Summary Plan Description

Introduction

Dental Benefits Are Not Available Under Retiree Coverage

Eligibility

Dental and orthodontic benefits are available to participants and dependents covered under dollar bank eligibility and for participants and dependents who elect to pay for them under Self-Contribution Coverage and COBRA Coverage.

Dental Benefits

Dental benefits are available to you and your dependents. Dental benefits are reimbursed up to the amount allowed in the Dental Fee Schedule, regardless of whether services are provided by a network or non-network provider. There is a $2,000 annual maximum for the Western and Central Washington benefit package and a $1,500 annual maximum for the Eastern Washington, Idaho, Montana, and Wyoming benefit package. These expenses are not subject to the $200/$400 annual deductible or $2,300/$4,600 annual coinsurance maximum or $4,000/$8,000 out-of-pocket maximum. You and your dependents are responsible for paying amounts over the scheduled allowances, amounts over the plan maximums and any expenses not covered.

Dental Implant Benefits

Dental implants are available to you and your dependents under the Western and Central Washington benefit package and are paid at 50 percent with a $1,000 lifetime maximum. These expenses are not subject to the $200/$400 annual deductible or $2,300/$4,600 annual coinsurance maximum or $4,000/$8,000 out-of-pocket maximum.

Orthodontic Benefits

Orthodontic benefits are available to you and your dependents and are paid at 50 percent with a lifetime maximum of $1,500 under the Western and Central Washington benefit package and at 50 percent with a lifetime maximum of $1,000 for dependent children age 18 and younger under the Eastern Washington, Idaho, Montana, and Wyoming benefit package. These expenses are not subject to the $200/$400 annual deductible or $2,300/$4,600 annual coinsurance maximum or $4,000/$8,000 out-of-pocket maximum.