Public Service Dental Care Plan member booklet

Table of Contents


Introduction

The Public Service Dental Care Plan (PSDCP) is an employer-paid plan providing dental services coverage to eligible employees and their eligible family members for specific dental services and supplies that are not covered under a provincial or territorial health or dental care plan.

The Plan consists of 5 components:

  • Plan 55555 – National Joint Council Component
  • Plan 55666 – Public Service Alliance of Canada
  • Plan 55777 – Canadian Forces Dependants'
  • Plan 55888 – Royal Canadian Mounted Police Dependants'
  • Plan 55999 – Canadian Forces Reserves

With the exception of certain Leave Without Pay situations, the cost of the PSDCP is fully paid by the employer. The current Administrator for your PSDCP is Great-West Life. The Government of Canada is the Plan sponsor and the Treasury Board Secretariat is responsible for the oversight and management of the Plan.

This booklet describes the benefits provided to you as a member of the PSDCP. It contains general information about membership, benefits, levels of reimbursement and limitations on benefits. It also explains how to submit a claim. The complete terms and conditions of the Plan are set out in the PSDCP Rules; if there is a discrepancy between information in this document and that contained in the PSDCP Rules, the Rules will take precedence.

Membership

Who is covered by the Plan

The Public Service Dental Care Plan (PSDCP) covers all eligible federal public service employees, employees of a number of separate employers and their eligible dependants.

Eligible employees

The Plan covers full-time indeterminate employees, seasonal employees, employees appointed for a term of six (6) months or more, employees who have completed six (6) months of continuous employment, and part-time employees whose assigned work week is more than 1/3 of the normally scheduled hours for a full-time employee in the same occupational group.

Please contact your departmental Compensation services or the Public Service Pay Centre if you have questions regarding your eligibility.

Eligible spouse

For the purposes of this plan, "spouse" means a person legally married to you.

Eligible common-law partner

For the purpose of this plan, "common-law partner" means a person who has lived with you in a conjugal relationship for a continuous period of at least one (1) year and with whom you continue to live.

Eligible children

  • For the purposes of this plan, "child" means you or your spouse or common-law partner's unmarried child or children (including an adopted child, a step-child or a foster-child) under twenty-one (21) years of age;
  • between twenty-one (21) and twenty-five (25) years of age and in full-time attendance at a recognized educational institution; or
  • twenty-one (21) years of age and over with a mental or physical impairment who is incapable of engaging in self-sustaining employment and who is primarily dependent upon you for support.*

*Note: This description must apply to your child on the date you become subject to the Plan; otherwise the child has to have been covered under the Plan immediately before his or her 21st birthday. If the child becomes impaired after reaching the age of 21, he or she must have been covered under the Plan as a full-time student at the time the impairment began.

A child who does not meet the definition of Eligible Child but is a child for whom the member stands in place of a parent, may be considered for coverage with the approval of the Board of Management, which decides eligibility in such instances. Supporting documentation must be submitted to the appropriate Board of Management. Examples of supporting documents include:

  • a permanent guardianship (court) order;
  • a custodial (court) order;
  • a notarized private guardianship/care-giving agreement or a notarized voluntary surrender of custody and guardianship, indicating the parent(s) relinquish parental responsibility to you.

The Board will also consider the extent to which you, as the plan member, is financially responsible for the child; whether your relationship is that of parent and child, and the expected duration of the relationship.

When coverage starts

When you become eligible, membership and coverage under the Public Service Dental Care Plan (PSDCP) begins following exactly three (3) months of continuous employment. Coverage is extended to the employee's eligible dependants on the same date.

New dependants have dental coverage from the date they become eligible dependants.

If you are on Leave Without Pay or on seasonal lay-off on the day you would normally have become a member of the Plan, your coverage will begin the first day of the month after the month you resume duty with pay. Coverage for your eligible dependants will also begin on that date.

Seasonal employees

Once in the Plan, seasonal employees have continuous year-round coverage, including the time while on seasonal lay-off.

Leave without pay

If you go on authorized Leave Without Pay for any of the following reasons, employer-paid coverage will be extended to you for the total period of absence:

  • maternity leave;
  • parental leave (within the 52-week period following the birth or adoption of a child);
  • sick Leave Without Pay or disability;
  • educational Leave Without Pay at the request of the employer;
  • leave to serve with another organization recognized as being to the advantage of the department or to the Government of Canada;
  • leave to serve with the Canadian Forces and Reserve Forces training /activities; and
  • the leave portion of Leave with Income Averaging and Pre-retirement Transition Leave.

If you proceed on any other type of Leave Without Pay, employer-paid coverage will continue during the first three consecutive calendar months of leave. Following this period, if you would like to maintain your Public Service Dental Care Plan (PSDCP) coverage, you must pay contributions (including applicable provincial sales tax) quarterly in advance, starting with the fourth (4th) month of your leave of absence and continuing for the duration of the Leave Without Pay, including the month you return to work. A table of monthly contributions is included in Appendix A.

Prior to taking a Leave Without Pay, you are responsible for notifying your departmental Compensation Office or the Public Service Pay Centre of the details regarding your leave and to arrange to pay your contributions quarterly in advance, when required. Your departmental Compensation services or the Public Service Pay Centre will provide you with a letter describing your responsibilities for maintaining continuous PSDCP coverage.

Employer-paid coverage will not resume until the first of the month following your return to work. Please note that this is not the same as the Public Service Health Care Plan (PSHCP).

Example

e.g. You take a Relocation of Spouse Leave Without Pay from to and return to work on .

You have employer-paid Public Service Dental Care Plan (PSDCP) coverage through the first three full months of Leave Without Pay (March, April and May 2012). This employer-paid coverage will cease on .

You must remit contributions in advance on a quarterly basis for the period beginning if you wish to have continued PSDCP coverage throughout the remaining period of Leave Without Pay. Contributions would be required for June through November of 2012 (inclusively) as employer-paid coverage would not be reinstated until (the first of the month following the month you return to work).

Coverage During Two or More Subsequent Periods of Leave Without Pay

You may take a period of Leave Without Pay where employer-paid coverage continues during that period of absence, followed immediately by a second period of Leave Without Pay where employer-paid coverage does not continue.

In this situation, if you wish to have continuous Public Service Dental Care Plan (PSDCP) coverage for the entire leave period, contributions are required starting the first full month in which the second type of Leave Without Pay begins. These contributions must be remitted in advance on a quarterly basis, through to (and including) the month you return to work.

Retroactive reinstatement of coverage is not possible while you are on Leave Without Pay and your contributions have not been paid in advance on a quarterly basis. If coverage ceases, it can only be reinstated the first of the month following the month you return to work.

Paying Contributions

You may choose which contribution rate you wish to pay:

  • Employee only = $23;
  • Employee and spouse or Employee with children = $46; or
  • Employee, spouse and children = $69.

* Note, you are also required to pay Provincial Sales Taxes, where applicable.

To avoid lapses in coverage, payment should be provided to your departmental Compensation Services or the Public Service Pay Centre, before the last day of the month in which employer-paid coverage would cease. For example, if employer-paid coverage were to cease on , you would need to submit a cheque or money order payable to the Receiver General Canada, before .

Unlike the Public Service Health Care Plan (PSHCP), if you do not pay the required contributions quarterly in advance, your PSDCP coverage will be suspended until the first of the month following the month you return to work.

Termination of coverage

Your membership in the Plan ends automatically on the date you cease to be employed or on the date you cease to qualify as an eligible employee. For example, if you become a part-time employee working one-third (1/3) or less of the normally scheduled hours for a full-time employee in the same occupational group, your coverage will cease.

Your spouse or common-law partner is no longer covered by the Plan when he or she ceases to be your spouse or common-law partner, or when you are no longer a member of the Plan, whichever date is earlier.

Your child is no longer covered by the Plan when he or she ceases to be an eligible child (for example a child reaches 21 years of age, or age 25 if in full-time attendance at a recognized educational institution) or when you are no longer a member of the Plan, whichever date is earlier.

Note:

If you have Public Service Dental Care Plan (PSDCP) coverage and you are laid off, dental coverage may be continued for a period of up to one year provided you pay the full cost of contributions. An exception to this Rule occurs when a dental treatment requiring more than one sitting began while you or your eligible dependants were in the Plan; coverage for that treatment will continue if it is completed within 31 calendar days of the termination date. Examples include root canal treatment where the pulp chamber is opened prior to termination, a crown where the tooth is prepared and impressions are taken prior to termination of coverage, or ongoing orthodontic treatment where the initial appliance was inserted prior to the termination date. Please contact your Compensation Advisor for further details regarding your eligibility in these circumstances. If your coverage is terminated due to retirement, you may be eligible to apply for coverage under the Pensioners' Dental Services Plan.

Reporting changes affecting coverage

As the plan member covered under the Public Service Dental Care Plan (PSDCP), you are responsible for notifying Great-West Life, in writing, when there are changes to your personal circumstances that could affect your coverage. Contact information is located in Appendix D.

Examples of changes affecting coverage:

  • Spouse/common-law partner, no longer eligible dependant;
  • New spouse/common-law partner; and
  • change in school attendance for dependants between 21 and 25 years of age.

Once you become a plan member, Great-West Life will issue you an identity card. This card indicates the effective date of your coverage, the plan number and your certificate number you will use to identify yourself and your eligible dependants to Great-West Life when you file your claims. You must record the plan number and your certificate number on all claims submitted for yourself and your eligible dependants, and on all correspondence with Great-West Life.

Should you lose your identity card, please contact your departmental Compensation services or the Public Service Pay Centre to obtain a replacement card.

Benefits

General description of the coverage

The Public Service Dental Care Plan (PSDCP) provides coverage for specific services and supplies that are not covered under a provincial health or dental care plan. Further, the Plan covers only reasonable and customary dental treatment, necessary to prevent or correct dental disease or defect, provided the treatment is consistent with generally accepted dental practices.

The Plan will reimburse Members for eligible expenses incurred for dental services performed by:

  • dentists, dental specialists or dental mechanics;
  • denturists or denturologists;
  • dental hygienists if the dental service is performed in a province or territory of Canada in which dental hygienists are licensed to provide such services (otherwise, under the direct supervision of a dentist or dental specialist);
  • anaesthetists (in connection with oral surgery and drug injections).

The dental practitioner must be licensed to provide dental services in the province or territory where the service is received.

Canadian residents

If you reside in Canada, the Plan will provide reimbursement up to the amounts specified in the following Dental Association Fee Guides for practitioners:

  • for services received in Canada (except Alberta) – the Fee Guide in the province or territory where the treatment is received will apply;
  • for services received in the Province of Alberta – the Alberta Dental Association does not provide a provincial Fee Guide, therefore, Great-West Life creates an annual representative guide that provides a reasonable price in order to fairly assess eligible dental charges;
  • if you or your eligible dependants incur charges while temporarily outside of Canada, the Fee Guide of the province or territory where the Member permanently resides will apply.

The Dental Association Fee Guides are listings of charges established by dental associations for specified services provided by dentists in their province or territory. It is common practice to use the Fee Guide in effect the previous year.

Residents outside Canada

If you resided outside of Canada, the Plan will reimburse eligible expenses based on the actual incurred expenses provided those amounts are considered "reasonable and customary" in that region. Any expenses in excess of the reasonable and customary amounts will not be covered under the Plan. The Fee Guide in effect for the province of Ontario will be used to determine the limits on the reimbursement of expenses.

Note: If services are provided by a qualified specialist in endodontics, prosthodontics, oral surgery, periodontics, paedodontics or orthodontics (whose dental practice is limited to that specialty), the Fee Guide approved by the provincial or territorial Dental Association for that specialist will be used.

Reasonable and customary

Reasonable and Customary means the amount that is usually charged to a person without coverage and does not exceed the general level of charges for the specific service in the location where it was performed. Great-West Life determines these amounts by consulting the available Fee Guides of provincial, territorial or national practitioner associations.

Annual deductible

The annual deductible is a specific dollar amount that you must satisfy each calendar year before you receive reimbursement on your first claim. The annual deductible amount is $25 per covered person and $50 for a family.

Carry-over deductible:

If the first dental expenses in a calendar year are incurred in the last quarter of the year (October-December) and the applicable deductible is satisfied, a new deductible will not be applied in the following calendar year.

Co-payment amount

After the annual deductible amount has been satisfied, the Plan will reimburse you for a percentage of the cost of the covered expenses (i.e., 90% for eligible preventive and basic dental supplies and services, and 50% for eligible major dental procedures). The remainder (i.e., 50% for major restorative and 10% for other eligible services) is the amount that you are required to pay toward each eligible expense. This is referred to as the co-payment amount.

Important: The Member is responsible for any portion not reimbursed by the Plan, even in cases where the dental practitioner charges more for a given service or procedure than the amount specified in the applicable Dental Association Fee Guides in effect the previous year.

Maximum reimbursement amount

In any calendar year, the Plan will reimburse an annual maximum amount of $1,700 for each covered person. This excludes orthodontic services, which has a separate lifetime limit (see below).

If your coverage starts in the second half of the year (i.e., on or after July 1st of that year), the maximum amount that the Plan will reimburse for that year will be $850.

Lifetime limit – orthdontic services

Orthodontic services are subject to a separate lifetime limit of $2,500 for each covered person.

Treatment plan

Before beginning a treatment or procedure that is expected to cost more than $300, you and/or your dentist should submit an estimate of the proposed work to Great-West Life. Great-West Life will send you a Predetermination of benefits statement to let you know if the work is covered by the Plan and, if so, the amount of the estimated cost that will be paid. In some cases, the treatment you are requesting may not be covered however an alternate treatment may be considered. The Public Service Dental Care Plan (PSDCP) has an Alternate Benefit Clause (ABC) which is a plan provision that allows payment towards an expense that would otherwise not be covered, or limits payment to the cost of a less expensive, reasonable and customary dental service. For example, dental implants are not covered but the Plan may pay an alternate benefit based on the cost of a partial denture or fixed bridge. An ABC is not payable in all cases. For example, if you choose an onlay where a filling would have been considered a viable treatment option, none of the costs are covered.

It is important to read all notes and remarks included on the Predetermination of benefits statement issued by Great-West Life and also to ensure that you have not exceeded the yearly maximum reimbursement amount allowed under the Plan. A pre-treatment plan may indicate that a treatment or service is eligible however; there may be limitations or time restrictions that apply. A Predetermination of Benefits statement is valid for six months provided that you and/or your dependants are still covered under the Plan.

Eligible services

Below is a summary of the major features of the Plan's eligible services, by category.

You should refer to the detailed description of eligible dental services in Appendix B for the specific limits on how often certain services will be reimbursed under the Plan. Please note, exclusions and limitations are described in Appendix C.

Benefits Reimbursed at 90%

Diagnostic (excluding services related to major prosthodontic)

  • Examinations , x-rays, tests and laboratory reports (including diagnostic services related to orthodontic treatment)

Preventive

  • Dental cleaning and polishing, topical application of fluoride, pit and fissure sealants, oral hygiene instruction, space maintainers

Minor Restorative

  • Amalgam, acrylic and composite fillings

Endodontics

  • Root canal therapy

Periodontics

  • Treatment of gums

Minor Prosthodontic Services (removable dentures):

  • Repairs and adjustments, relining and rebasing

Surgery

  • Extractions of teeth, other surgical procedures

Adjunctive Services

  • Emergency services not otherwise specified, anaesthesia

Benefits Reimbursed at 50%

Major Restorative

  • Gold foil restorations, metal and porcelain inlays;
  • Onlays; and
  • Crowns

Major Prosthodontic Services

  • Diagnostic services, complete dentures, partial dentures, fixed bridges (abutments/retainers, pontics), repairs of fixed bridges.

Orthodontic

Surgical services, observation and adjustments, fixed appliances, removable appliances

Submitting your claims

Claims must be submitted to Great-West Life within fifteen (15) months of the date on which the expense was incurred. For orthodontic treatment, claims must be submitted within fifteen (15) months of the date of each monthly visit throughout the treatment period. Claims submitted after that fifteen (15) month period will not be paid unless the member can demonstrate that it was impossible to submit the claim within that time. Further, except in the case of legal incapacity, no claim will be paid if it is submitted more than 24 months after the expense was incurred.

If you have incurred expenses that are eligible for reimbursement, you should complete an authorized claim form with the appropriate information, including:

  • your full name and address, including your postal code;
  • your plan and certificate number;
  • your spouse or common-law partner's plan and certificate number, when applicable,; and
  • your signature.

The dentist must also complete his or her section on the claim form. Incomplete forms will be returned to you for completion. Attach your bills or receipts, ensuring they provide full details of the services rendered or purchases made.

Your claims should be sent to the appropriate group benefit payment office as outlined in Appendix D.

Online Services

You may also submit claims electronically through the Great-West Life GroupNet for Plan Members Web site. You will need your plan and certificate number (available on your Benefit ID Card) to access the site. Here you can find information about your benefits including how to:

  • sign up for direct deposit to have claim payment cheques automatically deposited into your bank account;
  • complete and print personalized dental claim forms;
  • access information about your coverage;
  • view and print your claims summaries to track your claim history and use for income tax purposes when claiming medical expenses not covered by the Plan;
  • view the status of your claims and your Explanation of Benefits statements for the last 24 months; and
  • check your dental care balance and the date of your next eligible checkup.

For claims submitted electronically, it is your responsibility to authorize your dentist to submit claims and to ensure your personal information, including plan and certificate number and address, is correct.

Duplicate Protection

  1. Coverage under a provincial plan

    If you live in a province that insures dental service, you should first submit your claim to the provincial authorities. When that claim has been processed, you may submit a claim to your dental plan for any remaining eligible expenses.

  2. Coverage under employer sponsored dental plans

    When you and your spouse or common-law partner are covered under two different plans, or are members each in your own right under the Public Service Dental Care Plan (PSDCP) (including the Canadian Forces/ Royal Canadian Mounted Police (RCMP) Dependants Dental Plan), you can benefit from the co-ordination of benefits for dental expenses incurred by yourself and your eligible dependants provided you and your spouse have family coverage under your own respective plans. In all cases, the combined reimbursement from all plans cannot exceed the lesser of the expenses incurred or the amount specified in the current year fee guide of the province where the treatment is rendered for that procedure. Please note also that plan exclusions and individual calendar year maximum reimbursement limits apply separately under each plan.

  3. Coverage under the Public Service Health Care Plan (PSHCP)

    If you are a member of the Public Service Dental Care Plan (PSDCP) and of the Public Service Health Care Plan (PSHCP), you benefit from combined protection for certain types of complex surgical dental services and for dental services required as a result of injury to natural teeth.

    If such services are rendered to you or your covered dependants:

    Due to Injury

    You must first submit a claim to the PSHCP. If you do not obtain full reimbursement for your dental expenses, you may then submit a duplicate of your claim form, along with a copy of the PSHCP Explanation of Benefits, to the PSDCP.

    For Surgical Procedures

    First submit your claim to the PSDCP and, where applicable, you may submit a claim for any unpaid expenses to the PSHCP. To obtain additional information, please contact your departmental Compensation services or Public Service Pay Centre.

Submitting your coordination of benefits claims

If you are a member of the Public Service Dental Care Plan (PSDCP) and are also covered under your spouse or common-law partner's plan as an eligible dependant, you should submit your claim to your own plan first.

If your spouse or common-law partner is covered under another plan and is also covered as an eligible dependant under your PSDCP membership, claims for your spouse or common-law partners expenses should be submitted to his or her own plan first.

When your children are covered under both your plan and your spouse or common-law partner's plan as eligible dependants, the plan that pays first will be determined by the Canadian Life and Health Insurance Association (CLHIA) guidelines for co-ordination of benefits. Under these guidelines, the spouse or common-law partner whose birthday falls earlier in the year must claim the children's expenses first under his or her plan. In case of divorce or separation, the following order of submission must be followed:

  • the plan of the parent that has custody of the child;
  • the plan of the spouse of the parent that has custody of the child;
  • the plan of the parent that does not have custody of the child; and finally
  • the plan of the spouse of the parent that does not have custody of the child.

Note: If you and your spouse or common-law partner are both members of the PSDCP, follow the process noted above to determine which plan you should first submit your expenses to. A claim does not need to be submitted to the other plan/certificate number for the unpaid balance of eligible expenses. Indicate the plan and certificate number of your spouse/common-law partner's dental plan on the initial claim form, and Great-West Life will process the eligible claims under both memberships. Payment under your spouse/common law partner's plan and certificate number will be made to your spouse or common-law partner unless he or she authorizes Great-West Life to issue the payment directly to you by completing the "Authorization for Claims Submission and Redirection of Payment form".

Claims payment

Once your claim has been assessed, an Explanation of Benefits will be forwarded to you by the Great-West Life with your benefit payment. Payment will be issued to you or, on signed instructions from you, may be issued to your spouse or common-law partner ("Authorization for Claims Submission and Redirection of Payment form") or to the dentist (claim form (PDF version, 126 KB)) (The Great-West Life Assurance Company). Payments are normally made in a lump sum. However for orthodontic services, you will normally be reimbursed on a monthly basis provided a completed claim form with receipts are forwarded to Great-West Life. The calculations for these payments will be based on the information submitted by the orthodontist on the pre-treatment plan.

You may re-direct payment of claims for your eligible dependants to your spouse or common-law partner using a form called the Public Service Dental Care Plan (PSDCP) Authorization for Claims Submission and Redirection (PDF version, 57 KB).

As the member, you can authorize a spouse or common-law partner to submit dental claims on your behalf when the claims are for your eligible dependants.

In some situations you may not have care and custody of your eligible child(ren). In that case, you may authorize the person who does have care and custody to file claims and receive claims payment for dental services received by your eligible child(ren). Should you subsequently wish to rescind such an authorization, you may do so by writing to Great-West Life.

Appealing an assessment

Occasionally you may disagree with an assessment made by Great-West Life. When an issue cannot be resolved with Great West Life, the matter should be referred to the appropriate Board of Management at the address indicated below. The member, your departmental Compensation services or bargaining agent referring the matter should ensure that all the particulars of the case are provided.

For members represented by Public Service Alliance of Canada (PSAC), details related to your appeal should be addressed to:

Board of Management
Dental Care Plan (PSAC)
140 O’Connor Street
8th Floor East Tower, #08102
Ottawa, Ontario
K1A 0R5

For members of the Canadian Armed Forces, details related to your appeal should be addressed to:

Canadian Armed Forces Dental Care Plan Board
Director General Compensation and Benefits
Directorate of Pensions and Social Programs
MGen George R. Pearkes Building
101 Colonel By Drive
Ottawa ON K1A 0K2

For members of the Royal Canadian Mounted Police, details related to your appeal should be addressed to:

RCMP Dental Care Plan Board of Management
National Compensation Services - Insurance
73 Leikin Drive, M5-4-101
Mailstop #31
Ottawa ON
K1A 0R2

For all other members, details of the case should be addressed to:

Board of Management
Dental Care Plan (NJC)
P.O. Box 1525, Station B
240 Sparks Street West
7th Floor
Ottawa, Ontario
K1P 5V2

Fraud and plan abuse

You can help protect your benefits and reduce the incidence of fraud and Plan abuse by following these tips:

  • confirm a service is necessary before having it performed;
  • verify the Explanation of Benefits to ensure the services billed for were actually received; refuse receipts for services or supplies you have not received;
  • do not change dates on a claim or provide false or incomplete information to ensure payment;
  • do not provide blank, signed claim forms to a service provider. These can be used to submit fraudulent claims in your name;
  • notify Great-West Life if your spouse or eligible dependant(s) are no longer covered under the Plan.

If you suspect Plan fraud or abuse:

Tip lines are confidential.

Appendix A - Table of monthly contributions (not including applicable Provincial Sales Tax)

Effective :
Employee only $23.00
Employee and spouse or Employee with children $46.00
Employee, spouse and children $69.00

Appendix B - Eligible Dental Services

Eligible dental services mean services listed hereafter, when rendered by a dentist or dental specialist, or rendered by an independently licensed dental hygienist, a dental hygienist under the direct supervision of a dentist or dental specialist, or rendered by a dental mechanic (also referred to as a denturist or denturologist) who is licensed to provide services in the province or territory in which the service was received, and who is permitted by law to deal directly with the public. This section should be read in conjunction with Appendix C, which lists exclusions and limitations on dental services and supplies.

Where it cannot be determined that the dental services rendered are covered services, the Great-West Life will identify which of the covered services listed below can be considered to be alternative services, and will base reimbursement on those services.

Diagnostic

Examination and Diagnosis

  • complete oral examination
  • recall oral examination
    (once every 9 months)
  • specific oral examination
  • emergency oral examination
  • treatment planning

Note: Reimbursement for a complete oral exam once every 3 years (36 months) except for limited oral exam of a new patient exam, which is unlimited

Tests, Laboratory Examinations

  • biopsy of oral tissue
  • pulp vitality tests

Radiographs

  • periapical - one complete series every
    3 years (36 months)
  • occlusal
  • bitewings (once every 9 months)
  • extra-oral
  • sialography, use of dyes
  • panoramic - once every 3 years (36 months)
  • interpretation of radiographs from another source

Preventive

Routine Services

  • dental cleaning and polishing
    (once every 9 months)
  • topical application of fluoride
    (once every 9 months)
  • pit and fissure sealants
    (for children under 15 years of age only)
  • caries control
  • enameloplasty
  • space maintainers
    (not involving movement of teeth)
  • oral hygiene instructions
    (once per calendar year)

Note: Children recall exams, including cleaning and polishing, topical application of flouride and bite-wing X-rays are limited to once every 6 months.

Restorative

Minor

  • amalgam
  • acrylic or composite
  • pin reinforcements for these restorations

Note: Expenses for fillings for the same tooth and surface are covered no more than once every 24 months.

Major

  • gold foil
  • gold inlays
  • retentive pins, posts and cores
  • porcelain inlays
  • crowns
  • other restorative services

Note: Prefabricated crowns for primary teeth ONLY will be covered under routine services. (This concerns stainless steel crowns previously covered under major restorations.)

Note: Reimbursement of replacement crowns is limited to once every 60 consecutive months, irrespective of the age of the crown.

Endodontics

  • pulp capping
  • pulpotomy
  • root canal therapy
  • periapical services
  • other endodontic procedures

Periodontics

  • non-surgical services
  • surgical services
  • post-surgical treatment
  • occlusal equilibration
    not exceeding 8 time units per year (12 months)
  • scaling and root planing (limited to 6 time units per calendar year)
  • other periodontic services

Note: Up to 6 additional units of scaling/root planing can be allowed in cases of documented periodontitis with the pre-approval of a treatment plan.

Note: One (1) time unit means 15 minutes.

Prosthodontics

Minor Services for Removable Dentures

  • repairs
  • adjustments
  • relining and rebasing -
    once every 3 years (36 months)

Major

(this section should be read in conjunction with the specific limitations listed in Appendix C)

  • exams, films and diagnostic casts
  • addition of tooth to a removable denture
  • artial and complete dentures

    Note: The replacement of dentures will be covered once every 60 consecutive months (5 years) irrespective of the age of the denture.

  • repairs of fixed appliances
  • other prosthodontic services
  • fixed bridges (abutments/retainers, pontics )

Oral Surgery

  • uncomplicated removal
  • surgical removal and tooth repositioning
  • alveoloplasty, gingivoplasty, stomatoplasty, osteoplasty, tuberoplasty
  • removal of excess mucosa
  • surgical excision
  • removal of cyst
  • surgical incision
  • removal of impacted teeth
  • repair of soft tissue
  • frenectomy, dislocations
  • miscellaneous surgical services

Orthodontic Services

Diagnostic

  • orthodontic exam
  • films
  • diagnostic casts

Observation and Adjustment

  • surgical services
  • observation and adjustments
  • repairs, alterations

Appliances

  • removable appliances
  • fixed appliances
  • retention appliances
  • appliances to control harmful habits

Adjunctive General Services

  • emergency services not otherwise specified
  • anaesthesia in connection with oral surgery and drug injections
  • drug injections
  • consultation
  • house call, hospital call and special office visit

Appendix C - Exclusions and limitations

General

No benefit is payable under the PSDCP for the following dental services and supplies:

  1. services and supplies, or any portion thereof, that are covered under any provincial, territorial or other public dental, hospital or health plan under which the person is eligible;
  2. services and supplies, or any portion thereof, that are the legal liability of any other party;
  3. services and supplies rendered or provided to which a person is entitled without charge pursuant to any law, including, but not limited to, Workers' Compensation or similar law, or for which there is no cost to the person except for the existence of insurance against such cost;
  4. services and supplies received in a hospital owned or operated by a government, unless the person is required to pay for such services or supplies regardless of the existence of insurance;
  5. services and supplies rendered outside Canada to persons residing in Canada, or to children of a member residing in Canada, that would be payable under a provincial health, dental or hospital plan if the services had been rendered in Canada;
  6. dental treatment involving the use of precious and non-precious metals, if such treatment could have been rendered at a lower cost by means of a reasonable substitute consistent with generally accepted dental practice, except for that portion of expenses that would have been incurred for treatment by means of a reasonable substitute;
  7. user fees, co-insurance charges or similar charges that are in excess of charges payable by a government dental, hospital or health plan;
  8. dental treatment that is not yet approved by the Canadian Dental Association or that, in the opinion of Great-West Life, is clearly experimental in nature;
  9. services and supplies that, in the opinion of Great-West Life, are rendered principally for cosmetic purposes including, but not limited to, porcelain or composite facings on crowns or pontics on molar teeth;
  10. services and supplies related to the purchase, repair, modification or replacement of a duplicate prosthodontic appliance, for any reasons;
  11. services rendered and supplies purchased before the date the persons became covered under this Plan;
  12. charges for an appliance or a modification of one where an impression is made for such appliance or modification before the person became covered under this Plan; charges for crowns, bridges and gold restorations for which a tooth was prepared before the person became covered under this Plan; charges for root canal therapy where the pulp chamber was opened before the person became covered under this Plan;
  13. services and supplies rendered as a result of a congenital or developmental malformation that is not a Class I, II or III malocclusion, except for a child under 19 years of age;
  14. charges for a periodontal appliance, occlusal equilibration, and other related service as a result of a temporo-mandibular joint dysfunction (TMJ dysfunction) or vertical dimension correction; and
  15. implants and implant-related services.

Specific limitations with respect to major services

  1. Services for the installation of prosthodontic appliances (for example, fixed bridges, pontics and abutments, temporary or permanent, partial or complete dentures) constitute eligible dental services only if they are rendered for:
    1. an initial prosthodontic appliance, or
    2. the replacement of an existing prosthodontic appliance, including the addition of teeth to an existing appliance, if:
      1. the replacement or the addition of teeth is required because at least one additional natural tooth was extracted after the insertion of the existing appliance, and the appliance could not have been made serviceable. If the existing appliance could have been made serviceable, only the expense for that portion of the replacement appliance that replaces the teeth extracted shall be covered;
      2. the existing fixed bridge is at least five (5) years old and cannot be made serviceable (irrespective of who paid for the existing appliance);
      3. reimbursement of existing denture under the PSDCP was at least 5 years ago;
      4. the existing appliance was temporarily installed; When a temporary prosthodontic appliance is installed as part of major restorative services, plan coverage for permanent prosthodontic appliances will be provided without regard to when the temporary appliances was first installed provided that the person was covered under the Plan when the temporary appliance was installed.
      5. the replacement appliance is required as a result of the installation of an initial opposing denture after the date the person becomes covered under the Plan; or
      6. the replacement appliance is required as a result of accidental dental injury to a natural tooth that occurred after the date the person became covered under the Plan.
  2. The necessary replacement of fillings (same tooth and surface) will be paid under this plan once every 24 months irrespective of the age of the filling. The necessary replacement of crowns will be paid under this plan once every 60 months irrespective of the age of the crown.
  3. The necessary replacement of crowns will be paid under this Plan once every 60 months irrespective of the age of the crown.

Appendix D - Claims Offices

All claims should be sent to the Public Service Dental Care Plan (PSDCP) Administrator, the Great-West Life Assurance Company, to one of the following mailing addresses, as appropriate.

For Canadian residents except residents of Quebec:

Health and Dental Claims Centre
P.O. Box 6025, Station Main
Winnipeg MB
Canada
R3C 3C7

Toll free numbers: 1-855-415-4414 (service in English and French)

TTY – For the Deaf or Hard of Hearing: 1-800-990-6654 or Winnipeg (204) 946-7281

For Quebec residents, other than the National Capital Region:

Montreal Benefit Payments
Place Bonaventure
800 de la Gauchetière Street West
Suite 5800
Montreal QC
Canada
H5A 1B9

Toll free number: 1-855-415-4414 (service in English and French)

TTY – For the Deaf or Hard of Hearing: 1-800-990-6654 or Winnipeg (204) 946-7281

For employees residing outside Canada

Great-West Life Health and Dental Benefits
Foreign Benefits Payments
P.O. Box 6000
Winnipeg MB
Canada
R3C 3A5

Toll free numbers: 1-855-415-4414 (service in English and French)

TTY – For the Deaf or Hard of Hearing: 1-800-990-6654 or Winnipeg (204) 946-7281

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