Aetna-Dental Plan Exclusion and Limitation
Aetna
Aetna is an American managed health care company that sells traditional and consumer directed health care insurance and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans, primarily through employer-paid (fully or partly) insurance and benefit programs, and through Medicare
The company's network includes 22.1 million medical members, 12.7 million dental members, 13.1 million pharmacy benefit management services members, 1.2 million health-care professionals, over 690,000 primary care doctors and specialists, and over 5,700 hospitals.
PLAN EXCLUSIONS AND LIMITATIONS
Some Services Not Covered Under the Plan Are:
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.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.
3.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.
4.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.
5. 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.
Other Important Information
This benefits summary of the Aetna Dental DMO (Dental Maintenance Organization) provides information on benefits provided when services are rendered by a participating dentist. In order for a covered person to be eligible for benefits, dental services must be provided by a primary care dentist selected from the network of participating DMO dentists. In some states, limited coverage may be available for non-emergency services referred by a nonparticipating provider.
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. You should contact your Primary Care Dentist to receive treatment. If you are unable to contact your PCD, or you are more than 50 miles from your home address, you should contact Member Services for assistance in locating a dentist. If you receive treatment from a non-participating dentist more than 50 miles away from your home, then the emergency services will be covered up to a maximum of $100. You must submit a claim to Aetna in order to receive benefits. 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.
Notes:
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