Dental Coverage
This page outlines your extended dental care covered expenses, limitations and exclusions.
The cost of the retiree plan is fully paid for by the participating members. Premiums are adjusted annually on May 1st.
Policy details, premiums and rate comparisons can be found by visiting Policy Administration.
What coverage does the Dental Plan provide?
Your Dental Plan coverage is described below. Eligible expenses are reimbursed at the percentage shown, up to the limits stated based on reasonable and customary amounts suggested in the current Ontario General Practitioner Dental Fee Guide.
When the plan does not cover an expense at 100%, employees are responsible to pay for the portion not covered. For example, if you have a claim for an eligible major restorative treatment, the plan will reimburse you 65% of the total cost up to the Ontario General Practitioner Dental Fee Guide maximum. You will pay the remainder of the cost.
If an expense is not eligible under the Dental Plan, you are responsible for its cost. See Excluded expenses for a list of ineligible expenses.
If your dentist recommends a treatment or service that is not mentioned, call Sun Life at 1-800-361-6212. They will help you determine if the expense is covered and if it is subject to any restrictions.
Is there an upper limit to my reimbursement under the Dental Plan?
The plan covers eligible expenses up to an unlimited overall lifetime maximum, but some eligible expenses are subject to maximums or limitations.
Please note that each eligible expense is allocated to the benefit year in which it is incurred. The benefit year runs from January 1 to December 31 each year.
What is the coverage maximum?
The plan pays 100% of many eligible routine dental expenses and 65% of major restorative services subject to a combined annual limit of $3500. Additionally, the plan covers 50% of orthodontic services per person per year with no annual dollar limit.
Expenses are subject to the Ontario General Practitioner Dental Fee Guide.
Specifics of coverage
Preventative, restorative and surgical services
The services below are considered “preventative, restorative and surgical services” and are eligible for 100% reimbursement to the limits indicated. All reimbursement is based on the current Ontario General Practitioner Dental Fee Guide.
Description of services
- polishing teeth
Maximums and limitations
- must be separated by at least five months, limited to two per benefit year
Description of services
- root canal therapy and root canal fillings
- treatment of diseases of the pulp tissue, including pulpcapping, pulpotomy, periapical services, and other endodontic procedures
- emergency endodontic procedures
Description of services
- covered types: amalgam, silicate, acrylic, composite resin
- transitional restoration of fractured anterior teeth
- steel crowns on primary teeth
- cement
Description of services
- topical application of fluoride
- polishing
Maximums and limitations
- must be separated by at least five months, limited to two per benefit year
Description of services
- treatment of diseases of the gums and other supporting tissues of the teeth
Maximums and limitations
- occlusal equilibration may not exceed 8 units per year
- see also Scaling
Description of services
- complete examinations
- recall examinations
- emergency or specific examinations
Maximums and limitations
- recall examinations must be separated by at least five months, limited to two per benefit year
Maximums and limitations
- only reimbursed for persons under age 19
Description of services
- scraping teeth to remove tartar
Maximums and limitations
- scaling may not exceed 16 units per year
Description of services
- uncomplicated removals
- surgical removals and repositioning
- surgical excision or incision
- fractures, lacerations, frenectomy, and miscellaneous surgical services
Maximums and limitations
- excludes implants, transplants, and repositioning of the jaw
Description of services
- diagnostic and laboratory services
- includes biopsy of oral tissue and pulp vitality tests
Maximums and limitations
- see About the dental fee guide for limitations on laboratory charges
Description of services
- X-rays to diagnose a symptom or examine progress of a particular course of treatment, including: full-mouth, bitewing, periapical, occlusal, or extra oral X-rays; sialography; fistulography; cystography; tomography; and panoramic
- radiopaque dyes to demonstrate lesions
- interpretation of X-rays received from another source
Maximums and limitations
- full-mouth X-rays (panographic or panoramic) once in any 24-month period
- bitewing X-rays every five months, limited to two per benefit year
- periapical X-rays limited to one complete series every 24 months
Description of services/Maximums and limitations
- anaesthesia related to any routine services
- antibiotic drug injections by the attending dentist
- consultations that are required with another dentist
- dentures: rebasing or relining of an existing partial or complete denture
- emergency or pain relief services
- extractions (removal of teeth and related anaesthesia)
- house calls, institutional calls, and office visits
- prefabricated metal restorations and repair, other than in conjunction with the placement of permanent crowns
- space maintainers (provision of)
Major restorative services
The services below are considered "prosthodontic procedures" and are eligible for 65% reimbursement, up to the limits indicated. All reimbursement is based on the current Ontario General Practitioner Dental Fee Guide.
Description of services
- bridge pontics, retainers, abutments, and other prosthetic services
- construction and insertion and repairs
Maximums and limitations
- the fee for a replacement bridge is not an eligible expense during the five-year period following the construction or insertion of a previous bridge, unless it is needed to replace one which has caused temporomandibular joint disturbances (TMJ), and which cannot be economically modified to correct the condition
Description of services
- crowns and their repairs
Maximums and limitations
- does not include prefabricated metal restorations (covered under Routine services)
Description of services
- construction and insertion of implants to replace a tooth or teeth
Maximums and limitations
- coverage is limited to a maximum eligible expense of the value and quality of the appropriate denture (where a complete denture is the only alternative treatment) or bridge, which would have been placed had implants not been selected
- a treatment plan and a request for pre-determination must be submitted to Sun Life prior to the commencement of treatment or the claim will be denied
- payment will be approved up to the maximum of the appropriate alternative treatment procedure
- if some type of appliance is already replacing missing teeth, coverage for dental implants will only be eligible if the appliance is greater than 5 years old
Description of services
- complete dentures, partial dentures, and partial denture additions
- construction and insertion and repairs
Maximums and limitations
The fee for a replacement standard denture is not an eligible expense during the five-year period following the construction or insertion of a previous standard denture, unless one of the following situations occurs:
- it is needed to replace one which has caused temporomandibular joint disturbances (TMJ), and which cannot be economically modified to correct the condition, or
- it is needed to replace a transitional denture which was inserted shortly following extraction of teeth and which cannot be economically modified to the final shape required
Description of services
- metal or porcelain restorations
Description of services
- surgical services and related anaesthesia
Maximums and limitations
- excludes removal of impacted teeth (covered under Routine services), implants, transplants, or repositioning of the jaw
Description of services
- surgical services
- post-surgical treatment
- adjunctive procedures
- post-treatment evaluation
Orthodontic procedures
The services below are considered “orthodontic procedures” and are eligible for up to 50% reimbursement to the limits indicated. All reimbursement is based on the current Ontario General Practitioner Dental Fee Guide.
Description of services
- oral examinations
- skull and facial bone surveys
- cephalometric radiographs
- diagnostic casts
- surgical services
- observation, adjustments
- removable or fixed appliances, repairs, and alterations
- active appliances for tooth guidance or uncomplicated tooth movement
- retention appliances
Maximums and limitations
- does not include space maintainers (covered under Routine services)
Description of services
- treatment utilizing removable or fixed appliances, or a combination of both
- includes diagnostic procedures, formal treatment, and retention
The cost of the implant procedure will be eligible, providing that the cost to the University does not exceed the cost of conventional procedures currently provided under the Dental Plan and providing that the treatment is not for cosmetic purposes. Conventional procedures currently provided under the Dental Plan include bridgework or dentures. Benefits will be reimbursed based on the coinsurance level applicable to the plan member's benefit group.
Eligible plan members and their eligible dependents requiring major restorative dental treatment.
- A treatment plan and request for predetermination must be submitted to Sun Life prior to commencement of treatment. A claim will not be considered valid in the absence of a treatment plan.
- Sun Life will approve payment up to the maximum eligible expense of the appropriate alternate treatment procedure according to the Ontario General Practitioner Dental Fee Guide.
- Sun Life will advise the plan member of the dollar amount that will be reimbursed prior to the person deciding upon a procedure.
- Payment will be limited to the predetermination amount stated.
- arranging for the dental practitioner to prepare a treatment plan outlining the entire procedures and charges for the dental implant and request for predetermination
- deciding upon the course of treatment in consultation with the dental practitioner
- responding to the treatment plan with a predetermination, which outlines the implant procedure and the dollar amount allowed based on the maximum eligible expense of the appropriate alternative treatment
- liaising with the dental practitioner/plan member in the event clarification of the treatment plan is required
- paying the claim based on the cost of the appropriate alternative treatment
- adjudicating in the matters of disputes
- coverage is limited to teeth extracted while the member is covered under the TMU Dental plan or in the case where the member already has some type of appliance replacing the missing teeth, the appliance must be greater than five years old
- payment for implants will not be approved for cosmetic purposes. If there are no natural teeth missing then an implant or any type of replacement is not an eligible expense
- charges for replacement implants are not an eligible expense during a 5-year period following the construction/insertion of the initial appliance
Out-of-country coverage
The plan will reimburse your expenses up to the amount that would have been paid if the work had been done in Ontario. The procedures and associated costs must also be considered reasonable and customary in the area in which the service was performed.
If the dentist charges more than the fee that would have been paid if the expense was occurred in Ontario, then employees are responsible for paying the excess.
About the Dental Fee Guide
The current Ontario Dental Association (ODA) General Practitioner Fee Guide is used to determine the maximum that the Plan will pay for each dental service.
If your dentist chooses to charge more than the ODA fee guide, the portion of the cost above the recommended fee will not be reimbursed under the Dental Plan. If dental services are performed by a dental specialist, the maximum reimbursement will be 120% of the general practitioners fee guide.
Laboratory charges are limited to 67% of the procedure fee in the ODA fee guide.
Treatments over $200
If you expect a dental treatment to cost $200 or more, SunLife will review the expense in advance. This way you can find out how much the Dental Plan will cover and how much you will be responsible for paying.
How do I receive an advanced review of expenses?
In order to receive an advance review, ask your dentist for a detailed treatment plan – called a “pre-determination”– and then submit it to Sun Life before treatment begins. Alternatively, your dentist can submit the pre-determination electronically to Sun Life.
A pre-determination will identify whether a specific service is covered and clarify the reimbursement percentages and limits that apply. After the treatment is complete, you must submit a regular claim form to obtain reimbursement.
For help completing a pre-determination visit Sun Life’s website (external link) or call Sun Life at 1-800-361-6212.
Excluded expenses
What expenses are not covered by the Dental Plan?
Some expenses have specific maximums as listed under Specifics of Coverage.
Laboratory charges are limited to 67% of the procedure fee in the ODA fee guide.
The plan will not pay any portion of the cost for the following:
- services or treatments that are paid for or covered by any other employer, government plan, or the plan of any political subdivision or law
- replacement of a stolen or mislaid prosthetic device, appliance, or space maintainer
- supplies or services prescribed or recommended before you became insured by the Plan
- initial dentures and bridgework (including crowns and inlays) to replace a tooth or teeth that were congenitally missing before you became insured by the Plan
- cosmetic services
- prosthetic devices which are ordered while covered by the Plan, but installed after your coverage has ended
- charges for appointments not kept or for completion of claims forms
- expenses related to services or supplies normally intended for sport or home use (e.g., mouth guards)
- crowns and inlays placed on an incisor or cuspid tooth that is not functionally impaired
- expenses resulting from the hostile action of any armed forces, insurrection, or participation in a riot or civil commotion
- expenses resulting from participation in any military action in the armed forces of any country or established international authority
- expenses resulting from an attempted or actual criminal offence
- any expense for which indemnity or compensation is provided under any worker’s compensation act, criminal injuries compensation act or similar legislation
- expenses resulting from intentional, self-inflicted injury
For more information contact Sun Life at 1-800-361-6212.
TMU reserves the right, at any time, to amend, change or discontinue any benefit coverage. If there is a question about coverage referred to in any portion of this benefits communication, the master contract from the insurer is the governing document.