Dental Benefits Summary
Page 3
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.