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Sun Life Assurance Company of Canada
2092097 DEN57 CL2 02/28/2023 10:40:18
sunlife.com/us Dental Insurance
PROTECTS YOUR SMILE.
You can feel more confident with dental insurance that
encourages routine cleanings and checkups. Dental
insurance helps protect your teeth for a lifetime.
PREVENTS OTHER HEALTH ISSUES.
Just annual preventive care alone can help prevent other
health issues such as heart disease and diabetes. Many
plans cover preventive services at or near 100% to make it
easy for you to use your dental benefits.
LOWERS OUT-OF-POCKET EXPENSES.
Seeing an in-network dentist can reduce your fees
approximately 30% from their standard fees. Add the
benefits of your coinsurance to that and things are looking
good for your wallet.
Dental
Insurance
DENTAL FAST FACTS
Treating the inflammation
from periodontal disease
can help manage other
health problems such as
heart disease and
diabetes.
1
50% of adults over the age
of 30 are suffering from
periodontal disease.
2
COMMONLY
COVERED
Exams and cleanings
X-rays
Fillings
Tooth extractions
Adult and child braces
STATE OF WEST VIRGINIA
All Eligible Employees and Retirees Electing
Enhanced Plan
sunlife.com/us Dental Insurance
What’s covered
IN-NETWORK OUT-OF-NETWORK
PLAN YEAR MAXIMUM
Type I, II, III (Preventive, Basic and Major Services)
$1,500 per person $1,000 per person
Type IV Ortho Service
$1,250 lifetime child and
adult
$500 lifetime child and
adult
SERVICES
Type I Preventive Dental Services, including:
• Oral evaluations – 2 in any benefit year
• Routine dental cleanings – 2 in any benefit year
• Fluoride treatment – 1 in any 6 month period. Only for
children under age 19
• Sealants – no more than 1 per tooth in any 36 month
period, only for permanent molar teeth. Only for
children under age 14
• Space maintainers – only for children under age 19
• Bitewing x-rays – 2 in any 12 month period
• Intraoral complete series x-rays – 1 in any 36 month
period
• Genetic test for susceptibility to oral diseases
Type II Basic Dental Services, including:
• New fillings
• Simple extractions, incision and drainage
• Surgical extractions of erupted teeth, impacted teeth,
or exposed root
• Biopsy (including brush biopsy)
• Endodontics (includes root canal therapy) – 1 per tooth
in any 24 month period
• General anesthesia/IV sedation – medically required
• Minor gum disease (non-surgical periodontics)
• Scaling and root planing – 1 in any 24 month period
per area
• Periodontal maintenance – 2 in any benefit year
• Localized delivery of antimicrobial agents
• Major gum disease (surgical periodontics)
Type III Major Dental Services, including:
• Dentures and bridges – subject to 5 year replacement
limit
• Stainless steel crowns– only for children under age 19
• Inlay, onlay, and crown restorations – 1 per tooth in
any 5 year period
• Treatment for TMJ Disorder - Non-Surgical TMJ
treatment $1,000 lifetime maximum
Type IV Ortho Services, including:
• No orthodontic treatment age limitation
Waiting Periods
For a complete description of services and waiting periods,
please review your certificate of insurance. If you were
covered under your employer’s prior plan the wait will be
waived for any type of service covered under the prior plan
and this plan.
• No waiting period for preventive or basic services
• 6 months for major services
• 6 months for orthodontic services
THE PLAN PAYS THE FOLLOWING PERCENTAGE FOR PROCEDURES
PROCEDURE
IN-NETWORK OUT-OF-NETWORK
Type I Preventive Services 100% 80%
Type II Basic Services 80% 60%
Type III Major Services 60% 40%
Type IV Ortho Services 40% 25%
PLAN YEAR DEDUCTIBLE
PROCEDURE
IN-NETWORK OUT-OF-NETWORK
Type I Preventive Services N/A N/A
Type II, III (Basic and Major Services) $50 individual/$150 family $50 individual/$150 family
Type IV Ortho Services N/A N/A
sunlife.com/us Dental Insurance
Frequently asked questions
How does a PPO work?
PPO stands for Participating Provider Organization. With a
dental PPO plan, dental providers agree to participate in a
dental network by offering discounted fees on most
dental procedures. When you visit a provider in the
network, you could see lower out-of-pocket costs
because providers in the network agree to these pre-
negotiated discounted fees on eligible claims.
How do I find a dentist?
Simply visit www.sunlife.com/sunlifedentalnetwork. Follow
the prompts to find a dentist in your area who participates
in the PPO network. You do not need to select a dentist in
advance. The PPO network for your plan is the Sun Life
Dental Network® with 130,000+ unique dentists
3
.
How can using a network dentist help lower my costs?
You are free to use the dentist or specialist of your choice.
However, this plan allows you to have access to the Sunlife
Dental Network® PPO dentists and to take advantage of
their fee discounts. Treatment is available from out-of-
network dentists, but their fees are subject to an allowable
charge. The allowable amount for out-of-network dentists
is based on 45% off the 80th percentile of the amount
charged by other dentists in the same geographic area.
Patients are responsible for fees in excess of the allowable
charge. There can be significant out-of-pocket expenses if
an out-of-network dentist is chosen.
Are my dependents eligible for coverage?
Yes. Your plan offers coverage for your spouse
4
and
dependent children. An eligible child is defined as a child to
age 26.
5
Do I have to file the claim?
Many dentists will file claims for you. If a dentist will not file
your claim, simply ask your dentist to complete a standard
American Dental Association (ADA) claim form and mail it
to Sun Life. The address will be provided on your dental ID
card.
What value added benefits does my plan include?
Your plan includes our Lifetime of Smiles® program, with
benefits many people prefer, such as brush biopsies for
the early detection of oral cancer.
CONSIDER A
PRE-DETERMINATION
OF BENEFITS
They allow us to review your
provider’s treatment plan to let
you know before treatment is
started how much of the work
should be covered by the plan,
and how much you may need to
cover. We recommend them for
any dental treatment expected
to exceed $500.
1. American Academy of Periodontology https://www.perio.org/consumer/gum-disease-and-other-diseases (accessed 07/21).
2. American Academy of Periodontology https://www.perio.org/newsroom/periodontal-disease-fact-sheet (accessed 07/21).
3. Zelis Network Analytics data as of January 2022 and based on unique dentist count. Sun Life's dental networks include its affiliate, Dental
Health Alliance, L.L.C.® (DHA), and dentists under access arrangements with other dental networks. Nationwide counts are state level totals.
4. If permitted by the Employer’s employee benefit plan and not prohibited by state law, the term “spouse” in this benefit includes any
individual who is either recognized as a spouse, a registered domestic partner, or a partner in a civil union, or otherwise accorded the same
rights as a spouse.
5. Please see your employer for more specific information.
Read the Important information section for more details including limitations and exclusions
sunlife.com/us Dental Insurance
Important information
Benefit adjustments
Benefits will be coordinated with any other dental coverage. Under the Alternative Treatment provision, benefits will
be payable for the most economical services or supplies meeting broadly accepted standards of dental care.
To become insured, you must meet the eligibility requirements set forth by your employer. Your coverage effective date
will be determined by the Policy and may be delayed if you are not actively at work on the date your coverage would
otherwise go into effect. Similarly, dependent coverage, if offered, may be delayed if your dependents are in
the hospital (except for newborns) on the date coverage would otherwise become effective. Refer to your Certificate for
details.
Limitations and exclusions
The below exclusions and limitations may vary by state law and regulations. This list may not be comprehensive. Please
see your Certificate or ask your benefits administrator for details.
Dental
We will not pay a benefit for any Dental procedure, which is not listed as a covered dental expense. Any dental
service incurred prior to the Effective date or after the termination date is not covered, unless specifically listed in the
certificate. A member must be a covered dental member under the Plan to receive dental benefits. The Plan has
frequency limitations on certain preventive and diagnostic services, restorations (fillings), periodontal services,
endodontic services, and replacement of dentures, bridges and crowns. All services must be necessary and provided
according to acceptable dental treatment standards. Treatment performed outside the United States is not covered,
except for emergency dental treatment, subject to a maximum benefit. Dental procedures for Orthodontics; TMJ;
replacing a tooth missing prior the effective date; implants and implant related services; or occlusal guards for
bruxism are not covered unless coverage is elected or mandated by the state.
This Overview is preliminary to the issuance of the Policy. Refer to your Certificate for details. Receipt of this
Overview does not constitute approval of coverage under the Policy. In the event of a discrepancy between this
Overview, the Certificate and the Policy, the terms of the Policy will govern. Product offerings may not be available
in all states and may vary depending on state laws and regulations.
This plan does not provide coverage for pediatric oral health services that satisfies the requirements for “minimum essential coverage” as
defined by The Patient Protection and Affordable Care Act (PPACA).
Sun Life companies include Sun Life and Health Insurance Company (U.S.) and Sun Life Assurance Company of Canada (collectively, “Sun Life”).
Group insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states, except New York, under
Policy Form Series 15-GP-01 and 16-DEN-C-01.
© 2019 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks
of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us.
GVBH-EE-8384 SLPC 29579
