Aetna PPO Dental Plan

Transcription

1 S U M M A R Y P L A N D E S C R I P T I O N L3 Technologies, Inc. Aetna PPO Dental Plan Effective January 1, 2017

2 Table of Contents The Aetna PPO Dental Plan 1 Before You Begin 1 Eligibility and Participation 2 Who s Eligible 2 Enrolling for Coverage 4 When Coverage Begins 7 Medical Child Support Orders 7 Cost of Coverage 8 Waiving Coverage 8 How the Plan Works 9 How Eligible Dental Expenses Are Defined 9 How To Use the Plan 9 Sharing in the Cost of Your Dental Expenses 10 Maximum Benefits 11 Pre-treatment Estimate 11 Aetna Member Services 12 Covered Dental Expenses 13 Preventive Dental Services 13 Basic Dental Services 14 Major Dental Services 15 Orthodontia Services 16 Benefits When Alternate Procedures Are Available 17 Prosthesis Replacement 17 What s Not Covered Under the Plan 18 How Benefits Can Be Forfeited or Lost 19 How To Claim Benefits 20 When To File Claims 20 When You Need To Support Your Claim 20 Proof and Payment of Claims 21 Payment of Benefits 21 Filing Claims When You Are Covered by More Than One Plan 21

3 Other Information You Should Know 22 Your Rights as a Patient 22 How Benefits Are Coordinated With Other Coverage 22 Subrogation and Reimbursement 25 Claim Fraud 27 Overpayment of Benefits 28 Continued Coverage Under the Federal Family and Medical Leave Act 28 When Coverage Ends 28 Extended Coverage 29 COBRA Continuation Coverage 29 Continued Coverage During a Military Leave of Absence 34 Ownership of Benefits 34 Plan Administration 35 Compliance With Federal Law 35 Claims Procedures 36 Confidentiality of Health Care Information 41 No Right to Continued Employment 41 Future of the Plan 42 Your Rights Under ERISA 43 Prudent Actions by Plan Fiduciaries 43 Enforcing Your Rights 44 Assistance With Your Questions 44 Plan Facts 45 Glossary 46

4 The Aetna PPO Dental Plan L3 Technologies, Inc. ( L3 ) offers the Aetna Preferred Provider Organization (PPO) Dental Plan (the Plan ) to eligible employees in certain business units of L3. The Plan is designed to help you meet the expense of proper dental care. It encourages preventive care and provides financial assistance toward paying for a wide range of other dental services. Please contact the L3 Benefit Center at to find out if the Plan is offered at your business unit. Before You Begin This Summary Plan Description (SPD) describes the most important features of the Plan. We ve tried to explain things in everyday language, but you will come across some words and phrases that have specific meanings within the context of the Plan. To help you understand them, they are italicized when first used and included in the Glossary that starts on page 46. Also be sure to read the Other Information You Should Know section of this SPD for important information and facts about your rights under the Plan. The Plan encourages preventive dental care and covers a wide range of other dental services aetna ppo dental plan 1

5 Eligibility and Participation You can enroll your eligible dependents in the Plan if you enroll, as long as you provide proper documentation (see Enrolling your dependents for coverage, page 4). Who s Eligible Employees. You are eligible to participate in the Plan if it is offered at your business unit and you are: a U.S.-based employee working in the U.S. and regularly scheduled to work 20 hours or more per week; employed in a job classification designated as benefits-eligible; and/or on an approved leave of absence that allows for continuation of benefits. If you are a collectively bargained employee, the terms of your collective bargaining agreement will govern your eligibility. If you have any questions about your eligibility, contact the L3 Benefit Center at Dependents. You can enroll your eligible dependents in the Plan if you enroll, as long as you provide proper documentation (see Enrolling your dependents for coverage, page 4). Your eligible dependents are your spouse and your children, defined as follows. Spouse. Your spouse is your lawfully married spouse. A common-law spouse will also be considered a spouse for Plan purposes, provided the common-law marriage took place in a state that treats common-law marriage as legal marriage and you satisfy applicable state law requirements (including any documentation requirements). Please note that a decree of divorce or legal separation requiring you to provide health coverage for your ex-spouse does not make your ex-spouse eligible for coverage under the Plan (see COBRA Continuation Coverage, page 29 for information about coverage that may be available to an ex-spouse). Children. Dependent children are your children under age 26 for whom proper documentation has been provided, including: your biological children your lawfully adopted children. If you have started legal adoption procedures, the child is considered a dependent if he/she lives with you full-time and depends on you for support. If you are adopting a child from birth, the child is considered a dependent from birth. your stepchildren any other child, including a grandchild, niece, nephew, etc. for whom you have proof of legal guardianship or a court order providing you (or you and your spouse) with sole legal custody, as long as the child lives with you in a parent-child relationship, you provide the sole support to the child and you can claim the child as a dependent on your federal income tax return. If you have started legal guardianship procedures, coverage is effective with the filing of the application. For coverage to continue, you must be appointed a legal guardian within three months of filing your application. Participants claiming that a child qualifies for coverage based on sole custody by the participant or the participant and spouse will be required to complete an affidavit and provide a court order demonstrating satisfaction of Plan requirements. 2 eligibility and participation

6 You may also cover any other dependent children for whom Plan coverage has been court-ordered through a Qualified Medical Child Support Order (QMCSO) or through a National Medical Child Support Notice (NMCSN). See page 7 for more information on QMCSOs and NMCSNs. Continued coverage for handicapped children. While coverage normally ends on the last day of the month in which a dependent child reaches age 26, you can apply for continued coverage for a handicapped dependent child. Children are considered handicapped when they are primarily dependent on you for financial support and maintenance because of a mental or physical condition that started before age 26. You must provide proof to Aetna that your child s handicap began before the child reached age 26, and you must do so within 60 days after the child s 26th birthday. Coverage stays in force for as long as dependent coverage under the Plan continues and the child remains handicapped, as defined above. For all handicapped children age 26 and over, Aetna periodically requires substantiation of the child s continued handicap, which may include a physical exam. Without this proof, coverage will not be continued. Please note: You are required to notify the L3 Benefit Center within 60 days if your child is age 26 or over and no longer meets the criteria described above for continued coverage for handicapped children. Some employees have the option of choosing a different L3 Dental Plan instead of the Aetna PPO Dental Plan. Contact the L3 Benefit Center to find out what other Dental Plan(s), if any, your business unit offers in your area. When family members work for L3. The following eligibility rules apply when multiple family members work for L3: Employees. An employee cannot be enrolled as both an employee and a dependent. If you elect coverage as an employee and are also covered as a dependent by another employee (e.g., your spouse or parent), only the coverage you elect as an employee will be effective. If you are eligible for coverage as both an employee and spouse, and you lose coverage as an employee (e.g., your employment terminates), your spouse must make a new election to cover you as a spouse. Children. Dependent children of married couples who both work for L3 can be enrolled under only one parent s coverage. If you and your spouse work at different L3 business units, you may choose family coverage at either business unit, and enroll either of your children. If two employees elect dependent coverage for the same child, only the coverage that was elected first for that child will be effective. In addition, a person cannot be covered as both an employee and a retiree, or as a dependent of both an employee and a retiree. eligibility and participation 3

7 Enrolling for Coverage Participation in the Plan is not automatic; you must enroll to have coverage. You and your dependents can enroll: within 31 days of your eligibility date; When you enroll your dependents for coverage, you will be required to complete the L3 Dependent Eligibility Questionnaire and provide certain documents to prove that your dependents are eligible. This requirement applies in ALL circumstances in which you may want to enroll a dependent. You will be required to certify your dependents continued eligibility each year during annual enrollment. during the annual enrollment period, which is held in the fall; or within 60 days of a qualifying event (see Making changes mid-year, page 5). HIPAA special enrollment rights. If you decline enrollment for yourself and/or your dependents (including your spouse) because you have other medical insurance or group health plan coverage and the other coverage ends, you may enroll yourself and/or your dependents in the Plan if you request enrollment within 60 days after your other coverage ends. To enroll for coverage, you must provide written proof that your other coverage has ended. Similarly, if you decline coverage because you have other employer-sponsored coverage (such as through your spouse s employer) and the employer stops contributing toward your or your dependents other coverage, you may enroll yourself and/or your dependents in the Plan if you request enrollment within 60 days after employer contributions for your other coverage end. To enroll for coverage, you must provide written proof that employer contributions for your other coverage have ended. In addition, if you have a new dependent as a result of a marriage, birth, adoption or placement for adoption, you may enroll yourself and your dependent(s) if you request enrollment within 60 days after the marriage, birth, adoption or placement for adoption. You must provide documented proof that your dependents are eligible, as described below. To request special enrollment or obtain more information, contact the L3 Benefit Center. Enrolling your dependents for coverage. When you enroll your dependents for coverage, you will be required to complete the L3 Dependent Eligibility Questionnaire and provide certain documents to prove that your dependents are eligible. This requirement applies in ALL circumstances in which you may want to enroll a dependent, whether that s as a new hire, at annual enrollment, or when you have a qualifying event that allows you to add a dependent during the Plan Year (see Making changes mid-year, page 5). L3 reserves the right to confirm any dependent s eligibility at any time, including during annual enrollment or by conducting a formal dependent eligibility audit. Such an audit may be conducted by L3 or by a third party authorized by L3. If you do not respond to an audit request, coverage for your dependents will be terminated. Please note: You are required to notify the L3 Benefit Center within 60 days of any event that affects a dependent s eligibility. 4 eligibility and participation

8 Annual enrollment. L3 holds an annual enrollment each fall during which you can: enroll for coverage; change your previous election; cancel your own and/or your dependents coverage; or add dependent coverage (documentation will be required). The election you make during annual enrollment takes effect on the next January 1 and stays in effect for that full Plan Year unless you have a qualifying event (see Making changes mid-year, below). Choosing a coverage level. You may elect one of the following coverage levels: employee only employee and spouse employee and child(ren) employee and family. Some collective bargaining agreements may provide for different coverage levels. You will be notified which coverage levels are available to you. Making changes mid-year. The IRS requires that your election stays in effect throughout the full Plan Year unless you have a qualifying event. Please note that not all qualifying events enable you to make mid-year changes, and any change you are permitted to make must be directly related to the impact of the event on your benefits or eligibility. For example, it is not a qualifying event if you are a benefits-eligible part-time employee and you become a benefits-eligible full-time employee (or vice versa). Contact the Benefit Center to discuss your specific situation. You can t change your election during the Plan Year unless you have a qualifying event. Not all qualifying events enable you to make mid-year changes, and any change you are permitted to make must be directly related to the impact of the event on your benefits or eligibility. L3 abides by the IRS s definition of qualifying events, which includes: your legal marital status changes (e.g., through marriage, divorce, legal separation or annulment) the number of your dependents changes (e.g., through the birth or adoption of a child; a change in dependent status under the Internal Revenue Code; or the death of a child or spouse) you are required to cover a child pursuant to a Qualified Medical Child Support Order or a National Medical Child Support Notice your spouse or your dependent becomes employed or unemployed you, your spouse or your dependent takes or returns from an unpaid leave of absence your, your spouse s or your dependent s eligibility for benefits changes as a result of employment status changing from full-time to part-time (or vice versa) or from hourly to salaried (or vice versa) your dependent first meets or no longer satisfies the requirements for coverage because he/she reaches the limiting age, or any similar circumstance you, your spouse or your dependent goes on strike or is locked out, or returns from a strike or lockout eligibility and participation 5

9 the coverage options available to you change because you, your spouse or your dependent changes residences or work sites you previously waived participation because you were covered under your spouse s group health plan and you subsequently lose coverage under that plan If you have a qualifying event, you have 60 days from the event to change your coverage election. The change in your election must be due to and consistent with the qualifying event. you, your spouse or your dependent either becomes eligible or loses eligibility for Medicare or Medicaid coverage according to Internal Revenue Service guidelines, there s a significant change in your, your spouse s or your dependent s dental coverage you, your spouse or your dependent makes a change (or a change is made) under another employer group health plan you or your dependent loses eligibility under a Medicaid plan or a state child health insurance plan (SCHIP) you or your dependent becomes eligible for government assistance under a Medicaid plan or an SCHIP designed to help you pay for Plan coverage. If you have a qualifying event, you have 60 days from the event to change your coverage election. The change in your election must be due to and consistent with the qualifying event. (For example, if you are widowed mid-year, you could change from employee and spouse coverage to employee only coverage, but you couldn t drop your coverage.) Effective date of election changes. The effective date of your election change is the date of the qualifying event. For example, if your election change is due to the birth of a child, the change is effective as of the child s date of birth. Likewise, if your election change is due to divorce, coverage for your ex-spouse will be terminated retroactive to the date of the divorce. An election change will not become effective until you provide the required enrollment materials, including appropriate written documentation of the reason for the change. You also will need to complete the L3 Dependent Eligibility Questionnaire and provide certain documents to prove that the dependent is eligible. Contact the L3 Benefit Center as soon as you know that an event is about to take place (or immediately after it takes place) to make sure you allow yourself enough time to take the appropriate action. The L3 Benefit Center will explain the procedure to you. 6 eligibility and participation

10 When Coverage Begins For you. If you enroll for coverage, it starts on your first day at work, unless otherwise specified in your collective bargaining agreement (if applicable). For your dependents. If you enroll your eligible family members when you enroll, their coverage begins when yours does, as long as you have provided the required documentation for each dependent. If a dependent becomes eligible as a result of a qualifying event, coverage for that dependent starts on the date described above as long as you provide appropriate written documentation. If you enroll during the annual enrollment period. If you enroll for coverage during the annual enrollment period held each fall, coverage for you and your enrolled dependents starts on the following January 1. If you change your coverage because of a qualifying event. If a qualifying event occurs (as described on page 5) and you change your coverage as a result of that event, your coverage is effective as described above as long as you provide appropriate written documentation. Medical Child Support Orders If you are eligible for coverage under the Plan, you may be required to provide coverage for your child pursuant to a Qualified Medical Child Support Order (QMCSO) or a properly completed National Medical Child Support Notice (NMCSN). A QMCSO is a judgment, decree or order issued by a state court or agency that creates or recognizes the existence of an eligible child s right to receive health care coverage. A NMCSN is a standardized health care coverage child support notice that is used by state child support enforcement agencies to require children to be enrolled in an employer s group health care plan. The Order or Notice must comply with applicable law and must be approved and accepted as a QMCSO or a NMCSN by the Plan Administrator in accordance with Plan procedures. Contact the L3 Benefit Center at as soon as you know that a qualifying event is about to take place (or immediately after it takes place) to make sure you allow yourself enough time to take the appropriate action. If the Plan receives a QMCSO or a NMCSN requiring you to provide Plan coverage for an eligible child, deductions will be made automatically from your pay beginning as of the date specified in the QMCSO or the NMCSN. To get a free copy of the procedure followed by the Plan in determining whether an order is qualified, contact the L3 Benefit Center or L3 s QMCSO administrator: Aon Hewitt ATTN: L3 Technologies Qualified Order Team P.O. Box 1542 Lincolnshire, IL Phone: Fax: eligibility and participation 7

11 Cost of Coverage You and L3 share the cost of coverage. Your contributions are deducted from your paycheck each pay period. Contact the L3 Benefit Center to find out current contribution amounts. You and L3 share the cost of your coverage. Your contributions are deducted from each paycheck on a pre-tax basis (before taxes are taken out). That means you pay less out of your pocket for coverage than if you were paying on an after-tax basis (after taxes are taken out). Since your share of the cost is deducted from your paycheck on a pre-tax basis, L3 does not withhold federal income taxes, state income taxes (for most states) or Social Security taxes on your contributions. However, keep in mind that, because of the tax savings, you may pay less into Social Security, which means your Social Security benefit could be slightly lower. If you are a collectively bargained employee, the terms of your collective bargaining agreement will govern the cost of coverage. Waiving Coverage You also have the option of waiving participation. However, if you do so and want to enroll later, you will have to wait until the next annual enrollment or until you have a qualifying event, as described on page 5. Written proof of the qualifying event will be required. 8 eligibility and participation

12 How the Plan Works The Plan is designed to help you pay for reasonably necessary dental care. Read this section carefully to fully understand which expenses are covered, and how they re covered, keeping in mind that, as a rule, the Plan covers only those services that are considered essential to good dental health. How Eligible Dental Expenses Are Defined To be considered for reimbursement, a dental service must meet the following three criteria: 1. It must be provided or performed by a dentist (or, for some treatments such as teeth cleaning, by a licensed dental hygienist working under the dentist s supervision). 2. It must be for reasonably necessary dental care. 3. It must be a covered expense. How To Use the Plan The Plan is a fee-for-service dental plan that includes Aetna s Dental Preferred Provider Organization (PPO) feature. You may visit any dentist or specialist you wish. However, depending on whether or not you use a PPO dentist, there are some differences in how the Plan works. If you are on temporary assignment outside the U.S. (that is, assignment outside the U.S. for less than six months) and receive dental care, benefits for covered expenses will be paid on a non-network (non-ppo dentist) basis. Using PPO dentists. When you receive care from a PPO dentist you will pay less, because Aetna has negotiated discounted fees with PPO dentists. Also, PPO dentists usually will file claims for you at no extra charge. For a directory of participating PPO dentists in your area, log in to Aetna Navigator, which you can do from Aetna s website ( In addition to customized provider searches, Navigator makes it easy for you to view Plan facts, check the status of a claim or print forms. Using non-ppo dentists. When you use a non-ppo dentist, you may need to pay the dentist in full at each visit, and then follow the PPO Dental Plan claims procedure. (See page 20.) If a non-ppo dentist charges you more than the reasonable and customary amount (see page 10), in addition to your normal coinsurance you will also have to pay the difference between the reasonable and customary charge and your dentist s charge. For example, if the reasonable and customary charge for a routine checkup is $100 but your dentist charges you $125, you d be responsible for the $25 difference. how the plan works 9

13 Reasonable and customary guidelines. Only charges that fall within the reasonable and customary range are reimbursed under the Plan. Determining Plan reimbursements based on what s considered reasonable and customary applies only to services you receive from non-ppo dentists, since they are the only dentists who will charge more than what s considered reasonable and customary. PPO dentists are contractually obligated to charge the lower, negotiated amounts. You are responsible for any charges over the amount Aetna determines is the reasonable and customary charge. The reasonable and customary charge is determined by Aetna (in accordance with guidelines established by the Health Insurance Association of America) and is the prevailing rate for a particular dental service or supply. First, the reasonable and customary guidelines are established by reviewing the charges made for all services within a given geographic area. Then, the Plan sets its reasonable and customary limits at the 80th percentile of charges, which means the billing practices of 80% of all the dentists in the specific geographic area will be within the Plan s guidelines. (For example, if the reasonable and customary charge for a specific procedure is $200, 80% of the dentists in your area charge $200 or less, with 20% charging more.) You are responsible for any charges in excess of the amount Aetna considers the reasonable and customary charge. If you have a question as to whether or not a particular dental service is covered, contact Aetna Member Services at the number on your ID card. Sharing in the Cost of Your Dental Expenses You share in the cost of your eligible dental expenses through deductibles and coinsurance, as explained below. The deductible. There is no deductible for Preventive Services. However, each participant has to satisfy a $100 deductible each calendar year before the Plan pays benefits for Basic, Major and Orthodontia Services. (These services are described beginning on page 14.) The family deductible is capped at three $100 individual deductibles. If you have employee and child(ren) or employee and family coverage, once three members of your family satisfy their individual $100 deductibles, the entire family is considered to have met the deductible obligation for the rest of that calendar year. Coinsurance. For eligible dental services and supplies, the Plan pays a percentage of the negotiated charge (if you use PPO dentists) or the reasonable and customary charge (if you use non-network dentists). You are responsible for the remaining percentage, known as your coinsurance. Keep in mind that since the negotiated charge is less than the reasonable and customary charge, the dollar amount you pay as your coinsurance will be less when you use PPO dentists. Charges over the reasonable and customary amount. In addition to deductibles and coinsurance, you are also responsible for any expenses over the amount Aetna determines is the reasonable and customary charge. Reasonable and customary is a factor only for non-network dentists charges; PPO dentists are contractually obligated to charge the lower, negotiated amounts. 10 how the plan works

14 Maximum Benefits The most the Plan will pay in a calendar year for each eligible, enrolled person is $2,000 in non-orthodontia benefits. The most the Plan will pay in orthodontia benefits for each eligible, enrolled dependent under age 19 is $2,000 per lifetime. Please note that when you use PPO dentists, you can get more services and supplies before you reach each maximum benefit because PPO dentists generally charge less than non-network dentists. Pre-treatment Estimate The Pre-treatment Estimate is a special feature of the Plan that lets you know which expenses you can expect the Plan to cover and how much will be paid for a particular course of treatment. The Pre-treatment Estimate is an estimate of the amount and scope of benefits payable under the Plan. It is not a guarantee of benefit payments, which are determined when you submit a claim for the actual services and/or supplies rendered during a course of dental treatment. Pre-treatment Estimates are strongly recommended for treatment that is expected to cost more than $400. When to get a Pre-treatment Estimate. A Pre-treatment Estimate is strongly recommended before having a course of dental treatment expected to cost at least $400. This way, you have an idea of what the Plan will pay before you actually have the expense. Understanding what s meant by a course of dental treatment. A course of dental treatment is a planned program of one or more services or supplies provided by one or more dentists to treat a dental condition diagnosed by the attending dentist as a result of an oral examination. A course of treatment starts on the date your dentist first provides a service to correct or treat the diagnosed dental condition. If you go to your dentist and an exam is performed, he or she should advise you of all the problems with your teeth (for example, five cavities and one root canal), not just some of the problems. Whether you choose to have all the work done at once or over a period of time is your decision, but keep in mind that if correcting all the problems will exceed $400, a Pre-treatment Estimate is recommended. What you ll have to provide. When submitting a Pre-treatment Estimate, your dentist should include as much objective diagnostic information as possible, including a full series of x-rays, photographs, pre-treatment diagnostic models and, when necessary, periodontal soft tissue records. If you or your dentist is uncertain about the types of supporting documentation required for your Pre-treatment Estimate, contact Aetna Member Services for a detailed description. (See page 20 for details on required documentation.) how the plan works 11

15 In determining the amount of benefits payable, Aetna will take into account alternate procedures, services or courses of treatment for the dental condition concerned in order to accomplish the appropriate result. How to file a Pre-treatment Estimate. Your dentist should send a description of the proposed procedures to be performed, along with an estimate of charges, to Aetna before treatment starts. (The dental claim form includes the pre-treatment information.) Benefits will then be prestated, which means Aetna will notify you and your dentist of the estimated benefits payable based upon the proposed course of treatment. (Generally, Aetna s Pre-treatment Estimate is considered valid for up to one year from the date it is forwarded to your dentist.) Your dentist can discuss the Pre-treatment Estimate with you. It is then up to you whether or not to proceed with the proposed course of treatment. In determining the amount of benefits payable, Aetna will take into account alternate procedures, services or courses of treatment for the dental condition concerned in order to accomplish the appropriate result. (See Benefits When Alternate Procedures Are Available, page 17, for more information on alternate dental procedures.) Aetna Member Services Contact Aetna Member Services if you want more information regarding a particular PPO provider. Member Services also can answer questions about your benefits and claim status. To reach Member Services, call the number on your ID card, Monday through Friday, 8:00 a.m. to 6:00 p.m., local time zone. Aetna Member Services for the hearing-impaired. If you need to contact Aetna Member Services from a TDD (Telecommunications Device for the Deaf ) telephone, call This line is staffed Monday through Friday, 8:00 a.m. to 6:00 p.m., ET. At other times, callers will receive this message: The office is now closed. Please type your name, Social Security number and TDD telephone number and a representative will get back to you the next business day. Aetna online. You can find out about dentists who participate in the PPO dental network by logging in to Aetna Navigator, which you can do from Aetna s website ( In addition to customized provider searches, Navigator makes it easy for you to view Plan facts, check the status of a claim or print forms. Online directories are updated continually and are available 24 hours a day, seven days a week. When making an appointment with your chosen provider, be sure to confirm that he/she still participates in the Aetna PPO Dental network. Your ID card. You will receive one Plan ID card to access PPO dental benefits. If you have family coverage, you will receive two Plan ID cards: one for you and one for your spouse. Each ID card will list all of your enrolled dependents. Extra ID cards are exclusively available online. Aetna will not provide additional printed ID cards. Your digital ID card is identical to your printed ID card and is accepted by all providers. You can view, download or print your digital ID card from Aetna Navigator or the Aetna Mobile app. 12 how the plan works

16 Covered Dental Expenses Below is a summary of the expenses that are eligible for reimbursement, as well as the percentage of the negotiated charge or the reasonable and customary charge, as applicable, at which they are paid. Preventive Dental Services The Plan will pay 100% of the negotiated charge (for PPO care) or 100% of the reasonable and customary charge (for non-ppo care) for the Preventive Dental Services shown below. There is no annual deductible for these services. Two routine oral examinations by a dentist each calendar year Cleaning of teeth twice each calendar year Topical application of fluoride twice each calendar year for enrolled dependents under age 14 Preventive Dental Services are covered at 100% of the negotiated charge (for PPO care) or 100% of the reasonable and customary charge (for non-ppo care) with no annual deductible. Sealants (limited to one application per tooth every three calendar years for permanent bicuspids and molars only) Vertical bitewing x-rays (limited to one set every 36 months) A full series of routine x-rays for non-emergency dental treatment, subject to the following limitations: not more than one full mouth x-ray series or panorex in any 36-month period; and not more than one set of bitewing x-rays in a calendar year Periapical x-rays (single films) Intra-oral, occlusal view, maxillary or mandibular x-rays. Additional coverage for certain medical conditions. The Plan provides additional benefits for participants with at least one of the following conditions: Pregnancy; Coronary artery disease/cardiovascular disease; Cerebrovascular disease; or Diabetes. If you or your covered dependent has one or more of the covered conditions, the Plan will pay 100% of the negotiated charge (for PPO care) or 100% of the reasonable and customary charge (for non-ppo care) for the services shown below. There is no annual deductible for these services. One additional cleaning per year Scaling and root planing Full mouth debridement One additional periodontal maintenance treatment per year Localized delivery of antimicrobial agents (not covered for pregnancy). how the plan works 13

17 Basic Dental Services After you meet the $100 annual deductible, the Plan will pay 80% of the negotiated charge (for PPO care) or 80% of the reasonable and customary charge (for non-ppo care) for the Basic Dental Services shown below, up to the annual benefit maximum. Basic Dental Services are covered at 80% of the negotiated charge (for PPO care) or 80% of the reasonable and customary charge (for non-ppo care) after the annual deductible, up to the annual benefit maximum. The initial installation of a space maintainer to prevent loss of space for prematurely lost baby molars (deciduous molars). This service is covered for enrolled dependent children to age 12. Amalgam and anterior composite restorations Non-surgical treatment of diseased periodontal structures Periodontal maintenance following active periodontal therapy, limited to two treatments per calendar year Non-surgical endodontic treatment, such as root canal therapy Repair of removable complete or partial dentures Relining or rebasing of dentures, limited to one relining every 24 months Re-cementing of crowns, inlays/onlays or fixed bridgework Repair of fixed bridgework Oral surgery procedures that Aetna considers to be dental in nature Addition of teeth to an existing partial, removable denture Emergency oral examination (limited to one exam per calendar year) Extraction of impacted teeth. Pre-treatment Estimates are strongly recommended before having impacted wisdom teeth removed. General anesthesia and IV sedation, when provided in conjunction with a covered surgical procedure. Restorative replacements. Replacements of existing amalgam or composite fillings will be covered when Aetna determines that the present amalgam or composite filling cannot be made serviceable. 14 how the plan works

18 Major Dental Services After you meet the $100 annual deductible, the Plan will pay 60% of the negotiated charge (for PPO care) or 60% of the reasonable and customary charge (for non-ppo care) for the Major Dental Services shown below, up to the annual benefit maximum. Onlays or crowns Initial insertion of fixed bridgework to replace one or more natural teeth, subject to the Alternate Procedure rule. (See Benefits When Alternate Procedures Are Available, page 17.) Initial placement or replacement of an existing partial denture or fixed bridgework, provided the replacement and/or addition meets the Prosthesis Replacement Rule (See Prosthesis Replacement, page 17) Replacement of an existing removable denture or fixed bridgework by a new prosthesis. Only replacements that meet the Prosthesis Replacement Rule will be covered. (See Prosthesis Replacement, page 17.) Initial insertion of removable, complete or partial dentures to replace one or more natural teeth Endosteal implants. If you have only one missing tooth per arch, one endosseous implant per arch may be covered, including related crowns and prosthodontics, if the tooth was extracted while you are covered under the Plan and all your other teeth are periodontally and endodontically sound, and your remaining teeth are restored to form and function. Coverage is subject to Plan exclusions and limitations. (See Benefits When Alternate Procedures Are Available and Prosthesis Replacement, page 17.) Major Dental Services are covered at 60% of the negotiated charge (for PPO care) or 60% of the reasonable and customary charge (for non-ppo care) after the annual deductible, up to the annual benefit maximum. Occlusal guard for bruxism (limited to one every 36 months). Please note that fees for dentures and partial dentures include relines, rebases and adjustments within six months after installation. Fees for relines and rebases include adjustments within six months after installation. Specialized techniques and characterizations are not eligible. Restorative replacements. Replacements of certain existing dental work will be covered when the following criteria are met: Crowns, inlays and onlays are covered when Aetna determines that the present crown, inlay or onlay cannot be made serviceable. Composite inlays and onlays are not covered by the Plan. Bridges are covered when Aetna determines that the present bridge cannot be made serviceable. In addition, the original bridge had to have been inserted at least eight years prior to its replacement. Also see When You Need To Support Your Claim, page 20, for important information about documentation requirements. how the plan works 15

19 Orthodontia Services After you meet the $100 annual deductible, the Plan will pay 50% of the negotiated charge (for PPO care) or 50% of the reasonable and customary charge (for non-ppo care) for the following Orthodontia Services, up to the lifetime Orthodontia benefit maximum. Diagnosis and treatment plan to correct crooked, crowded or protruding teeth Orthodontia Services are covered at 50% of the negotiated charge (for PPO care) or 50% of the reasonable and customary charge (for non-ppo care) after the annual deductible, up to the lifetime Orthodontia benefit maximum. Braces Examinations and related x-rays Appliances to control harmful habits and for tooth guidance Appliance adjustments. Orthodontia benefits are provided for enrolled dependent children under age 19 only. Benefits may be based on an alternate treatment. (See page 17.) If a course of orthodontic treatment begins before a dependent child becomes eligible for the Plan, benefits are payable only for services rendered following the child s eligibility date. Treatments begun before the child reaches age 19 will continue to be covered after the child turns 19, subject to the $2,000 lifetime Orthodontia maximum benefit. Orthodontia reimbursement through your Health Care FSA. If you make upfront payments for Orthodontia Services, you may use your Health Care Flexible Spending Account or Dental and Vision Flexible Spending Account (whichever applies, if you contribute to an Account) to reimburse yourself for them, even if treatment will extend over more than one Plan Year. To receive reimbursement for your payments, you must submit a copy of the payment schedule showing the start date, length of treatment, total amount, initial upfront payment amount and monthly payment amounts. You must also provide proof of payments made, such as a cancelled check, credit card receipt or bill from a provider indicating payments made. For more information about using your FSA for Orthodontia Services, contact WageWorks, the FSA Administrator, at WageWorks. 16 how the plan works

20 Benefits When Alternate Procedures Are Available Sometimes there are several ways to treat a dental problem, all of which provide acceptable results and are recognized by the profession as appropriate methods of treatment in accordance with broadly accepted national standards of dental practice. When alternate services or supplies can be used, the Plan will cover the least expensive services or supplies necessary to treat the condition. Of course, you and your dentist can still choose the more costly treatment method, in which case you would be responsible for any charges the Plan will not cover. In particular, the following procedures are subject to this rule. Baked porcelain restorations, crowns and jackets. If a tooth can be restored with a material (such as amalgam) but another type of restoration (baked porcelain, for example) is selected by the patient and the dentist, payment will be based on the amalgam procedure, not the more costly treatment chosen by the patient. You should review with your dentist the differences in the cost of alternative treatment. If you use a non-ppo dentist, you are responsible for filing claims with Aetna. Reconstruction. When the patient requires treatment necessary to eliminate oral disease or to replace missing teeth, payment will be based on the applicable percentage of the negotiated charge or the reasonable and customary charge. Prosthesis Replacement Dentures, bridgework and implants are subject to the Plan s Prosthesis Replacement Rule. That means certain replacements or additions to existing dentures, bridgework and implants are covered only when you give proof to Aetna that: the replacement or addition of teeth is required to replace all teeth extracted after the existing denture, bridgework or implant was inserted, and that the work was done while the patient was participating in the Plan the present denture was inserted at least eight years before its replacement and cannot be made serviceable the present fixed bridgework was inserted at least eight years before its replacement and cannot be made serviceable the present implant and implant prosthesis were inserted at least eight years before their replacement and cannot be made serviceable. Immediate upper denture coverage includes limited follow-up care. how the plan works 17

21 What s Not Covered Under the Plan This is a representative list of dental expenses the Plan does not cover in any circumstance. To find out whether an unlisted dental procedure is excluded, contact Aetna Member Services. coinsurance and deductibles a covered person is required to pay This is a representative list of dental expenses the Plan does not cover in any circumstance. To find out whether an unlisted dental procedure is excluded, contact Aetna Member Services. any cosmetic treatment temporary crowns, if billed separately temporary partial dentures, if billed separately any surgical or non-surgical treatment of a temporomandibular joint disorder (TMJ) hospitalization (inpatient or outpatient) for the treatment of teeth, gums and bone, including removal of covered impactions local anesthesia, if billed separately and not as part of the charge for the actual service rendered analgesia for the treatment of teeth, gums and bone, including the removal of a covered impaction, alveoloplasty, exostosis, hyperplastic tissue removal, surgical endodontics, surgical periodontics, restorative, and/or prosthetic treatment of teeth any type of splinting of teeth osteotomies or orthognathic surgery, even when necessary to correct a functional problem topical application of fluoride for anyone over age 14 consultations (procedure code D9310) pulp vitality tests (procedure code D0460) orthodontia treatment rendered before coverage was in place services or supplies to repair or replace an orthodontic appliance procedures to change vertical dimension, even when necessary to correct a functional problem dentistry (including procedures, services, drugs or other supplies) Aetna determines experimental or still under clinical investigation dental expenses for treatment of accidental injury to sound, natural teeth. These may be covered under your medical plan; see your medical plan SPD for details. dental services and supplies entirely or partially covered by any other group benefit plan provided by L3 treatment by someone other than a dentist, except for a licensed dental hygienist cleaning teeth under the supervision and guidance of a dentist charges for services and supplies that any school system is required by law to provide acupuncture therapy services of a resident physician or intern rendered in that capacity charges that are made only because this coverage exists 18 what s not covered

22 charges for missed dental appointments charges that a covered person is not legally obligated to pay charges that are excluded from payment because of the Plan s frequency limitations charges over the amount Aetna determines is the reasonable and customary charge services furnished, paid for or for which benefits are provided or required under any governmental law services furnished, paid for or for which benefits are provided or required because of a covered person s past or present service in the armed forces or government services furnished in connection with any condition arising out of, or in the course of, employment compensable under a Workers Compensation or Employers Liability Law detailed and extensive oral evaluation (procedure code D0160) re-evaluation limited, problem-focused (procedure code D0170) comprehensive periodontal evaluation new or established patient (procedure code D0180) This is a representative list of dental expenses the Plan does not cover in any circumstance. To find out whether an unlisted dental procedure is excluded, contact Aetna Member Services. pulp caps (procedure code D3120) periodontal grafting procedures (procedure codes D4274/D4275) full mouth debridement other drugs and/or medicaments (procedure code D9630) high noble crowns (crowns Aetna determines essential will be paid at the applicable crown allowance) composite fillings on posterior teeth (these will only be paid up to the benefit for an amalgam filling) removal of non-diseased impacted teeth e.g., wisdom teeth How Benefits Can Be Forfeited or Lost Benefits can be forfeited or lost under certain situations. Most of these circumstances are also described in other sections. However, benefit payments also may be forfeited or lost if: you or your beneficiary does not properly file an application for benefits within the time periods required; your claim for benefits and appeals are denied and you do not start legal action to recover benefits under the Plan within two years of the date the initial claim for benefits was filed with Aetna; or you do not furnish information required by Aetna to complete or verify your claim. Your benefits also may be delayed or lost entirely if your current address is not on file with L3 or with Aetna. You should know that benefits are not payable for expenses that dependents may have after they become ineligible for any reason including but not limited to age, divorce or legal separation. what s not covered 19

23 How To Claim Benefits When To File Claims If you use a PPO dentist, the dentist will file claims for you. Contact Aetna Member Services if you need claims assistance. If you use a non-ppo dentist, you are responsible for filing claims with Aetna. You can obtain a dental claim form from the L3 Benefit Center or by contacting Aetna Member Services. You and your dentist should then complete the form, following the printed instructions. Mail your claim, along with any other documentation that may be required, to Aetna at this address: Aetna P.O. Box Lexington, KY When You Need To Support Your Claim When you use a PPO dentist, your dentist will file claims for you and will provide Aetna with additional information needed to support your claim. To avoid a processing delay when you use a non-ppo dentist, be sure to include all pertinent information that may be required when you submit your claim. Be sure all supporting information is well identified and attached to the claim form. It is the responsibility of you and your provider to provide Aetna with all required information to support your claim. The following guidelines will help you in your effort to submit a complete claim. Your provider also may want to visit for detailed instructions on submitting documentation in support of a claim. Dental Service New restorations (fillings, crowns, veneers, etc.) Removal of impacted wisdom teeth with pre-treatment x-ray What You Must Submit Pre-treatment x-rays, photos or study models Pre-treatment x-ray, which views the pathology and impacted tooth; a copy of the treatment record substantiating the problematic tooth Endodontic treatment Pre-treatment x-ray, which views the extent of disease or injury; additional clinical exam information on the need for endodontic therapy Denture and bridges (initial) Prosthesis replacements Scalings, root planings and periodontal surgery Endosteal implants Pre-treatment full-mouth x-rays, which view the extent of the disease; dates of extraction for teeth to be replaced; tooth numbers of all missing teeth Dental or laboratory records to substantiate the date the appliance was initially installed; dates of extraction for teeth to be replaced; tooth numbers of all missing teeth; date of prior prosthetic placement (fixed and/or removable dentures, and rationale); rationale for replacement, if applicable Pre-treatment full series of x-rays; a copy of a soft-tissue exam chart Pre-treatment full-mouth x-rays; dates of extraction for tooth to be replaced; tooth numbers of all missing teeth 20 claiming benefits