I was offered wo plans from Aetna, DMO Plan 65 and PPO Dental (no additional identifying information for policy)
I don’t understand why the PPO plan is so much more expensive because it caps coverage per year at $1500 and it groups expenses as type “A”, “B”, “C” without dicating what types of expenses fall into each category. Coinsurance for the categories are 100%, 80%, and 50%
Meanwhile, the DMO plan details different services and specifically dictates the copayment amount for each service. It also doesn’t dictate a plan maximum amount.
It looks like the DMO plan is the better and less expensive plan, but I don’t know anything about insurance so I can’t tell why the PPO plan is more expensive and seemingly worse coverage.
Schedule of Benefits (GR-9N-S-01-001-01 FL) Employer: Group Policy Number: Issue Date: November 8, 2018 Effective Date: October 1, 2018 Schedule: 2A Cert Base: 2 For: PPO Dental This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information. Comprehensive Dental Plan (PPO) Schedule of Comprehensive Dental Benefits (GR-9N-S-21-005-01) PLAN FEATURES NETWORK OUT-OF-NETWORK Calendar Year Deductible Individual $50 Family $150 Individual $50 Family $150 The Calendar Year deductible applies to all covered expenses except Type A Expenses. (GR-9N-S-21-010-01) Please refer to the listing of covered expenses and the percentage payable appearing below. The percentage the plan will pay varies by the type of expense. PLAN COINSURANCE NETWORK COINSURANCE OUT-OF-NETWORK COINSURANCE Type A Expenses 100% 100% Type B Expenses 80% 80% Type C Expenses 50% 50% Calendar Year Maximum Benefit (GR-9N-S-21-010-01) Calendar Year Maximum: $1,500 The most the plan will pay for covered expenses incurred by any one covered person in a Calendar Year is called the Calendar Year Maximum Benefit. The Calendar Year maximum benefit applies to network and out-of-network covered dental expenses combined. GR-9N 2 Expense Provisions (GR-9N-S-09-05-01 FL) The following provisions apply to your health expense plan. This section describes cost sharing features, benefit maximums and other important provisions that apply to your Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the attached health expense sections of this Schedule of Benefits. The insurance described in this Schedule of Benefits will be provided under Aetna Life Insurance Company’s policy form GR-29N. Keep This Schedule of Benefits With Your Booklet-Certificate. Deductible Provisions (GR-9N-S-09-05-01 FL) Network Calendar Year Deductible This is an amount of network covered expenses incurred each Calendar Year for which no benefits will be paid. The network Calendar Year deductible applies separately to you and each of your covered dependents. After covered expenses reach the network Calendar Year deductible, the plan will begin to pay benefits for covered expenses for the rest of the Calendar Year. Out-of-Network Calendar Year Deductible This is an amount of out-of-network covered expenses incurred each Calendar Year for which no benefits will be paid. The out-of-network Calendar Year deductible applies separately to you and each of your covered dependents. After covered expenses reach the out-of-network Calendar Year deductible, the plan will begin to pay benefits for covered expenses for the rest of the Calendar Year. Covered expenses applied to the out-of-network deductible will be applied to satisfy the network deductible and covered expenses applied to the network deductible will be applied to satisfy the out-of-network deductible. Network Family Deductible Limit When you incur network covered expenses that apply toward the network Calendar Year deductibles for you and each of your covered dependents these expenses will also count toward the network Calendar Year family deductible limit. Your network family deductible limit will be considered to be met for the rest of the Calendar Year once the combined covered expenses reach the network family deductible limit in a Calendar Year. Out-of-Network Family Deductible Limit When you incur out-of-network covered expenses that apply toward the out-of-network Calendar Year deductibles for you and each of your covered dependents these expenses will also count toward the out-of-network Calendar Year family deductible limit. Your out-of-network family deductible limit will be considered to be met for the rest of the Calendar Year once the combined covered expenses reach the out-of-network family deductible limit in a Calendar Year. Covered expenses applied to the out-of-network deductible will be applied to satisfy the network deductible and covered expenses applied to the network deductible will be applied to satisfy the out-of-network deductible. Copayments and Benefit Deductible Provisions (GR-9N-09-015-01 FL) Copayment, Copay This is a specified dollar amount or percentage, shown in the Schedule of Benefits, you are required to pay for covered expenses. GR-9N 3 Coinsurance Provisions (GR-9N S-09-020 01) Coinsurance This is the percentage of your covered expenses that the plan pays and the percentage of covered expenses that you pay. The percentage that the plan pays is referred to as the “Plan Coinsurance”. Once applicable deductibles have been met, your plan will pay a percentage of the covered expenses, and you will be responsible for the rest of the costs. The coinsurance percentage may vary by the type of expense. Refer to your Schedule of Benefits for coinsurance amounts for each covered benefit. Maximum Benefit Provisions (GR-9N S-09-025 01) Calendar Year Maximum Benefit The most the plan will pay for covered expenses incurred by any one covered person in a Calendar Year is called the Calendar Year maximum benefit. The Calendar Year maximum benefit will not deny benefits for certain covered expenses in any one Calendar Year. The Calendar Year maximum benefit applies to network care and out-of-network care expenses combined. General (GR-9N-28-01-01-FL) This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your plan of benefits. Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot be accepted. This Schedule is part of your Booklet-Certificate and should be kept with your Booklet-Certificate form GR-9N. Coverage is underwritten by Aetna Life Insurance Company.
Schedule of Benefits (GR-9N-S-01-001-01 FL) Employer: Group Policy Number: Issue Date: November 8, 2018 Effective Date: October 1, 2018 Schedule: 1A Cert Base: 1 For: DMO PLan 65 This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information. Managed Dental Plan Schedule of Managed Dental Benefits (GR-9N-22-005-02 FL) This Schedule Applies to Covered Expenses Provided by Network Providers. Office Visit Copayment $5 per visit. Dental Emergency Maximum: $100 Dental Care Schedule The following dental care schedule shows services that require a copay; and the copay amount. Dental services that are considered covered expenses as shown in the dental care schedule must be given by network providers, at the dental office location. The exceptions to this rule are when Aetna approves referral care, or for out-of-area emergency dental care. In addition to copays for covered expenses shown in the following schedule, you will also be responsible for an office visit copay as shown above. If: A charge is made for an unlisted service given for the dental care of a specific condition; and The list includes one or more services that, under standard practices, are separately suitable for the dental care of that condition, then the charge will be considered to have been made for a service that would have produced professionally acceptable result, as determined by Aetna. GR-9N 2 This Schedule Applies to Services Provided by Network Providers Primary Care Dentist Services (GR-9N-S-22-010-01) Visits and Exams Copayment Amount Oral examination (limited to total of 4 visits per year) $0 Emergency palliative treatment $10 Prophylaxis (cleaning), (limited to 2 treatments per year) Adult $0 Child $0 Topical application of fluoride (limited to 1 treatment per year and to covered persons under age 16) $0 Oral hygiene instruction $0 Sealants, per tooth (limited to 1 application every 3 years for permanent molars and to covered persons under age 16) $0 Pulp vitality test $0 Consultation $0 Diagnostic casts $0 X-Rays and Pathology Bitewing x-rays (limited to 1 set per year) $0 Entire series, including bitewings, or panoramic film, (limited to 1 set every 3 years) $0 Vertical bitewing X-rays (limited to 1 set every 3 years) $0 Periapical x-ray $0 Intra-oral, occlusal view, maxillary or mandibular $0 Extra-oral upper or lower jaw $0 Accession of oral tissue $0 Space Maintainers – (only when needed to preserve space resulting from premature loss of primary teeth) Includes all adjustments within six months after installation Fixed $0 Removable $0 Recement space maintainer $12 Remove fixed space maintainer (by dentist who did not place appliance) $12 Endodontics Pulp cap $0 Pulpotomy $0 Root canal therapy, including necessary x-rays Anterior $50 Bicuspid $70 Restorations and Repairs (Copayments for crowns and pontics are per unit.) There will be an additional patient charge for the actual cost of high noble metal (“gold”) when used for services shown with an asterisk. Amalgam restoration 1 surface $0 2 surfaces $0 3 surfaces $0 4 or more surfaces $0 GR-9N 3 Resin-based composite restoration (anterior) 1 surface $0 2 surfaces $0 3 surfaces $0 4 or more surfaces or incisal angle $40 Resin-based composite crown, anterior $40 Resin-based composite restoration (posterior) 1 surface $35 2 surfaces $45 3 surfaces $55 4 or more surfaces $75 Retention pins $10 Stainless steel crowns, prefabricated, primary tooth $0 Stainless steel crowns, prefabricated, permanent tooth $40 Recementing inlays or crowns $5 Recementing bridges $15 Sedative filling $0 Inlays metallic* $190 Crowns Porcelain $225 Porcelain with metal (includes abutments)* $225 Metallic (full cast) (includes abutments)* $225 Metallic (3/4 cast)* $225 Cast post and core* $80 Prefabricated post and core $70 Core buildup including pins $60 Pontics Metallic (full cast)* $225 Porcelain with metal* $225 Full mouth rehabilitation, per unit (This means 6 or more covered units of crowns and/or pontics under one treatment plan.) $125 Dentures and Partials – (Includes relines, rebases and adjustments within six months after installation. Adjustments within first six months are limited to four.) Complete, upper or lower $275 Partial, upper or lower Resin base $275 Cast metal base $325 Immediate, upper or lower (does not include charge for reline) $325 Adjust complete denture, upper or lower $10 Adjust partial denture, upper or lower $10 Repair broken acrylic, complete denture, upper or lower $30 Replace one tooth on complete denture $35 Repair resin denture base, cast frame, broken clasp $35 Replace broken tooth, partial $35 Add tooth to existing partial denture $35 Add clasp to existing partial $40 Replace all teeth and acrylic on cast metal framework $100 Rebase, complete denture, upper or lower $100 Rebase, partial denture, upper or lower $100 Reline, complete denture, upper or lower (chairside) $40 Reline, partial denture, upper or lower (chairside) $40 Reline, complete denture, upper or lower (laboratory) $90 Reline, partial denture, upper or lower (laboratory) $90 GR-9N 4 Interim partial denture, upper or lower (stayplate), anterior only $90 Tissue conditioning for dentures $40 Periodontics Scaling and root planing, per quadrant (limited to 4 separate quadrants every 2 years) $50 Scaling and root planing -1 to 3 teeth per quadrant (limited to once per site every 2 years) $30 Periodontal maintenance procedures following surgical therapy (limited to 2 per year) $30 Occlusal guard (for bruxism only), limited to 1 every 3 years $100 Oral Surgery – Includes local anesthetics and routine post-operative care Extraction – exposed root or erupted tooth $0 Extraction – coronal remnants – deciduous tooth uncomplicated $0 Surgical removal of erupted tooth $0 Surgical removal of impacted tooth (soft tissue) $0 Incision and drainage of intraoral abscess $10 Mobilization of erupted or malpositioned tooth to aid eruption. $30 Biopsy of oral tissue $50 Specialty Services Copayment Amount Endodontics – Includes local anesthetics where necessary Apicoectomy/periradicular surgery Anterior $65 Bicuspid, first root $65 Molar, first root $80 Each additional root $40 Retrograde filling, per root $20 Root amputation, per root $60 Molar root canal therapy $175 Retreatment of previous root canal therapy Anterior $150 Bicuspid $170 Molar $275 Oral Surgery – Includes local anesthetics where necessary and post-operative care Surgical removal of residual tooth roots $15 Frenectomy $24 Alveoloplasty in conjunction with extractions – per quadrant $18 Alveoloplasty not in conjunction with extractions – per quadrant $25 Surgical removal of impacted tooth Partially bony $45 Completely bony $70 Completely bony with unusual surgical complications $70 Periodontics Gingivectomy or gingivoplasty – per quadrant, limited to 1 per quadrant, every 3 years $100 Gingivectomy or gingivoplasty – 1-3 teeth, limited to 1 per site, every 3 years $30 Gingival flap procedure – per quadrant $110 Gingival flap procedure – 1-3 teeth one per quadrant $66 Occlusal adjustment (other than with an appliance or restoration) Limited $20 Complete $80 Osseous surgery (including flap entry and closure) – per quadrant, limited to 1 per quadrant, every 3 years $250 GR-9N 5 Osseous surgery (including flap entry and closure) – 1 to 3 teeth, limited to once per site every 3 years $150 Surgical revision procedure, per tooth $100 Pedicle soft tissue graft $190 Free soft tissue graft (including donor site surgery) $205 Subepithelial connective tissue graft $115 Soft tissue allograft $230 Combined connective tissue and double pedicle graft $190 Clinical crown lengthening – hard tissue $150 General Anesthesia and Intravenous Sedation – (only when provided in conjunction with a covered surgical procedure) Deep sedation/General Anesthesia First 30 minutes $165 each additional 15 minutes $70 Intravenous conscious sedation/analgesia First 30 minutes $165 each additional 15 minutes $70 Orthodontics Limited to treatment of cleft lip or cleft palate for a child under age 18 ** Oral Surgery – Includes local anesthesia where necessary and post-operative care Cleft lip or cleft palate surgery for a child under age 18 ** **An amount to be determined which is consistent with other covered services in this section as shown in this Schedule of Benefits. Expense Provisions (GR-9N-S-09-05-01 FL) The following provisions apply to your health expense plan. This section describes cost sharing features, benefit maximums and other important provisions that apply to your Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the attached health expense sections of this Schedule of Benefits. The insurance described in this Schedule of Benefits will be provided under Aetna Life Insurance Company’s policy form GR-29N. Keep This Schedule of Benefits With Your Booklet-Certificate. Copayments and Benefit Deductible Provisions (GR-9N-09-015-01 FL) Copayment, Copay This is a specified dollar amount or percentage, shown in the Schedule of Benefits, you are required to pay for covered expenses. General (GR-9N-28-01-01-FL) This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your plan of benefits. Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot be accepted. This Schedule is part of your Booklet-Certificate and should be kept with your Booklet-Certificate form GR-9N. Coverage is underwritten by Aetna Life Insurance Company.
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[link] [comments]I was offered wo plans from Aetna, DMO Plan 65 and PPO Dental (no additional identifying information for policy) I don’t understand why the PPO plan is so much more expensive because it caps coverage per year at $1500 and it groups expenses as type “A”, “B”, “C” without dicating what types of expenses fall into each category. Coinsurance for the categories are 100%, 80%, and 50% Meanwhile, the DMO plan details different services and specifically dictates the copayment amount for each service. It also doesn’t dictate a plan maximum amount. It looks like the DMO plan is the better and less expensive plan, but I don’t know anything about insurance so I can’t tell why the PPO plan is more expensive and seemingly worse coverage. Schedule of Benefits (GR-9N-S-01-001-01 FL) Employer: Group Policy Number: Issue Date: November 8, 2018 Effective Date: October 1, 2018 Schedule: 2A Cert Base: 2 For: PPO Dental This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information. Comprehensive Dental Plan (PPO) Schedule of Comprehensive Dental Benefits (GR-9N-S-21-005-01) PLAN FEATURES NETWORK OUT-OF-NETWORK Calendar Year Deductible Individual $50 Family $150 Individual $50 Family $150 The Calendar Year deductible applies to all covered expenses except Type A Expenses. (GR-9N-S-21-010-01) Please refer to the listing of covered expenses and the percentage payable appearing below. The percentage the plan will pay varies by the type of expense. PLAN COINSURANCE NETWORK COINSURANCE OUT-OF-NETWORK COINSURANCE Type A Expenses 100% 100% Type B Expenses 80% 80% Type C Expenses 50% 50% Calendar Year Maximum Benefit (GR-9N-S-21-010-01) Calendar Year Maximum: $1,500 The most the plan will pay for covered expenses incurred by any one covered person in a Calendar Year is called the Calendar Year Maximum Benefit. The Calendar Year maximum benefit applies to network and out-of-network covered dental expenses combined. GR-9N 2 Expense Provisions (GR-9N-S-09-05-01 FL) The following provisions apply to your health expense plan. This section describes cost sharing features, benefit maximums and other important provisions that apply to your Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the attached health expense sections of this Schedule of Benefits. The insurance described in this Schedule of Benefits will be provided under Aetna Life Insurance Company’s policy form GR-29N. Keep This Schedule of Benefits With Your Booklet-Certificate. Deductible Provisions (GR-9N-S-09-05-01 FL) Network Calendar Year Deductible This is an amount of network covered expenses incurred each Calendar Year for which no benefits will be paid. The network Calendar Year deductible applies separately to you and each of your covered dependents. After covered expenses reach the network Calendar Year deductible, the plan will begin to pay benefits for covered expenses for the rest of the Calendar Year. Out-of-Network Calendar Year Deductible This is an amount of out-of-network covered expenses incurred each Calendar Year for which no benefits will be paid. The out-of-network Calendar Year deductible applies separately to you and each of your covered dependents. After covered expenses reach the out-of-network Calendar Year deductible, the plan will begin to pay benefits for covered expenses for the rest of the Calendar Year. Covered expenses applied to the out-of-network deductible will be applied to satisfy the network deductible and covered expenses applied to the network deductible will be applied to satisfy the out-of-network deductible. Network Family Deductible Limit When you incur network covered expenses that apply toward the network Calendar Year deductibles for you and each of your covered dependents these expenses will also count toward the network Calendar Year family deductible limit. Your network family deductible limit will be considered to be met for the rest of the Calendar Year once the combined covered expenses reach the network family deductible limit in a Calendar Year. Out-of-Network Family Deductible Limit When you incur out-of-network covered expenses that apply toward the out-of-network Calendar Year deductibles for you and each of your covered dependents these expenses will also count toward the out-of-network Calendar Year family deductible limit. Your out-of-network family deductible limit will be considered to be met for the rest of the Calendar Year once the combined covered expenses reach the out-of-network family deductible limit in a Calendar Year. Covered expenses applied to the out-of-network deductible will be applied to satisfy the network deductible and covered expenses applied to the network deductible will be applied to satisfy the out-of-network deductible. Copayments and Benefit Deductible Provisions (GR-9N-09-015-01 FL) Copayment, Copay This is a specified dollar amount or percentage, shown in the Schedule of Benefits, you are required to pay for covered expenses. GR-9N 3 Coinsurance Provisions (GR-9N S-09-020 01) Coinsurance This is the percentage of your covered expenses that the plan pays and the percentage of covered expenses that you pay. The percentage that the plan pays is referred to as the “Plan Coinsurance”. Once applicable deductibles have been met, your plan will pay a percentage of the covered expenses, and you will be responsible for the rest of the costs. The coinsurance percentage may vary by the type of expense. Refer to your Schedule of Benefits for coinsurance amounts for each covered benefit. Maximum Benefit Provisions (GR-9N S-09-025 01) Calendar Year Maximum Benefit The most the plan will pay for covered expenses incurred by any one covered person in a Calendar Year is called the Calendar Year maximum benefit. The Calendar Year maximum benefit will not deny benefits for certain covered expenses in any one Calendar Year. The Calendar Year maximum benefit applies to network care and out-of-network care expenses combined. General (GR-9N-28-01-01-FL) This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your plan of benefits. Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot be accepted. This Schedule is part of your Booklet-Certificate and should be kept with your Booklet-Certificate form GR-9N. Coverage is underwritten by Aetna Life Insurance Company. Schedule of Benefits (GR-9N-S-01-001-01 FL) Employer: Group Policy Number: Issue Date: November 8, 2018 Effective Date: October 1, 2018 Schedule: 1A Cert Base: 1 For: DMO PLan 65 This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information. Managed Dental Plan Schedule of Managed Dental Benefits (GR-9N-22-005-02 FL) This Schedule Applies to Covered Expenses Provided by Network Providers. Office Visit Copayment $5 per visit. Dental Emergency Maximum: $100 Dental Care Schedule The following dental care schedule shows services that require a copay; and the copay amount. Dental services that are considered covered expenses as shown in the dental care schedule must be given by network providers, at the dental office location. The exceptions to this rule are when Aetna approves referral care, or for out-of-area emergency dental care. In addition to copays for covered expenses shown in the following schedule, you will also be responsible for an office visit copay as shown above. If: A charge is made for an unlisted service given for the dental care of a specific condition; and The list includes one or more services that, under standard practices, are separately suitable for the dental care of that condition, then the charge will be considered to have been made for a service that would have produced professionally acceptable result, as determined by Aetna. GR-9N 2 This Schedule Applies to Services Provided by Network Providers Primary Care Dentist Services (GR-9N-S-22-010-01) Visits and Exams Copayment Amount Oral examination (limited to total of 4 visits per year) $0 Emergency palliative treatment $10 Prophylaxis (cleaning), (limited to 2 treatments per year) Adult $0 Child $0 Topical application of fluoride (limited to 1 treatment per year and to covered persons under age 16) $0 Oral hygiene instruction $0 Sealants, per tooth (limited to 1 application every 3 years for permanent molars and to covered persons under age 16) $0 Pulp vitality test $0 Consultation $0 Diagnostic casts $0 X-Rays and Pathology Bitewing x-rays (limited to 1 set per year) $0 Entire series, including bitewings, or panoramic film, (limited to 1 set every 3 years) $0 Vertical bitewing X-rays (limited to 1 set every 3 years) $0 Periapical x-ray $0 Intra-oral, occlusal view, maxillary or mandibular $0 Extra-oral upper or lower jaw $0 Accession of oral tissue $0 Space Maintainers – (only when needed to preserve space resulting from premature loss of primary teeth) Includes all adjustments within six months after installation Fixed $0 Removable $0 Recement space maintainer $12 Remove fixed space maintainer (by dentist who did not place appliance) $12 Endodontics Pulp cap $0 Pulpotomy $0 Root canal therapy, including necessary x-rays Anterior $50 Bicuspid $70 Restorations and Repairs (Copayments for crowns and pontics are per unit.) There will be an additional patient charge for the actual cost of high noble metal (“gold”) when used for services shown with an asterisk. Amalgam restoration 1 surface $0 2 surfaces $0 3 surfaces $0 4 or more surfaces $0 GR-9N 3 Resin-based composite restoration (anterior) 1 surface $0 2 surfaces $0 3 surfaces $0 4 or more surfaces or incisal angle $40 Resin-based composite crown, anterior $40 Resin-based composite restoration (posterior) 1 surface $35 2 surfaces $45 3 surfaces $55 4 or more surfaces $75 Retention pins $10 Stainless steel crowns, prefabricated, primary tooth $0 Stainless steel crowns, prefabricated, permanent tooth $40 Recementing inlays or crowns $5 Recementing bridges $15 Sedative filling $0 Inlays metallic* $190 Crowns Porcelain $225 Porcelain with metal (includes abutments)* $225 Metallic (full cast) (includes abutments)* $225 Metallic (3/4 cast)* $225 Cast post and core* $80 Prefabricated post and core $70 Core buildup including pins $60 Pontics Metallic (full cast)* $225 Porcelain with metal* $225 Full mouth rehabilitation, per unit (This means 6 or more covered units of crowns and/or pontics under one treatment plan.) $125 Dentures and Partials – (Includes relines, rebases and adjustments within six months after installation. Adjustments within first six months are limited to four.) Complete, upper or lower $275 Partial, upper or lower Resin base $275 Cast metal base $325 Immediate, upper or lower (does not include charge for reline) $325 Adjust complete denture, upper or lower $10 Adjust partial denture, upper or lower $10 Repair broken acrylic, complete denture, upper or lower $30 Replace one tooth on complete denture $35 Repair resin denture base, cast frame, broken clasp $35 Replace broken tooth, partial $35 Add tooth to existing partial denture $35 Add clasp to existing partial $40 Replace all teeth and acrylic on cast metal framework $100 Rebase, complete denture, upper or lower $100 Rebase, partial denture, upper or lower $100 Reline, complete denture, upper or lower (chairside) $40 Reline, partial denture, upper or lower (chairside) $40 Reline, complete denture, upper or lower (laboratory) $90 Reline, partial denture, upper or lower (laboratory) $90 GR-9N 4 Interim partial denture, upper or lower (stayplate), anterior only $90 Tissue conditioning for dentures $40 Periodontics Scaling and root planing, per quadrant (limited to 4 separate quadrants every 2 years) $50 Scaling and root planing -1 to 3 teeth per quadrant (limited to once per site every 2 years) $30 Periodontal maintenance procedures following surgical therapy (limited to 2 per year) $30 Occlusal guard (for bruxism only), limited to 1 every 3 years $100 Oral Surgery – Includes local anesthetics and routine post-operative care Extraction – exposed root or erupted tooth $0 Extraction – coronal remnants – deciduous tooth uncomplicated $0 Surgical removal of erupted tooth $0 Surgical removal of impacted tooth (soft tissue) $0 Incision and drainage of intraoral abscess $10 Mobilization of erupted or malpositioned tooth to aid eruption. $30 Biopsy of oral tissue $50 Specialty Services Copayment Amount Endodontics – Includes local anesthetics where necessary Apicoectomy/periradicular surgery Anterior $65 Bicuspid, first root $65 Molar, first root $80 Each additional root $40 Retrograde filling, per root $20 Root amputation, per root $60 Molar root canal therapy $175 Retreatment of previous root canal therapy Anterior $150 Bicuspid $170 Molar $275 Oral Surgery – Includes local anesthetics where necessary and post-operative care Surgical removal of residual tooth roots $15 Frenectomy $24 Alveoloplasty in conjunction with extractions – per quadrant $18 Alveoloplasty not in conjunction with extractions – per quadrant $25 Surgical removal of impacted tooth Partially bony $45 Completely bony $70 Completely bony with unusual surgical complications $70 Periodontics Gingivectomy or gingivoplasty – per quadrant, limited to 1 per quadrant, every 3 years $100 Gingivectomy or gingivoplasty – 1-3 teeth, limited to 1 per site, every 3 years $30 Gingival flap procedure – per quadrant $110 Gingival flap procedure – 1-3 teeth one per quadrant $66 Occlusal adjustment (other than with an appliance or restoration) Limited $20 Complete $80 Osseous surgery (including flap entry and closure) – per quadrant, limited to 1 per quadrant, every 3 years $250 GR-9N 5 Osseous surgery (including flap entry and closure) – 1 to 3 teeth, limited to once per site every 3 years $150 Surgical revision procedure, per tooth $100 Pedicle soft tissue graft $190 Free soft tissue graft (including donor site surgery) $205 Subepithelial connective tissue graft $115 Soft tissue allograft $230 Combined connective tissue and double pedicle graft $190 Clinical crown lengthening – hard tissue $150 General Anesthesia and Intravenous Sedation – (only when provided in conjunction with a covered surgical procedure) Deep sedation/General Anesthesia First 30 minutes $165 each additional 15 minutes $70 Intravenous conscious sedation/analgesia First 30 minutes $165 each additional 15 minutes $70 Orthodontics Limited to treatment of cleft lip or cleft palate for a child under age 18 ** Oral Surgery – Includes local anesthesia where necessary and post-operative care Cleft lip or cleft palate surgery for a child under age 18 ** **An amount to be determined which is consistent with other covered services in this section as shown in this Schedule of Benefits. Expense Provisions (GR-9N-S-09-05-01 FL) The following provisions apply to your health expense plan. This section describes cost sharing features, benefit maximums and other important provisions that apply to your Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the attached health expense sections of this Schedule of Benefits. The insurance described in this Schedule of Benefits will be provided under Aetna Life Insurance Company’s policy form GR-29N. Keep This Schedule of Benefits With Your Booklet-Certificate. Copayments and Benefit Deductible Provisions (GR-9N-09-015-01 FL) Copayment, Copay This is a specified dollar amount or percentage, shown in the Schedule of Benefits, you are required to pay for covered expenses. General (GR-9N-28-01-01-FL) This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your plan of benefits. Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot be accepted. This Schedule is part of your Booklet-Certificate and should be kept with your Booklet-Certificate form GR-9N. Coverage is underwritten by Aetna Life Insurance Company. submitted by /u/ProtContQB1 [link] [comments]Read Morer/HealthInsurance