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Summary of Dental Benefits

Participants with Active coverage under the Northwest Laborers-Employers Health & Safety Trust must choose between Dental Plan A and Dental Plan B. You will be given an opportunity to make your selection once you have established eligibility, by completing an enrollment card and indicating your choice. If you do not make a selection within 90 days of your initial eligibility, you will automatically be enrolled in Dental Plan B. You will not be allowed to change dental plans until the next open enrollment period. Each year the Trust will hold an open enrollment period during which time you may select a new dental plan option.

Brief Overview of Benefits

The following is a partial listing of benefits provided by each dental plan. All benefits provided by Dental Plan A and Dental Plan B are subject to the limitations and exclusions listed separately for each Plan in the official Plan booklet. This summary is intended only to provide a sample listing of applicable co-pays for Dental Plan A and Dental Plan B schedule of benefits for some common dental procedures. To obtain a copy of the Plan booklet, please contact the Trust office at 206-282-3600 or toll free at 800-826-2102, Option #2 then Option #2 again at the second prompt.

Dental Plan A

WILLAMETTE DENTAL OF WASHINGTON INC., is a network of dental clinics in Washington, Oregon and Idaho that provides dental care to enrolled participants and their eligible dependents. If you select Dental Plan A for your dental benefits, you must receive your dental care at one of the Willamette Dental network clinics. Family members do not have to use the same Willamette Dental Clinic. The co-pay represents your out of pocket expense for he dental services received and must be paid at the time of treatment.

The following represents your out of pocket expense for each procedure listed. A complete listing of procedures and co-pays is on file with the Trust office. Please refer to the Plan Booklet for a complete listing of Dental Plan A limitations and exclusions. To see a complete listing of the Willamette Dental clinics and phone numbers, please visitWillamettedental.com or call Willamette Dental at 855-433-6825.

Benefit Category

Co-Pay

Office Visit

$15

Emergency Treatment (after hours)

$25

Diagnostic/Routine/Preventative/Basic Services

Exams, Cleaning, Fluoride Treatments, X-Rays, Sealants, Space Maintainers, Periodontal scale/prophy, minor restorations

No Co-Pay

Oral Surgery

Routine extractions

No Co-Pay

Extractions soft tissue, partial and full bony impaction (per tooth)

$100

Prosthetics

Stainless Crown, primary

No Co-Pay

Metal or porcelain crowns or 3/4 crowns

$250

Upper or lower dentures, full or partial

$300

Endodontics

Anterior root canal

$75

Bicuspid root canal

$150

Molar root canal

$225

General Anesthesia

First 30 minutes

$100

Orthodontics

Class 1, Class 2 and Class 3

$2800

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