Dental Coverage

This page outlines your extended dental care covered expenses, limitations and exclusions.

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. These limits are based on the Ontario General Practitioner Dental Fee Guide and there is a two year delay on this fee guide. For example, 2022 claims will be based on the 2020 fee guide.

The plan covers basic preventative services, at 50% and 20% of minor restorative/surgical services 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 annual limit of $250 per person for basic preventative, minor restorative and surgical procedures.. 

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 covers eligible expenses up to an annual limit of $250 per person for basic preventative, minor restorative and surgical procedures. 

Expenses are subject to the Ontario General Practitioner Dental Fee Guide with a two year delay.

Specifics of coverage

Basic and preventative  services

The services below are considered “basic and preventative services” and are eligible for 50% reimbursement to the limits indicated. All reimbursement is based on the Ontario General Practitioner Dental Fee Guide with a two year delay.

Minor restorative and surgical services

The services below are considered “minor restorative and surgical services” and are eligible for 20% reimbursement to the limits indicated. All reimbursement is based on the Ontario General Practitioner Dental Fee Guide with a two year delay.

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 Ontario Dental Association (ODA) General Practitioner Fee Guide is used to determine the maximum that the Plan will pay for each dental service. There is a two year delay on this fee guide. For example, 2022 claims will be based on the 2020 fee guide.

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.