If you use an out–of–network (non–PPO) dentist, the Trust will pay the amount indicated in the second (2nd) column of the fee schedule regardless of how much your out-of-network dentist charges for the services. You will be responsible for all charges over and above that amount. After you have met the annual plan maximum, you will be responsible for all charges incurred for the remainder of the year.

Listed fees do not guarantee coverage. Covered services are determined by the Summary Plan Document. Please refer to the Teachers Health Trust Summary Plan Document available on this website for covered benefits. You can also contact the Teachers Health Trust Service Department for more information on covered services.

The out–of–network dental fee schedule, effective as of January 1, 2010, is displayed below.

Get a Printable Version of The 2010 Out–Of–Network Dental Fee Schedule