Dental Benefits Summary
Page 1
Gold
Passive PPO
With PPOII and ExtendSM Networks
Annual Deductible*
Individual
Family
Preventive Services
Basic Services
Major Services
Annual Benefit Maximum
Office Visit Copay
Orthodontic Services (Adult and Child)
Orthodontic Deductible
Orthodontic Lifetime Maximum
*The deductible applies to: Basic & Major services only
$50
$150
100%
80%
80%
$2500
N/A
50%
None
$2000
Partial List of Services
Preventive
Passive PPO
With PPOII and ExtendSM Networks
Oral examinations (a)
100%
Cleanings (a) Adult/Child
100%
Fluoride (a)
100%
Sealants (permanent molars only) (a)
100%
Bitewing Images (a)
100%
Full mouth series Images (a)
100%
Space Maintainers
100%
Basic
Root canal therapy
Anterior teeth / Bicuspid teeth
80%
Root canal therapy, molar teeth
80%
Scaling and root planing (a)
80%
Gingivectomy (a)*
80%
Amalgam (silver) fillings
80%
Composite fillings
80%
Dental Benefits Summary
Page 2
Gold
Stainless steel crowns
80%
Incision and drainage of abscess*
80%
Uncomplicated extractions
80%
Surgical removal of erupted tooth*
80%
Surgical removal of impacted tooth (soft tissue)*
80%
Osseous surgery (a)*
80%
Surgical removal of impacted tooth (partial bony/ full bony)*
80%
General anesthesia/intravenous sedation*
80%
Crown
Lengthening
80%
Major
Inlays
80%
Onlays
80%
Crowns
80%
Full & partial dentures
80%
Pontics
80%
Denture
repairs
80%
Crown Build-Ups
80%
Implants
80%
*Certain services may be covered under the Medical Plan. Contact Member Services for more details.
(a) Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certificate.
Other Important Information
This Aetna Dental® Preferred Provider Organization (PPO) benefits summary is provided by Aetna Life Insurance
Company for some of the more frequently performed dental procedures.
Under the Dental Preferred Provider Organization (PPO) plan, you may choose at the time of service either a PPO
participating dentist or any nonparticipating dentist. With the PPO plan, savings are possible because the participating
dentists have agreed to provide care for covered services at negotiated rates. Non-participating benefits are subject to
recognized charge limits.
Out-of-Network plan payments are based on the 70th percentile of prevailing charges for the geographic area.
Emergency Dental Care
If you need emergency dental care for the palliative treatment (pain relieving, stabilizing) of a dental emergency, you are
covered 24 hours a day, 7 days a week.
Dental Benefits Summary
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Gold
When emergency services are provided by a participating PPO dentist, your co-payment/coinsurance amount will be based
on a negotiated fee schedule. When emergency services are provided by a non-participating dentist, you will be
responsible for the difference between the plan payment and the dentist's usual charge. Refer to your plan documents for
details. Subject to state requirements. Out-of-area emergency dental care may be reviewed by our dental consultants to
verify appropriateness of treatment.
Partial List of Exclusions and Limitations* - Coverage is not provided for the following:
1.
Services or supplies that are covered in whole or in part:
(a) under any other part of this Dental Care Plan; or
(b) under any other plan of group benefits provided by or through your employer.
2.
Services and supplies to diagnose or treat a disease or injury that is not:
(a) a non-occupational disease; or
(b) a non-occupational injury.
3.
Services not listed in the Dental Care Schedule that applies, unless otherwise specified in the Booklet-Certificate.
4.
Those for replacement of a lost, missing or stolen appliance, and those for replacement of appliances that have been
damaged due to abuse, misuse or neglect.
5.
Those for plastic, reconstructive or cosmetic surgery, or other dental services or supplies, that are primarily intended to
improve, alter or enhance appearance. This applies whether or not the services and supplies are for psychological or
emotional reasons. Facings on molar crowns and pontics will always be considered cosmetic.
6.
Those for or in connection with services, procedures, drugs or other supplies that are determined by Aetna to be
experimental or still under clinical investigation by health professionals.
7.
Those for dentures, crowns, inlays, onlays, bridgework, or other appliances or services used for the purpose of
splinting, to alter vertical dimension, to restore occlusion, or to correct attrition, abrasion or erosion.
8.
Services that Aetna defines as not necessary for the diagnosis, care or treatment of the condition involved. This applies
even if they are prescribed, recommended or approved by the attending physician or dentist.
9.
Those for services intended for treatment of any jaw joint disorder, unless otherwise specified in the Booklet-Certificate.
10.
Those for space maintainers, except when needed to preserve space resulting from the premature loss of deciduous
teeth.
11.
Those for orthodontic treatment, unless otherwise specified in the Booklet-Certificate.
12.
Those for general anesthesia and intravenous sedation, unless specifically covered. For plans that cover these
services, they will not be eligible for benefits unless done in conjunction with another necessary covered service.
13.
Those for treatment by other than a dentist, except that scaling or cleaning of teeth and topical application of fluoride
may be done by a licensed dental hygienist. In this case, the treatment must be given under the supervision and guidance
of a dentist.
Dental Benefits Summary
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Gold
14.
Those in connection with a service given to a person age 5 or older if that person becomes a covered person other than
(Does not apply to Maine contract state and Maine residents):
(a) during the first 31 days the person is eligible for this coverage, or
(b) as prescribed for any period of open enrollment agreed to by the employer and Aetna. This does not apply to
charges incurred:
(i) after the end of the 12-month period starting on the date the person became a covered person; or
(ii) as a result of accidental injuries sustained while the person was a covered person; or
(iii) for a primary care service in the Dental Care Schedule that applies as shown under the headings
Visits and Exams, and X-rays and Pathology.
15.
Services given by a nonparticipating dental provider to the extent that the charges exceed the amount payable for the
services shown in the Dental Care Schedule that applies.
16.
Those for a crown, cast or processed restoration unless:
(a) it is treatment for decay or traumatic injury, and teeth cannot be restored with a filling material; or
(b) the tooth is an abutment to a covered partial denture or fixed bridge.
17.
Those for pontics, crowns, cast or processed restorations made with high-noble metals, unless otherwise specified in
the Booklet-Certificate.
18.
Those for surgical removal of impacted wisdom teeth only for orthodontic reasons, unless otherwise specified in the
Booklet-Certificate.
19.
Services needed solely in connection with non-covered services.
20.
Services done where there is no evidence of pathology, dysfunction or disease other than covered preventive services.
Any exclusion above will not apply to the extent that coverage of the charges is required under any law that applies to the
coverage.
*This is a partial list of exclusions and limitations, others may apply. Please check your plan booklet for details.
Your Dental Care Plan Coverage Is Subject to the Following Rules:
Replacement Rule
The replacement of; addition to; or modification of: existing dentures; crowns; casts or processed restorations; removable
denture; fixed bridgework; or other prosthetic services is covered only if one of the following terms is met:
The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or
bridgework was installed. This coverage must have been in force for the covered person when the extraction took place.
The existing denture, crown; cast or processed restoration, removable denture, bridgework, or other prosthetic service
cannot be made serviceable, and was installed at least 7 years before its replacement.
Dental Benefits Summary
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Gold
The existing denture is an immediate temporary one to replace one or more natural teeth extracted while the person is
covered, and cannot be made permanent, and replacement by a permanent denture is required. The replacement must take
place within 12 months from the date of initial installation of the immediate temporary denture.
The extraction of a third molar does not qualify. Any such appliance or fixed bridge must include the replacement of an
extracted tooth or teeth.
Alternate Treatment Rule: If more than one service can be used to treat a covered person’s dental condition, Aetna may
decide to authorize coverage only for a less costly covered service provided that all of the following terms are met:
(a) the service must be listed on the Dental Care Schedule;
(b) the service selected must be deemed by the dental profession to be an appropriate method of treatment; and
(c) the service selected must meet broadly accepted national standards of dental practice.
If treatment is being given by a participating dental provider and the covered person asks for a more costly covered service
than that for which coverage is approved, the specific copayment for such service will consist of:
(a) the copayment for the approved less costly service; plus
(b) the difference in cost between the approved less costly service and the more costly covered service.
Finding Participating Providers
Consult Aetna Dentals online provider search for the most current provider listings. Participating providers are
independent contractors in private practice and are neither employees nor agents of Aetna Dental or its affiliates. The
availability of any particular provider cannot be guaranteed, and provider network composition is subject to change
without notice. For the most current information, please contact the selected provider or Aetna Member Services at the
toll-free number on your online ID card, or use our Internet-based provider search available at www.aetna.com.
Specific products may not be available on both a self-funded and insured basis. The information in this document is
subject to change without notice. In case of a conflict between your plan documents and this information, the plan
documents will govern.
In the event of a problem with coverage, members should contact Member Services at the toll-free number on their online
ID cards for information on how to utilize the grievance procedure when appropriate.
All member care and related decisions are the sole responsibility of participating providers. Aetna Dental does not provide
health care services and, therefore, cannot guarantee any results or outcomes.
Dental plans are provided or administered by Aetna Life Insurance Company, Aetna Dental Inc., Aetna Dental of
California Inc. and/or Aetna Health Inc.
Telehealth Services: the plan will reimburse the treating or consulting provider for the diagnosis, consultation, or treatment
of an enrollee via telehealth on the same basis and to the same extent that the plan would reimburse the same covered
in-person service.
In Texas, the Dental Preferred Provider Organization (PPO) is known as the Participating Dental Network (PDN), and is
administered by Aetna Life Insurance Company.
Dental Benefits Summary
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Gold
This material is for informational purposes only and is neither an offer of coverage nor dental advice. It contains only a
partial, general description of plan or program benefits and does not constitute a contract. The availability of a plan or
program may vary by geographic service area. Certain dental plans are available only for groups of a certain size in
accordance with underwriting guidelines. Some benefits are subject to limitations or exclusions. Consult the plan
documents (Schedule of Benefits, Certificate/Evidence of Coverage, Booklet, Booklet-Certificate, Group Agreement,
Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to
your plan.
Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently
based on their race, color, national origin, sex, age, or disability.
Aetna provides free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call 877-238-6200.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above,
you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705),
.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights
Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human
Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019,
800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).
WALGREEN CO.
Effective Date: 01-01-2024
