[PDF] Aetna Student Health Aetna PPO Dental Plan Design and Benefits

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AetnaStudentHealth

AetnaPPODentalPlanDesignand

BenefitsSummary

PolicyYear:2016Ͳ2017

PolicyNumber474968

www.aetnastudenthealth.com (888)Ͳ238Ͳ4825 2

CoveragePeriods

coveragedatesontheCertificateofCoverage. theinsuredstudent'scoverageis describedintheCertificateofCoverage. Rates

2016Ͳ2017DentalPlanRates

AnnualNewSpringStudents

StudentOnly$332.00$332.00

AddSpouse/DomesticPartner$328.00$328.00

Add1Child$242.00$242.00

Add2ormoreChildren$484.00$484.00

CoveragePeriods

Deadline

Annual08/01/201607/31/201709/19/2016

3

VirginiaTech2016Ͳ2017Page3

StudentCoverage

Eligibility

coveragebecomeseffective. fulfilltheeligibility

DependentCoverage

Eligibility

totheageof19.

PreferredProviderNetwork

,forthemostcurrentproviderlistings. www.aetna.com. coveredservices. youradvantagetouseaPreferredProvider whenappropriate. 4

VirginiaTech2016Ͳ2017Page4

DescriptionofBenefits

paymentof benefits.

PolicyYearMaximum$750

PreferredCareNonͲPreferredCare

DEDUCTIBLE*

*Thedeductibleappliesto:

Basic&MajorServicesonlyIndividual:

$50

Family:

$150Individual: $50

Family:

$150

PREVENTIVESERVICES100%

ofthenegotiatedcharge100% oftherecognizedcharge

BASICSERVICES80%

ofthenegotiatedcharge60% oftherecognizedcharge

MAJORSERVICES50%

ofthenegotiatedcharge40% oftherecognizedcharge

ORTHODONTICSNotCoveredNotCovered

CoveredPreventiveServices

VisitsandXͲRays

underage14)

Sealants;per

only;andtochildrenunderage14)

BitewingXͲrays(limitedto1setperyear)

panoramicfilmlimitedto1set every5years) 5

VisitsandXͲRays(continued)

• Professionalvisitafterhours(paymentwillbemadeonthebasisofservicesrenderedorvisit; whicheverisgreater) • Emergencypalliativetreatment;pervisit

XͲRayandPathology

• PeriapicalxͲrays(singlefilmsupto13) • Upperorlower jaw;extraͲoral

OralSurgery

• Extractions • Exposedrootoreruptedtooth •Surgicalremovaloferuptedtooth • ImpactedTeeth •Removaloftooth(softtissue) • OdontogenicCystsandNeoplasms oIncisionanddrainageofabscess oRemovalofodontogeniccystortumor •OtherSurgicalProcedures oAlveoplasty; oClosureofsalivaryfistula oExcisionofhyperplastictissue oRemovalofexostosis o

Transplantationoftoothortoothbud

oClosureoforalfistulaofmaxillarysinus oSequestrectomy oCrownexposure toaideruption oRemovalofforeignbodyfromsofttissue oFrenectomy oSutureofsofttissueinjury

Periodontics

• Occlusaladjustment(otherthanwithanapplianceorbyrestoration) • Rootplanningandscaling;perquadrant(limitedto4separatequadrantsevery2years) • Rootplanningandscaling-1to3 • Gingivectomy;perquadrant(limitedto1perquadrantevery3years) • Gingivectomy;1to3teethperquadrant;limitedto1persiteevery3years • GingivalflapprocedureͲperquadrant(limitedto1perquadrantevery3years) • Gingivalflapprocedure-1to3teethperquadrant(limitedto1persiteevery3years) • Periodontalmaintenanceproceduresfollowingactivetherapy(limitedto2peryear) • Localizeddeliveryofchemotherapeuticagents 6

Endodontics

• Pulpcap • Pulpotomy • Apexification/recalcification • Apicoectomy • RootcanaltherapyincludingnecessaryXͲrays oBicuspidAnterior oBicuspid •Amalgam restorations formolars) •Pins •Pinretention - pertooth;inadditiontoamalgamorresinrestoration • Prefabricatedstainlesssteel • Prefabricatedresincrown(excludingtemporarycrowns) • Recementation oInlay o Crown oBridge

CoveredMajorServices

OralSurgery

• ImpactedTeeth oRemovaloftooth(partiallybony) oRemovaloftooth(completelybony)

Periodontics

• Osseoussurgery(includingflapandclosure);1to3teethperquadrant;limitedto1per quadrant;every5years • Osseoussurgery(includingflapandclosure);perquadrant;limitedto1persite;every5 years •Softtissuegraftprocedures

Endodontics

• RootcanaltherapyincludingnecessaryXͲrays •Molar toothisanabutment • Inlays/OnlaysͲMetallicorPorcelain/Ceramic oInlay;1ormoresurfaces oOnlay;2ormoresurfaces • Inlays/OnlaysͲResinͲbasedcomposite oInlay;1ormoresurfaces o

Onlay;2ormoresurfaces

7

Endodontics(continued)

•LabialVeneers oLaminateͲchairside oResinlaminate-laboratory oPorcelainlaminate-laboratory •Crowns •Resin oResinwithnoblemetal oResinwithbasemetal • Porcelain oPorcelainwithnoblemetal oPorcelainwithbasemetal •Basemetal(fullcast) • Noble metal(fullcast) • Metallic(3/4cast) •Postandcore denturesislimited to1every10years.(SeeReplacementRule.) • Pontics oBasemetal(fullcast) oNoblemetal(fullcast) oBasemetal(fullcast) oPorcelainwithnoblemetal oPorcelainwithbasemetal oResinwithnoblemetal oResinwithbasemeta •RemovableBridge(unilateral) •One • DenturesandPartials(Feesfordenturesandpartialdenturesincluderelines;rebases;and • Feesforrelinesandrebasesincludeadjustmentswithin6monthsafterinstallation. • (Specializedtechniquesandcharacterizationsarenot eligible.) oCompleteupperdenture oCompletelowerdenture restsandteeth) 8

Endodontics(continued)

• Stressbreakers • Interimpartialdenture(stayplate);anterioronly • Officereline oLaboratoryreline oSpecialtissueconditioning;perdenture oRebase;perdenture •Fullandpartialdenturerepairs • Brokendentures;noteethinvolved

Repaircastframework

•Replacingmissingorbroken teeth;eachtooth • Addingteethtoexistingpartialdenture oEachtooth oEachclasp • Repairs:crownsandbridges • Occlusalguard(forbruxismonly);limitedto1every5years installation.) • Fixed(unilateralorbilateral) •Removable(unilateralorbilateral) • Fixedorcementedinhibitingappliancetocorrectthumbsucking coveredsurgicalprocedure)

EmergencyDentalCare*

emergency oftreatment. *Coveredemergencyservicesmay vary,basedonstatelaw. 9

VirginiaTech2016Ͳ2017Page9

Exclusions

In

1. Apicoectomy(dentalrootresection);rootcanaltreatment.

2. Cosmeticservicesandsuppliesincludingplasticsurgery;reconstructivesurgery;cosmeticsurgery;

improvealter

3. Crown;inlaysandonlays;andveneersunless:

material;or

4. Dentalimplants;falseteeth;prostheticrestorationofdentalimplants;plates;dentures;braces;

mouthguards;andotherdevicestoprotect,

5. Servicesandsuppliesprovidedforthecoveredperson'spersonalcomfortorconvenience,orthe

quotesdbs_dbs24.pdfusesText_30

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