prepared prior to termination of dental benefits; and
- Root canal therapy provided that the pulp chamber was opened prior to termination of dental benefits.
What’s Not Covered
Dental care benefits are not provided for:
- Any dental care, treatment or supply not prescribed by or under the direction of a dentist;
- Replacement of a lost, stolen, or broken prosthetic device;
- Appliances or restoration for the purpose of splinting, increasing vertical dimension or restoring occlusion;
- Dental services and supplies rendered solely for cosmetic purposes, unless required as a result of an accidental injury sustained while covered under this Plan or unless specifically provided under another provision of this Plan;
- An appliance or its modification, a crown, bridge, or gold restoration, or root canal therapy for which the impression was made, the tooth was prepared, or the pulp chamber was opened prior to coverage under this Plan;
- Replacement of an existing partial or full denture, splint or fixed bridgework; crowns and/or inlays installed as multiple abutments; splints for periodontal treatment; or prosthetic appliances, fixed or removable, used as an adjunct to periodontal treatment, unless satisfactory evidence is presented to the Fund that the existing denture or bridgework was installed at least 36 months prior to its replacement and the prosthetic appliance, fixed or removable, is required to replace a natural tooth;
- Dental services or prosthetics, or the fitting of these items, other than as provided in the dental benefit, unless required due to an accidental injury; or
- Orthodontics or other treatment or procedure designed to prevent or correct malocclusion of the teeth.