A deductible may be applied before you are reimbursed. All expenses will be reimbursed at the level shown in the Benefit Summary. Benefits may be subject to plan maximums and frequency limits. Check the Benefit Summary for this information.
The plan covers customary charges to the extent they do not exceed the dental fee guide level shown in the Benefit Summary. Denturist fee guides are applicable when services are provided by a denturist. Dental hygienist fee guides are applicable when services are provided by a dental hygienist practicing independently.
All covered services and supplies must represent reasonable and customary treatment. Treatment is considered reasonable and customary if it is recognized by the Canadian Dental Association, it is proven to be effective, and it is of a form, frequency, and duration essential to the management of the person's dental health. To be considered reasonable, treatment must also be performed by a dentist or under a dentist’s supervision, performed by a dental hygienist entitled by law to practise independently, or performed by a denturist.
Reimbursement for certain procedures could be limited to the cost of an alternative service.
You are covered for only the dentalcare benefits that apply to the level that you are in as shown in the Benefit Summary.
- Your dentalcare coverage terminates when you no longer qualify for dentalcare coverage through the plan.
- Before incurring any large dental expenses, or beginning any orthodontic treatment, ask your dental service provider to complete a treatment plan and submit it to Great-West Life. Great-West Life will calculate the benefits payable for the proposed treatment, so you will know in advance the approximate portion of the cost you will have to pay.
The following expenses will be covered:
- Coverage for crowns on molars is limited to the cost of metal crowns. Coverage for complicated crowns is limited to the cost of standard crowns
- Coverage for tooth-coloured onlays on molars is limited to the cost of metal onlays
Replacement crowns and onlays are covered when the existing restoration is at least 5 years old and cannot be made serviceable
- Standard complete dentures, standard cast or acrylic partial dentures or complete overdentures or bridgework when required to replace one or more teeth extracted while the person is covered. Overdentures and bridgework are covered only when standard complete or partial dentures are not viable treatment options. Coverage for tooth-coloured retainers and pontics on molars is limited to the cost of metal retainers and pontics. Replacement appliances are covered only when:
- the existing appliance is a covered temporary appliance
- the existing appliance is at least 5 years old and cannot be made serviceable. If the existing appliance is less than 5 years old, a replacement will still be covered if the existing appliance becomes unserviceable while the person is covered and as a result of the placement of an initial opposing appliance or the extraction of additional teeth.
If additional teeth are extracted but the existing appliance can be made serviceable, coverage is limited to the replacement of the additional teeth
- Denture-related surgical services for remodelling and recontouring oral tissues
- Denture and bridgework maintenance following the 3-month post-insertion period including:
- denture remakes, once every 36 months
- denture adjustments, once every 12 months
- denture repairs and additions, tissue conditioning and resetting of denture teeth
- repairs to covered bridgework
- removal and recementation of bridgework
- Orthodontics are covered for children age 6 to 18 when treatment starts
Orthodontic expenses are considered to be incurred on a periodic basis throughout the course of treatment. All other expenses are considered to be incurred when you or your dependent receive the service or supply.
Accidental Dental Injury Coverage
- Treatment of injury to sound natural teeth. Treatment must start within 90 days after the accident unless delayed by a medical condition
A sound tooth is any tooth that did not require restorative treatment immediately before the accident. A natural tooth is any tooth that has not been artificially replaced
No benefits are paid for:
- Duplicate x-rays, custom fluoride appliances, any oral hygiene instruction and nutritional counselling
- The following endodontic services - root canal therapy for primary teeth, isolation of teeth, enlargement of pulp chambers and endosseous intra coronal implants
- The following periodontal services - topical application of antimicrobial agents, subgingival periodontal irrigation, charges for post surgical treatment and periodontal re-evaluations
- The following oral surgery services - implantology, surgical movement of teeth, services performed to remodel or recontour oral tissues (other than minor alveoloplasty, gingivoplasty and stomatoplasty) and alveoloplasty or gingivoplasty performed in conjunction with extractions. Services for remodeling and recontouring oral tissues will be covered under Major Coverage
- Hypnosis or acupuncture
- Veneers, recontouring existing crowns, and staining porcelain
- Crowns or onlays if the tooth could have been restored using other procedures. If crowns, onlays or inlays are provided, benefits will be based on coverage for fillings
- Overdentures or initial bridgework if provided when standard complete or partial dentures would have been a viable treatment option.
If overdentures are provided, coverage will be limited to standard complete dentures.
If initial bridgework is provided, coverage will be limited to a standard cast partial denture and restoration of abutment teeth when required for purposes other than bridgework
If additional bridgework is performed in the same arch within 60 months, coverage will be limited to the addition of teeth to a denture and restoration of abutment teeth when required for purposes other than bridgework
Benefits will be limited to standard dentures or bridgework when equilibrated and gnathological dentures, dentures with stress breaker, precision and semi-precision attachments, dentures with swing lock connectors, partial overdentures and dentures and bridgework related to implants are provided
- Expenses covered under another group plan's extension of benefits provision
- Accidental dental injury expenses for treatment performed more than 12 months after the accident, denture repair or replacement, or any orthodontic services
- Expenses private plans are not permitted to cover by law
- Services and supplies you are entitled to without charge by law or for which a charge is made only because you have insurance coverage
- Services or supplies that do not represent reasonable and customary treatment
- Treatment performed for cosmetic purposes only
- Congenital defects or developmental malformations in people 19 years of age or over
- Temporomandibular joint disorders, vertical dimension correction or myofacial pain
- Expenses arising from war, insurrection, or voluntary participation in a riot
How to Make a Claim
- Some dental offices will submit your claim electronically directly to Great-West Life.
- Claims for expenses incurred in Canada may be submitted online. Access GroupNet for Plan Members to obtain a personalized claim form or obtain claim forms from your employer and have your dental service provider complete the form. The completed claim form will contain the information necessary to enter the claim online. To use the online service you will need to be registered for GroupNet for Plan Members and signed up for direct deposit of claim payments with eDetails. For online claim submissions, your Explanation of Benefits will only be available online.
In the event your dentist provides you with a generic claim form that you wish to mail in to Great-West Life, you will need to complete all required information (eg policy number, personal information, etc.)
Claims must be submitted to Great-West Life as soon as possible, but no later than 12 months after the dental treatment.
You must retain your receipt(s) for 12 months from the date you submit your claim to Great-West Life as a record of the transaction, and you must submit it to Great-West Life on request.
- For all other Dentalcare claims, access GroupNet for Plan Members to obtain a personalized claim form or obtain claim form from your employer. Have your dental service provider complete the form and return it to the Great-West Life Benefit Payment Office as soon as possible, but no later than 12 months after the dental treatment.