aep comprehensive dental plan (dmo option) · pdf fileaep 2016 active and retiree dental dmo...

AEP Comprehensive Dental Plan (DMO Option)

Summary Plan Description for Active Employees, Retirees and Surviving Dependents

Issued 2016

AEP 2016 Active and Retiree Dental DMO Plan SPD

ID Cards If you are an enrollee with Aetna Dental coverage, you don't need an ID card. When visiting a dentist,

simply provide your name, date of birth and Member ID# (or social security number). The dental office

can use that information to verify your eligibility and benefits. If you still would like an ID card for you

and your dependents, you can print a customized ID card by going to the secure member website at

www.aetna.com. You can also access your benefits information when you’re on the go. To learn more,

visit us at www.aetna.com/mobile or call us at 1-877-238-6200.

Remember, DMO® members need to choose a primary care dentist in Aetna’s network. Otherwise, you

could end up paying more. You can use our provider search tool online or call us at 1-877-238-6200 to

make your selection.

CA /AZ DMO® participants, if you have not selected a PCD, one may have been selected for you. View

your digital ID card to determine if one was selected on your behalf.

http://www.aetna.com/


AEP System Comprehensive Dental Plan The American Electric Power System Comprehensive Dental Plan is administered by Aetna. The Dental

Plan is designed to provide you and your eligible dependents with high quality, cost-effective dental care.

The plan offers a wide range of preventive care, basic and major restorative care, and orthodontic

coverage for you and your covered dependents.

What’s Here: Your Dental Options at a Glance .................................................................................................................. 1

Dental Preferred Provider Organization (DPPO) .................................................................................... 1 Dental Maintenance Organization (DMO) ............................................................................................. 1 DPPO/DMO Comparison Chart ............................................................................................................. 2

Participating AEP Companies ....................................................................................................................... 3 Requirements for Coverage .......................................................................................................................... 3 Eligibility ...................................................................................................................................................... 4

Active Employees ................................................................................................................................... 4 Retirees ................................................................................................................................................... 4 Surviving Spouse and Dependent Eligibility .......................................................................................... 5 Dependent Eligibility .............................................................................................................................. 5

Enrolling for Coverage ................................................................................................................................. 7 How and When to Make Enrollment Elections and Changes ................................................................. 7 As a New Employee ................................................................................................................................ 7 Annual Enrollment for Employees ......................................................................................................... 8 As a New Retiree .................................................................................................................................... 8 As a New Surviving Dependent .............................................................................................................. 8 Annual Enrollment for Retirees and Surviving Dependents ................................................................... 9 Waiving Coverage .................................................................................................................................. 9

Qualified Medical Child Support Order (QMCSO) ...................................................................................... 9 Cost of Coverage......................................................................................................................................... 10

Employees ............................................................................................................................................. 10 Retirees and Surviving Dependents ...................................................................................................... 10

When Coverage Begins ............................................................................................................................... 10 The AEP Benefits Center ............................................................................................................................ 11 When Coverage Ends .................................................................................................................................. 11 Continuation of Coverage ........................................................................................................................... 11

Continuing Coverage as an AEP Retiree .............................................................................................. 11 Continuing Coverage as a Surviving Dependent .................................................................................. 11 Continuing Health Care Benefits Handicapped .................................................................................... 12 Continuing Dental Coverage under COBRA ........................................................................................ 12 Qualified Beneficiaries ......................................................................................................................... 12 COBRA Qualifying Events ................................................................................................................... 13 Obligation to Notify the Company of Certain Qualifying Events ........................................................ 14 Continuation of Coverage During Military Leave (USERRA) ............................................................. 16

Life Events and Your Coverage .................................................................................................................. 17 You Begin Working at AEP ................................................................................................................. 17 You Get Married ................................................................................................................................... 17 Your Marriage Ends .............................................................................................................................. 18


Your Domestic Partnership Ends .......................................................................................................... 18 You Are Unable to Work Due to an Illness or Injury ........................................................................... 18 You Die ................................................................................................................................................. 18 A Covered Family Member Dies .......................................................................................................... 19 Your Child Loses Dependent Status ..................................................................................................... 19 Birth, Adoption, Placement for Adoption or Legal Guardianship ........................................................ 19 Change in Your Spouse's/Domestic Partner’s Employment ................................................................. 20 You Begin a Family Medical Leave of Absence (FMLA) ................................................................... 20 You Begin an Unpaid Leave of Absence (non-FMLA) ........................................................................ 20 You Begin a Paid Military Leave of Absence ...................................................................................... 20 You Terminate Employment Before Qualifying for AEP Retiree Benefits.......................................... 21 You Terminate Employment After Becoming Retiree Benefits Eligible ............................................. 21 You Are Rehired at AEP ....................................................................................................................... 21 You Return from an Unpaid Leave of Absence .................................................................................... 21 You Return After Retirement ................................................................................................................ 22 Coverage or Employer Contributions Lost Under Another Dental Plan .............................................. 22 Newly Eligible Because of Change in AEP Employment Status ......................................................... 22

How Your Aetna Dental Plan Works .......................................................................................................... 22 Understanding Your Aetna Dental Plan ................................................................................................ 22 Accessing Network Providers ............................................................................................................... 23 Changing Your PCD ............................................................................................................................. 23 Using Your Dental Plan ........................................................................................................................ 24 In Case of a Dental Emergency............................................................................................................. 25

What the Plan Covers .................................................................................................................................. 25 Managed Dental Plan ............................................................................................................................ 25 Schedule of Benefits ............................................................................................................................. 26

General ........................................................................................................................................................ 34 Managed Dental Expense Coverage Plan ............................................................................................. 34 Rules and Limits That Apply to the Dental Plan .................................................................................. 35 What the Managed Dental Plan Does Not Cover ................................................................................. 37 Additional Items Not Covered by a Health Plan ................................................................................... 38

Coordination of Benefits – What Happens When There Is More Than One Health Plan .......................... 40 When Coordination of Benefits Applies ............................................................................................... 40 Which Plan Pays First ........................................................................................................................... 40 How Coordination of Benefits Works .................................................................................................. 42 When You Have Medicare Coverage ................................................................................................... 42

General Provisions ...................................................................................................................................... 44 Type of Coverage .................................................................................................................................. 44 Physical Examinations .......................................................................................................................... 44 Legal Action.......................................................................................................................................... 44 Confidentiality ...................................................................................................................................... 44 Additional Provisions ............................................................................................................................ 44 Assignments .......................................................................................................................................... 45 Misstatements ....................................................................................................................................... 45 Incontestability ...................................................................................................................................... 45 Recovery of Overpayments ................................................................................................................... 45 Reporting of Claims .............................................................................................................................. 46 Payment of Benefits .............................................................................................................................. 46


Contacting Aetna .................................................................................................................................. 46 Appeals Procedure ................................................................................................................................ 47

Your Legal Rights ....................................................................................................................................... 56 Receive Information about Your Plans and Benefits ............................................................................ 56 Continue Group Health Plan Coverage ................................................................................................. 57 Prudent Actions by Plan Fiduciaries ..................................................................................................... 57 Plan Documents .................................................................................................................................... 58 Transfer of Benefits .............................................................................................................................. 58 Plan Amendment or Termination .......................................................................................................... 58

Administrative Information ........................................................................................................................ 58 Glossary ...................................................................................................................................................... 59

Aetna ..................................................................................................................................................... 59 Coinsurance........................................................................................................................................... 59 Copay or Copayment ............................................................................................................................. 59 Cosmetic ............................................................................................................................................... 60 Covered Expenses ................................................................................................................................. 60 Deductible ............................................................................................................................................. 60 Dental Provider ..................................................................................................................................... 60 Dental Emergency ................................................................................................................................. 60 Dentist ................................................................................................................................................... 60 Directory ............................................................................................................................................... 60 Experimental or Investigational ............................................................................................................. 60 Hospital ................................................................................................................................................. 61 Illness .................................................................................................................................................... 61 Injury ..................................................................................................................................................... 61 Jaw Joint Disorder ................................................................................................................................. 61 Lifetime Maximum................................................................................................................................ 61 Medically Necessary or Medical Necessity ........................................................................................... 62 Negotiated Charge ................................................................................................................................. 62 Network Provider .................................................................................................................................. 62 Network Service(s) or Supply(ies) ........................................................................................................ 62 Non-Occupational Illness ...................................................................................................................... 62 Non-Occupational Injury ....................................................................................................................... 63 Occupational Injury or Occupational Illness ......................................................................................... 63 Occurrence ............................................................................................................................................ 63 Orthodontic Treatment .......................................................................................................................... 63 Out-of-Network Service(s) and Supply(ies) ......................................................................................... 63 Out-of-Network Provider ...................................................................................................................... 63 Physician ............................................................................................................................................... 63 Precertification or Precertify ................................................................................................................. 64 Prescriber .............................................................................................................................................. 64 Prescription ........................................................................................................................................... 64 Prescription Drug .................................................................................................................................. 64 Primary Care Dentist (PCD) .................................................................................................................. 64 Recognized Charge................................................................................................................................ 65 Referral ................................................................................................................................................. 66 Referral Care ......................................................................................................................................... 66 R.N. ....................................................................................................................................................... 66


Skilled Nursing Facility ......................................................................................................................... 66 Specialist ............................................................................................................................................... 67 Specialist Dentist ................................................................................................................................... 67 Specialty Care ....................................................................................................................................... 67

Confidentiality Notice ................................................................................................................................. 68 IMPORTANT NOTICE

This is a summary of the American Electric Power Comprehensive Dental Plan as in effect on

January 1, 2016. This description of the American Electric Power Comprehensive Dental Plan is not

intended as an employment contract or a guarantee of current or future employment. The Company

reserves the right to amend, modify, suspend, or terminate the Plan, in whole or in part, at any time, at its

discretion, with or without advance notice to participants, for any reason, subject to applicable law. The

Company further reserves the right to change the amount of required participant contributions for

coverage at any time, with or without advance notice to participants.

This Summary Plan Description (“SPD”) is an overview of the Plan documents as they apply to the

benefits described herein. In the event of a conflict between this Summary and any Plan documents, the

applicable Plan documents (excluding this Summary Plan Description) shall govern. For fully insured

benefits, any discrepancy will be governed by the insurance certificates or policies.

AEP 1 2016 Active and Retiree Dental DMO Plan SPD

Your Dental Options at a Glance

Dental Preferred Provider Organization (DPPO) The DPPO option, administered by Aetna, lets you choose between receiving in-network and out-of-

network care each time you need dental work. You will generally pay less for your dental care when you

use an Aetna in-network dental provider because in-network dentists have agreed to lower, negotiated

fees for their services.

Covered DPPO Expenses*

Annual deductible

(applies to basic and restorative expenses only)

$50/individual

$150/family

Preventive care 100% (no deductible)

Basic restorative care 80% after deductible

Major restorative care 50% after deductible

Orthodontia care

(eligible children under age 19)

50% of eligible expenses (no deductible)

Lifetime orthodontia maximum $1,500/lifetime per covered child under age 19

Annual maximum benefit

(excludes orthodontia)

$1,500/year per covered person

*Up to Aetna’s network discounted rates or Aetna’s recognized charges if a non-network provider is used.

Dental Maintenance Organization (DMO) The DMO option, administered by Aetna, offers you a broad range of dental services based on a Dental

Benefits Summary described in this document that shows the patient copay that applies to each covered

dental procedure. You are responsible for the applicable copay at the time the services are performed.

You agree to receive care solely from a primary care dentist (PCD) associated with the DMO network,

and in return, you will have:

No deductibles or annual maximum.

No copayment for covered preventive services.

Low, fixed copayments on other dental services.

No claim forms to file.


DPPO/DMO Comparison Chart

Features DPPO DMO

Cost Sharing Arrangement Coinsurance – you pay a

percentage of covered expenses

Copay – you pay a set dollar

amount at the time of service.

Primary Care Dentist Election Not required Yes, you must elect a PCD at

the time you enroll, either

online at www.aetna.com or

by calling 1-800-243-1809

Annual Deductible – the amount you

pay before your plan pays.

Individual: $50 Family:

$150

No Deductible

Annual Maximum – the maximum

amount your plan will pay out in a

Plan Year.

$1,500 per covered person No Limit

Orthodontics Eligibility Children under age 19 Adults and children

Orthodontics Out-of-Pocket

Maximum

No Limit $2,400 per covered person

Orthodontics Lifetime Maximum $1,500 No Limit

Out-of-Network Benefits Visit any licensed dentist to

receive benefits. You will

typically pay lower out-of-

pocket costs if you choose a

dentist who participates in the

Aetna DPPO network.

Out-of-network coverage is not

available in Arizona, Texas,

North Carolina, New Jersey, and

California. Contact Aetna at

1-800-243-1809 for state-

required benefits

Referrals – the primary care dentist

directs you to seek dental care from

another dental professional.

None required Referrals are required, except

when you visit an orthodontist

in the DMO network.

Procedures NOT covered by the

plan

You are responsible for the cost

of procedures not covered by

your plan. Note: Participating

DPPO dentists offer discounts on

procedures not covered by the

plan.

You are responsible for the

cost of procedures not covered

by the plan.

Please refer to the separate AEP Comprehensive Dental Plan (DPPO Option) Summary Plan Description

for Active Employees and Retirees for additional information about the DPPO option. You may also

obtain more information about your eligibility for the DPPO, how the DPPO works, and what the DPPO

covers if you would contact Aetna at 1-800-243-1809.


Participating AEP Companies Eligibility to participate in the plan depends, in part, on employment with a Participating AEP System

Company. The list of Participating AEP System Companies includes the following as of January 1, 2016,

but their inclusion may change for various reasons, including an amendment to the plan, or disposition of

AEP’s interest in the Company:

American Electric Power Service Corporation

AEP Energy Services, Inc.

AEP Energy Partners, Inc.

AEP Generating Company

AEP Generation Resources Inc.

AEP Onsite Partners, LLC

AEP Pro Serv, Inc.

AEP Texas Central Company

AEP Texas North Company

Appalachian Power Company

CSW Energy, Inc.

Dolet Hills Lignite Company, LLC

Indiana Michigan Power Company

Kentucky Power Company

Kingsport Power Company

Ohio Power Company

Public Service Company of Oklahoma

River Transportation Division I &MP

Southwestern Electric Power Company

Wheeling Power Company

This list is not complete. If you want more information on whether and when a particular AEP System

Company participated in the plan, please call the AEP Benefits Center toll-free at 1-888-237-2363.

Requirements for Coverage To be covered by the plan, services and supplies must meet all of the following requirements:

1. The service or supply must be covered by the plan. For a service or supply to be covered, it must:

Be included as a covered expense in this SPD;

Not be an excluded expense under this SPD. Refer to the “Exclusions” sections of this SPD for a

list of services and supplies that are excluded;

Not exceed the maximums and limitations outlined in this SPD. Refer to the “What the Plan

Covers” section and the “Schedule of Benefits” for information about certain expense limits; and

Be obtained in accordance with all the terms, policies and procedures outlined in this SPD.

2. The service or supply must be provided while coverage is in effect. See the “Who Can Be Covered,”

“How and When to Enroll,” “When Your Coverage Begins,” “When Coverage Ends” and

“Continuation of Coverage” sections for details on when coverage begins and ends.

3. The service or supply must be medically necessary. To meet this requirement, the dental service or

supply must be provided by a physician, or other health care provider or dental provider,

exercising prudent clinical judgment, to a patient for the purpose of preventing, evaluating,

diagnosing or treating an illness, injury, disease or its symptoms. The provision of the service or

supply must be:

(a) In accordance with generally accepted standards of dental practice;

(b) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and

(c) Not primarily for the convenience of the patient, physician or dental provider or other health care provider;

(d) And not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that

patient’s illness, injury, or disease.


For these purposes “generally accepted standards of dental practice” means standards that are based on

credible scientific evidence published in peer-reviewed dental literature generally recognized by the

relevant dental community, or otherwise consistent with physician or dental specialty society

recommendations and the views of physicians or dentists practicing in relevant clinical areas and any

other relevant factors.

Eligibility Important Reminder

Keep in mind that you cannot receive coverage under this Plan as:

Both an employee and a dependent; or

A dependent of more than one employee.

Active Employees You are eligible to enroll yourself and your eligible dependents in the AEP Comprehensive Dental Plan

on your first day of work if you are classified by AEP as:

A full-time active employee of a Participating AEP System Company scheduled to work an average

of at least 40 hours per week; or

A part-time active employee of a Participating AEP System Company scheduled to work an average

of at least 20 hours per week.

You are not eligible to participate if you are:

Not an employee of a Participating AEP System Company; or

Classified by AEP as a contractor, a temporary employee, a leased employee, or as an employee

under a collective bargaining agreement not covered under the plan.

Retirees You remain eligible to elect dental coverage for yourself and your eligible dependents if you were last

hired or rehired by an AEP Participating System Company on or before December 31, 2013 and you are

at least age 55 with 10 or more years of service with a Participating AEP Company and elected to enroll

in retiree dental coverage at retirement. If you do not remain covered by retiree dental coverage at

retirement, you will not be eligible to enroll in dental coverage at a later date.

In addition, if you are rehired by a Participating AEP System Company on or after January 1, 2014, you

may remain eligible to elect dental coverage for yourself and your eligible dependents upon your later

retirement if you were eligible to elect such benefits in connection with your pre-2014 employment with

AEP and maintained that coverage until your rehire date.

In determining whether a Retiree has met the service requirement, any service provided as a temporary

employee, independent contractor, leased employee or otherwise had services based upon a fee or

contract, will not be taken into account. You also will be excluded from eligibility if your benefits were

the subject of a collective bargaining agreement that does not provide for retiree coverage under this Plan.

Important Note

Not every service or supply that fits the definition for medical necessity is covered by the plan.

Exclusions and limitations apply to certain dental services, supplies and expenses. For example

some benefits are limited to a certain number of days, visits or a dollar maximum. Refer to the

“What the Plan Covers” section and the “Schedule of Benefits” for the plan limits and maximums.


Surviving Spouse and Dependent Eligibility

Survivors of Active Employees (not retiree benefit eligible) Surviving spouses of active employees who were not retiree benefit eligible on the date of death can elect

to continue dental coverage until the earlier of age 65 or remarriage, if the surviving spouse was enrolled

in the dental plan at the time of the employee’s death.

Surviving dependent children of an active employee who was not retiree benefit eligible on the date of

death can elect to continue dental coverage until they reach the limiting age (see the “Dependent

Eligibility” section), if the surviving dependent was enrolled in the dental plan at the time of the

employee’s death.

Survivors of Active Employees (retiree benefit eligible) Surviving spouses of active employees who were retiree benefit eligible on the date of death can elect

dental coverage until remarriage, if the surviving spouse was enrolled in the dental plan at the time of the

employee’s death. Surviving dependents of active employees who were retiree benefit eligible on the date

of death can elect dental coverage until the limiting age (see the “Dependent Eligibility” section), if the

surviving dependent was enrolled in dental coverage at the time of the employee’s death.

Survivors of Retirees Surviving spouses of retirees can elect dental coverage until remarriage, if the surviving spouse was

enrolled in the dental plan at the time of the retiree’s death. Surviving dependents of retirees can elect

dental coverage until the limiting age (see the “Dependent Eligibility” section), if the surviving dependent

was enrolled in dental coverage at the time of the retiree’s death.

Once a survivor waives or terminates participation in the dental plan, he or she cannot re-elect it.

Domestic Partners are not eligible for survivor dental benefits. However, AEP will offer COBRA-like

coverage to eligible Alternative Family Members. Refer to the “Continuing Dental Coverage through

COBRA” section for additional information.

Dependent Eligibility The AEP Comprehensive Dental Plan allows Employees and Retirees covered by the Plan to purchase

coverage for their eligible dependents. Survivors of active employees or Retirees generally cannot enroll

any of their own dependents who were not covered by the dental plan at the time of the Employee’s or

Retiree’s death.

Eligible dependents include the Employee’s or Retiree’s:

Spouse: As defined by state law where you live, including common law marriages. However, a same-sex

spouse relationship created under applicable law will be respected regardless of whether the state in

which you live recognizes it.

Domestic Partner: AEP no longer allows the addition of domestic partners to coverage under the Plan.

Only those same-sex domestic partners enrolled prior to October 28, 2015, are permitted to remain

covered, but only through December 31, 2016. Coverage after December 31, 2016 will be limited to those

who are legally married.


To qualify one for coverage as a domestic partner, you and your domestic partner must have certified and

declared that you met the criteria below. You and your domestic partner:

Must be the same gender.

Must not be related by blood.

Must be at least 18 years of age or older.

Must be jointly financially responsible for basic living expenses defined as the cost of food, shelter,

and any other expenses of maintaining a household. Your partner need not contribute equally or

jointly to the cost of these expenses as long as you both agree that you both are responsible for the

cost.

Must have been living with you in the same residence for at least six consecutive months with the

intent to continue doing so indefinitely.

Must be in a serious and committed relationship.

Must not be legally married to you or anyone else, in a partnership with another individual, or have

had another partner within the prior six months. The determination of whether you are legally married

will be determined based upon the law of the state in which you reside or where the marriage takes

place.

Must be legally competent – that is, legally and mentally capable of entering into a legally

enforceable contract.

Must have Affidavit of Domestic Partnership on file at the AEP Benefits Center.

Note: If you terminate your domestic partner relationship, or your domestic partner ceases to satisfy the

criteria above for an eligible domestic partner, you must notify the AEP Benefits Center to discontinue

your domestic partner from coverage. Failure to do so in a timely manner will not prevent their loss of

coverage retroactively but will result in their loss of eligibility to elect COBRA-like continuation

coverage.

You may cover your domestic partner whether or not he or she qualifies as your tax dependent. If your

domestic partner is not your tax dependent, you will incur imputed income on that benefit coverage.

Children: To qualify for coverage, your dependent child(ren) must be under age 26 and fall into one of

the following categories:

Your natural child or the natural child of your spouse or eligible domestic partner;

A child legally adopted by you, your spouse or eligible domestic partner or placed with you, your

spouse or covered domestic partner for adoption. “Placement for adoption” means the assumption and

retention by the Employee of the legal obligation for the total or partial support of a child to be

adopted. Placement ends whenever the legal support obligation ends.

Your foster child;

A child who resides in your household and for whom you, your spouse or your eligible domestic

partner are the court-appointed guardian;

A child for whom you are required to provide coverage as a result of a Qualified Medical Child

Support Order (QMSCO); or

Any other child you claim as a dependent on your federal income tax return, provided that neither

natural parent of the child lives with the child and you are acting as the child’s guardian.

Note: The FirstCare HMO medical plan option also allows you to cover your grandchildren whom you

claim as a dependent on your federal income tax return at the time of his or her initial enrollment,

regardless of whether the child’s natural parent resides with you or you are acting as the grandchild’s

guardian.


Disabled Dependents: To qualify for coverage beyond age 26, your disabled child(ren) must meet the

criteria listed under the “Children” section above, plus:

Disability must have occurred prior to attaining age 26.

The child must remain continuously covered under any of the options available under this Plan.

You must submit proof that the child reaching age 26 is disabled and incapable of self-support within

31 days after he or she reaches age 26. If you are enrolling the child for the first time after the child has

already reached age 26, you must submit proof that the child has been disabled and incapable of self-

support since age 26 within 31 days after enrolling the child. The Medical Claims Administrator has the

right to require, at reasonable intervals, proof that the child continues to be disabled and incapable of self-

support. If you fail to submit any required proof or if you refuse to permit a medical examination of the

child, he or she will not be considered disabled and therefore not eligible for coverage.

If Both You and Your Eligible Dependent have AEP Benefits If both you and your spouse/domestic partner or eligible dependent are eligible for the dental plan as an

AEP employee or retiree:

You may each enroll in the plan as an employee or retiree, as appropriate; or

One of you may enroll as an employee or retiree and the other as a dependent spouse, domestic

partner or child. Neither of you may be covered as both an employee or retiree and as a dependent.

Neither of you or your spouse or domestic partner can cover the same eligible dependent children.

Tax Considerations When Covering Your Dependents A number of benefits that AEP offers to its employees receive special tax treatment. For the most part, the

special tax provisions allow employees to pay their share of the cost of certain benefits on a before-tax

basis and AEP to pay its share of the cost without having to include those payments in the employees'

taxable wages.

AEP makes dental coverage available to dependents that may not satisfy the requirements to be treated as

dependents for tax purposes, and the employee’s contributions for covering those dependents would be

paid on an after-tax basis and AEP’s share of the cost of covering them would be taxable wages for the

employee. If you want more information on the requirements to be treated as a dependent for tax

purposes, please call the AEP Benefits Center toll-free at 1-888-237-2363.

When you enroll one or more dependents, you will be required to declare whether or not they are

considered your federal income tax dependent under Sections 152 and 106 of the Internal Revenue Code

for group health coverage purposes.

Enrolling for Coverage

How and When to Make Enrollment Elections and Changes You can enroll for coverage after you meet the eligibility requirements.

As a New Employee As a newly eligible employee of a Participating AEP System Company, you will receive information and

instructions about how to enroll for your benefits. You must indicate your dental election either online or

by phone to the AEP Benefits Center within 31 days of your date of hire. If you do not enroll within

31 days, you will not be covered by the Plan.


Annual Enrollment for Employees Each year, during a designated Annual Enrollment period, you will be given the opportunity to enroll in

or drop coverage, change your coverage elections, or change the dependents you cover. Your Annual

Enrollment materials will provide the options available to you and your share of the premium cost, if any,

for the coverages you elect. Your materials will also include what actions you must take to continue

certain coverages and will explain any applicable default coverage that you will be deemed to have

elected if you do not make the required elections by the specified deadline. The elections you make will

take effect on January 1 and stay in effect through December 31, unless you have a qualifying change in

status that permits you to make a mid-year election change. See the “Making Changes During the Year”

section.

As a New Retiree Your coverage in effect as an active employee will automatically continue into retirement. You will

continue being enrolled in the same option under the plan, covering the same eligible dependents. If you

wish to change plan options, drop coverage or add/remove dependents at the time of your retirement, you

must do so by contacting the AEP Benefits Center within 31 days of your retirement. You may NOT

change options under the AEP Dental Plan due to your retirement event.

If you are not enrolled in an AEP dental plan option at the time of your retirement, you will continue to

not be enrolled until you contact the AEP Benefits Center within 31 days of your retirement.

This is a one-time election. If you choose not to enroll in dental benefits or waive coverage as a new

retiree, you cannot enroll in dental coverage at any time in the future.

As a New Surviving Dependent As a new AEP surviving spouse or dependent, if all contributions are paid up to date at the time of the

Employee’s or Retiree’s death, you will automatically be enrolled in the same dental plan option you had

as of the date of death. You may NOT change dental plan options. If you do not wish to continue

coverage as a surviving spouse or dependent, you must contact the AEP Benefits Center within 31 days of

the Employee’s or Retiree’s death. If you choose not to enroll in dental coverage as a surviving spouse or

dependent, you will not be able to enroll at a later date, regardless of any changes in employment or

family status.

This is a one-time election. If you waive coverage as a new surviving spouse or surviving dependent,

you cannot enroll in dental coverage at any time in the future.

Social Security Numbers Generally Required for Enrollment Under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (“MMSEA”), the

Centers for Medicare & Medicaid Services (“CMS”) generally require Social Security numbers (or

Tax Identification number for non-USA citizens) for employees and dependents to assist with

reporting under the Medicare Secondary Payer requirements.

For a newborn child, the newborn may be enrolled under your coverage without a Social Security

number (provided you do so within 90 days of the birth). However, you should apply for the child’s

Social Security number as soon as possible and provide it to the AEP Benefits Center.


Annual Enrollment for Retirees and Surviving Dependents Each year, during a designated Annual Enrollment period, Retirees and then participating Surviving

Dependents will be given the opportunity to drop coverage or change coverage elections. Retirees may

change the dependents they cover, Surviving Dependents only would have the opportunity to drop any

eligible dependents that they cover. Your Annual Enrollment materials will provide the options available

to you and your share of the premium cost, if any, for the coverages you elect. Your materials will also

include what actions you must take to continue certain coverages and will explain any applicable default

coverage that you will be deemed to have elected if you do not make the required elections by the

specified deadline. The elections you make will take effect on January 1 and stay in effect through

December 31, unless you have a qualifying change in status that permits you to make a mid-year election

change. See the “Making Changes During the Year” section.

Making Changes During the Year In general, after you enroll in benefits, you may not change or cancel your election choices during the

year. However, certain qualifying changes in status may warrant benefit changes if they are due to and

consistent with the qualifying change in status that affects your eligibility for the coverage. If you

experience a qualifying change in status, you can make certain mid-year changes to your dental coverage

elections. Examples of these qualifying life events and what you need to do relative to your dental

coverage are listed in the "Life Events and Your Coverage" section.

Covering Your Family When you enroll yourself in dental coverage, you decide if you want to enroll your eligible dependents.

Refer to the “Eligibility” section for a definition of eligible dependents. You can choose one of the

following coverage levels:

Participant only;

Participant + Spouse or Domestic Partner (not applicable to surviving dependents);

Participant + Child(ren) and/or Domestic Partner’s Child(ren) (A surviving spouse or dependent child

may enroll the other surviving dependent children); or

Participant + Family (not applicable to surviving dependents).

You must be enrolled in dental coverage to enroll your eligible dependents. Coverage is provided only for

those eligible dependents the Employee, Retiree or Surviving Dependent has actually enrolled. You

should contact the AEP Benefits Center to confirm those enrolled or to add or remove dependents from

your coverage at permissible times.

Waiving Coverage You may also waive coverage under the AEP Comprehensive Dental Plan. If you elect to waive coverage

for yourself, you automatically waive coverage for your eligible dependents. If you are a Retiree or

Surviving Dependent, if you waive coverage, you cannot enroll at a later date.

Qualified Medical Child Support Order (QMCSO) In some cases, you may be required by a court or administrative order to cover a dependent under the

AEP Comprehensive Dental Plan. Federal law requires group health plans to comply with orders from

state courts and administrative agencies that meet the requirements to be considered Qualified Medical

Child Support Orders (QMCSOs). A QMCSO may require you to add your child as a dependent for

dental benefits in some situations, typically a divorce.


You must be enrolled in dental coverage to add a dependent pursuant to a QMCSO. When you receive a

QMCSO, you should contact the AEP Benefits Center toll-free at 1-888-237-2363 to request a change in

coverage. You will also need to forward a copy of the court or administrative order to the AEP Benefits

Center. Once you or your dependent furnishes a court or administrative order to the AEP Benefit Center,

you and each affected child will be informed of receipt of the order and will be provided a copy of the

procedures for determining if the order is a QMCSO. Subsequently, the interested parties will be notified

of the determination. You may also obtain a copy of the QMCSO administrative procedures, free of

charge, by contacting the AEP Benefits Center.

Cost of Coverage Each year, AEP evaluates plan costs and may adjust your cost of coverage for the next year. Your cost

may be affected by factors that AEP considers appropriate, such as the availability of other coverage to

covered dependents, the time and circumstances applicable to an Employee or Retiree at the time of

disability, retirement or death and wellness incentive programs that AEP may implement from time to

time. The applicable cost for the upcoming year is made available by the time the Annual Enrollment

period for that year begins.

Employees As an active employee, you and AEP share the cost of your dental coverage. Your monthly cost for dental

coverage is automatically deducted from 24 paychecks per year. For any period that your paycheck is not

sufficient to cover your cost, you will have to make payment as directed at that time.

The amount you contribute toward the cost of your benefits generally is determined by:

The options you choose.

The number of dependents you cover.

Your contributions generally will be paid through before-tax payroll deductions; however, some benefits

or other circumstances may require contributions to be paid with after-tax dollars.

Retirees and Surviving Dependents If you are covered as a Retiree or Surviving Dependent, you pay the full cost of your dental coverage on

an after-tax basis. If you are covered as a Retiree, you may be able to elect payment of your contribution

from a monthly annuity being paid to you by the AEP System Retirement Plan (including the portion

consisting of the former Central and South West Corporation Retirement Plan). Otherwise, you will

receive a monthly billing statement for your dental contributions. Failure to remit payments in a timely

manner will result in loss of coverage.

When Coverage Begins For New Hires — If you timely enroll as an eligible employee, your coverage begins on your date of

hire. Coverage for your dependents begins the same day that your coverage begins.

For New Retirees — If you timely enroll as a Retiree (or, if your coverage automatically continued,

failed to waive coverage), your retiree coverage begins the first of the month following your retirement

date.

For Newly Surviving Dependents — If you fail to waive coverage as a surviving dependent, your

coverage continues the first of the month following the date of the Employee’s or Retiree’s death.


During Annual Enrollment — If you make changes to your AEP Comprehensive Dental Plan election

during the Annual Enrollment period, coverage for you and your enrolled dependents begins on January 1

of the following year and continues through December 31.

If You Make Changes During the Year — You must notify the AEP Benefits Center, toll-free, at

1-888-237-2363 within 31 days of a qualifying change in status event (or within 90 days of a birth or

adoption),except as otherwise specified. To be qualified, the change that you make to your coverage must

be due to and consistent with the event and affect your eligibility for coverage. You also may be required

to provide proof of the qualifying status changes. If you make changes to your coverage because of a

qualifying status change, the change in your coverage generally will become effective as of the date of

your qualifying event.

Refer to the “Life Events and Your Coverage” section for a list of some possible qualifying events and

actions you must take if any of these events in your life occur.

The AEP Benefits Center You may contact the AEP Benefits Center in order to provide any notice required under these procedures

as follows:

AEP Benefits Center

P.O. Box 622

Des Moines, IA 50306-0622

Phone number: 1-888-237-2363

www.ibenefitcenter.com/aep

When Coverage Ends Under most circumstances, your AEP coverage ends on the last day of the month in which:

You stop paying required contributions;

You terminate employment;

You are no longer eligible;

The plan ends; or

You die.

Coverage for your eligible dependents ends on the last of the month in which your coverage ends, or in

which they are no longer eligible.

Continuation of Coverage

Continuing Coverage as an AEP Retiree If you are age 55 or older with at least 10 years of service when your employment with AEP ends, you

alternatively may be able to continue coverage for yourself as an AEP "retiree" and for your eligible

dependents. Please refer to the “Eligibility” section for more information.

Continuing Coverage as a Surviving Dependent If you are covered as a dependent spouse or child of an Employee or Retiree at the time of the

Employee’s or Retiree’s death, your coverage may be continued as a “Surviving Dependent. Please refer

to the “Eligibility” section for more information about the availability and additional circumstances that

may cause that coverage to terminate.


Continuing Health Care Benefits Handicapped

Dependent Children Health Expense Coverage for your fully handicapped dependent child may be continued past the

maximum age for a dependent child.

Your child is fully handicapped if:

he or she is not able to earn his or her own living because of mental retardation or a physical handicap

which started prior to the date he or she reaches the maximum age for dependent children under your

plan; and

he or she depends chiefly on you for support and maintenance.

Proof that your child is fully handicapped must be submitted to Aetna no later than 31 days after the date

your child reaches the maximum age under your plan.

Coverage will cease on the first to occur of:

Cessation of the handicap.

Failure to give proof that the handicap continues.

Failure to have any required exam.

Termination of Dependent Coverage as to your child for any reason other than reaching the maximum

age under your plan.

Aetna will have the right to require proof of the continuation of the handicap. Aetna also has the right to

examine your child as often as needed while the handicap continues at its own expense. An exam will not

be required more often than once each year after 2 years from the date your child reached the maximum

age under your plan.

Continuing Dental Coverage under COBRA Under the Consolidated Omnibus Budget Reconciliation Act, a federal law known as “COBRA,”

employers with 20 or more employees that sponsor group health plans generally are required to offer

employees and their families the opportunity for a temporary extension of health coverage (called

“continuation coverage”) at group rates in certain instances where coverage under the plan would

otherwise end. This section is intended to inform you, in a summary fashion, of your rights and

obligations under the continuation coverage provisions of COBRA in connection with the group health

benefits maintained by the Participating AEP Companies (generally referred to in this notice as the

“Company”). The group health benefits maintained by the Company include the American Electric Power

System Comprehensive Dental Plan (referred to as the “Plan”). You and your spouse should take the time

to read this notice carefully.

Qualified Beneficiaries Status as a qualified COBRA beneficiary gives an individual special rights under COBRA. Persons

covered by the plan will be considered COBRA qualified beneficiaries only if they fit into one of the

following categories:

Retiree;

Employee or former employee;

Spouse or former spouse of the retiree, employee, or former employee; or

Dependent child(ren) of the retiree, employee, or former employee.


Therefore, you, your spouse and dependent children who are covered by the Plan at the time of the

“qualifying event” generally will be considered “qualified COBRA beneficiaries” with respect to the

Plan. Any child born or placed for adoption during the COBRA continuation period will also be treated as

a qualified beneficiary if you have dependent coverage under the Plan at the time. Please remember that

to enroll a newborn infant or a child placed with you for adoption (or even any other child or other

dependents acquired through marriage) in the Plan, you must follow the enrollment procedures that are

described in the Plan. A child is considered “placed for adoption” when the adoptive parent assumes and

retains the legally enforceable obligation for the partial or total support of the child. This obligation

generally arises when the proper court or proper agency issues an order to that effect.

Although COBRA laws do not establish health benefit continuation rights for other categories of eligible

dependent children or Alternative Family Members (such as domestic partners), AEP offers COBRA-like

coverage to them under the AEP Comprehensive Dental Plan.

COBRA Qualifying Events Employee. You have a right to choose this continuation coverage if you lose your coverage because of a

reduction in your hours of employment or the termination of your employment (for reasons other than

gross misconduct on your part) or, if you are a retiree, because of a filing under Title 11 of the Federal

Bankruptcy Code with respect to your employer (with regard to this qualifying event, the loss of coverage

may include the substantial elimination of your coverage within one year before or after the filing).

Spouse or Domestic Partner. The spouse or domestic partner of an employee (or a retiree for

reason 6) covered by the Plan, has the right to choose continuation coverage for himself or herself if he or

she lost coverage under that plan for ANY of the following six (6) reasons:

1. Your death;

2. A surviving spouse’s remarriage within 36 months of your death;

3. The termination of your employment (for reasons other than gross misconduct) or reduction in your

hours;

4. Your divorce, legal separation or termination of domestic partnership;

5. You become eligible for benefits under Medicare Part A, Part B, or both; or

6. A filing under Title 11 of the Federal Bankruptcy Code with respect to the employer. With regard to

this qualifying event, the loss of coverage may include the substantial elimination of coverage within

one year before or after the filing.

Dependent Child. Your dependent child, if covered by the Plan, has the right to continuation coverage

under the Plan if coverage is lost for any of the following six (6) reasons:

1. Your death;

2. The termination of your employment (for reasons other than gross misconduct) or reduction in your

hours;

3. Your divorce, legal separation or termination of domestic partnership;

4. You become eligible for benefits under Medicare Part A, Part B, or both;

5. Your dependent ceases to be a “dependent child” under the Plan; or

6. A filing under Title 11 of the Federal Bankruptcy Code with respect to the employer. With regard to

this qualifying event, the loss of coverage may include the substantial elimination of coverage within

one year before or after the filing.


For qualifying event purposes, coverage will be considered lost if a person ceases to be covered under the

same terms and conditions as in effect immediately before the applicable qualifying event. Any increase

in the premium or contribution that you must pay (or that your spouse or dependent child must pay) for

coverage under a plan that results from the occurrence of a qualifying event is considered a loss of

coverage. The loss of coverage need not occur immediately after the qualifying event, so long as the event

occurs before the end of the maximum coverage period (discussed under the heading “Duration of

Continuation Coverage”).

The taking of leave under the Family and Medical Leave Act (FMLA) is not considered a qualifying

event under COBRA. A qualifying event may occur under COBRA, however, on the last day of your

FMLA leave.

Obligation to Notify the Company of Certain Qualifying Events Under COBRA, you or your family member has the responsibility to inform the Company of a divorce or

legal separation, or of a child losing dependent status under the Plan. This notice must be provided to the

AEP Benefits Center within 60 days of the qualifying event. If the AEP Benefits Center is not provided

such notice within that time, there will be no continuation coverage available with respect to that

qualifying event.

You or your covered family member also has the responsibility to inform the Company of a Social

Security determination that you or your covered family member was disabled either at the time of your

termination or reduction in hours, or within 60 days thereafter. This notice must be provided to the AEP

Benefits Center in writing during the initial 18 months of continuation coverage and within 60 days of the

Social Security determination. If the AEP Benefits Center is not provided such notice within that time, the

11-month extension of the maximum continuation coverage period will not be available.

Also, if a child is born to you or placed for adoption with you during the period that you have elected

continuation coverage, that child may also be added to your coverage assuming that you timely notify the

AEP Benefits Center of the addition of the child and timely pay any additional premium that becomes

payable as a result of the addition. Please refer to the section entitled “Dependent Eligibility” to determine

how and when you may add a child to your coverage.

The Company has the responsibility to notify the Plan of your death, termination of employment or

reduction in hours, or if you become eligible for Medicare. Therefore, you should immediately notify the

AEP Benefits Center if you or another covered individual becomes eligible for Medicare.

The Company also relies on you to notify the Plan of the death of a covered individual or if a covered

individual becomes eligible for Medicare. Therefore, please immediately notify the AEP Benefits Center

if any of these persons dies or becomes eligible for Medicare and of the death of a covered individual.

Notice of Election. When the AEP Benefits Center is notified that one of the applicable qualifying

events has occurred, the AEP Benefits Center will in turn notify the qualified beneficiary of the right to

choose continuation coverage. This COBRA Notification letter will be mailed to you and/or the other

qualified beneficiaries at the last known address; therefore, it is imperative that you and your dependents

keep the AEP Benefits Center informed of any address change.


Under COBRA, you and each qualified beneficiary have 60 days from the latter of the date you would

lose coverage because of one of the qualifying events previously described, or the date you are notified of

your rights to continue coverage, to inform the Company that you want continuation coverage. As

mentioned, to inform the Company of your decision, please contact the AEP Benefits Center toll-free at

1-888-237-2363. If you do not choose continuation coverage with respect to the Plan, your coverage

under the Plan will end.

If you choose continuation of coverage under the Plan, the Company is required to give you coverage

which is identical to the coverage provided under the Plan to similarly situated employees or family

members, as such coverage may change from time to time. You and each of your other qualified

beneficiaries are eligible to continue only those Plan coverages that were in effect immediately before the

qualifying event. No evidence of insurability is required for election of COBRA continuation coverage.

Of course, you must pay the required contributions for the continuation coverage in a timely manner. (See

the section on “Conditions on Continuation Coverage.”)

Duration of Continuation Coverage. COBRA requires that you be afforded the opportunity to

maintain continuation coverage for 36 months unless you lost coverage because of a termination of

employment or reduction in hours. In that case, the required continuation coverage period is 18-months,

unless the Social Security Administration determines that you or a member of your family were disabled

at the time of the termination or reduction of hours (or within 60 days thereafter), and you inform the AEP

Benefits Center in writing within 60 days of that determination and before the end of the 18-month

period, in which case your coverage and the coverage of your family members may be extended to as

many as 29 months. You may be requested to provide additional documentation in order to qualify for

this 11-month extension.

If, during the initial 18 months of continuation coverage, another qualifying event takes place that also

entitles you to coverage, coverage may be extended. In no case may the total amount of continued

coverage be more than 36 months. If a second event occurs, it is the qualified beneficiary’s obligation to

notify the AEP Benefits Center of the second qualifying even within 60 days of that event and within the

original 18-month period.

There is a special rule that applies if you become eligible for Medicare within the 18 months prior to

termination of employment or reduction in hours. Under that circumstance, although your spouse and/or

dependent children effectively lose coverage because of your termination of employment or reduction in

hours, they will be entitled to maintain continuation coverage for a period that does not expire before

36 months have passed since you became entitled to Medicare.

If you are a retiree or a spouse or dependent child of a retiree, special rules apply to determine your

maximum period of COBRA continuation coverage.

COBRA generally requires that a plan offer conversion health plan coverage to a qualified beneficiary

who uses continuation coverage for the maximum coverage period, but only if conversion coverage is

otherwise generally available under the Plan. Because the DPPO option offers no such conversion

coverage, none will be made available following the expiration of continuation coverage for any qualified

beneficiary. DMO option participants may be eligible to convert to an individual health plan without

providing proof of good health.


COBRA also provides that continuation coverage may be cut short for ANY of the following reasons:

1. The Company no longer provides group health coverage to any of its employees;

2. The contribution for continuation coverage is not paid in a timely fashion;

3. You, your spouse or dependent will lose COBRA continuation coverage upon becoming covered

under another group health plan that does not include a preexisting conditions clause that applies

(note that the Health Insurance Portability and Accountability Act of 1996 limits the circumstances in

which plans can apply preexisting conditions clauses);

4. You, your spouse or dependent will lose COBRA continuation coverage upon becoming entitled to

benefits under Medicare (Part A, Part B or both); or

5. For cause, such as fraudulent claim submission, on the same basis that coverage could terminate for

other similarly situated participants in the Plan.

Therefore, you must immediately notify the AEP Benefits Center if you, your spouse or any of your

covered dependents become eligible for benefits under Medicare.

Furthermore, if continuation coverage is extended beyond 18 months because of disability, continuation

coverage will be cut short after the latter of the expiration of the initial 18-month continuation period or

the date that the qualifying beneficiary is determined to be no longer disabled. You are required to notify

the AEP Benefits Center within 60 days of the date of any final determination by the Social Security

Administration that the qualified beneficiary is no longer disabled. If you fail to timely notify the AEP

Benefits Center, the Plan reserves the right to recover from you its costs associated with recovering the

excess benefits provided to you.

Conditions on Continuation Coverage. You do not have to show that you are insurable to choose

continuation coverage. However, under COBRA, you will have to timely pay all of the contributions for

your continuation coverage as outlined under the law. The contribution for your continuation coverage

generally is equal to no more than the full cost of the coverage plus a 2% charge to cover the cost of plan

administration. If you or your dependents are entitled to up to 29 months of continuation coverage due to

disability, the premium increases to as much as 150% of the full cost beginning with the 19th month of

continuation coverage. The AEP Benefits Center can provide you with current cost information.

You must pay for the coverage in monthly installments. Your first payment must be in full and received

no later than 45 days after the date you elect continuation coverage. For payment after that first payment,

you will have a grace period of at least 30 days to pay the premiums. As a general matter, coverage will

be suspended for any period that premiums have not been paid. However, coverage will be reinstated

upon the receipt of timely payment (taking into account the grace period for that payment).

Continuation of Coverage During Military Leave (USERRA) Under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), you may

have a right to continuation of benefits subject to the conditions described below.


Under USERRA, if the Employee (or his or her Dependents) is covered under this Plan, and if the

Employee becomes absent from employment by reason of military leave, the Employee (or his or her

Dependents) may have the right to elect to continue health coverage under the Plan. In order to be eligible

for coverage during the period that the Employee is gone on military leave, the Employee must give

reasonable notice to the Employer of his or her military leave and the Employee will be entitled to

COBRA-like rights with respect to his or her group health benefits in that the Employee and his or her

Dependents can elect to continue coverage under the plan for a period of 24 months from the date the

military leave commences or, if sooner, the period ending on the day after the deadline for the Employee

to apply for or return to work with the Employer. During military leave the Employee is required to pay

the Employer for the entire cost of such coverage, including any elected Dependents’ coverage. However,

if the Employee’s absence is less than 31 days, the Employer must continue to pay its portion of the

contributions and the Employee is only required to pay his or her share of the contributions without the

COBRA-type 2% administrative surcharge.

Also, when the Employee returns to work, if the Employee meets the requirements specified below,

USERRA states that the Employer must waive any exclusions and waiting periods, even if the Employee

did not elect COBRA continuation. These requirements are (i) the Employee gave reasonable notice to his

or her Employer of military leave, (ii) the military leave cannot exceed a prescribed period (which is

generally five (5) years, except in unusual or extraordinary circumstances) and the Employee must have

received no less than an honorable discharge (or, in the case of an officer, not been sentenced to a

correctional institution), and (iii) the Employee must apply for reemployment or return to work in a

timely manner upon expiration of the military leave (ranging from a single day up to 90 days, depending

upon the period that he or she was gone). The Employee may also have to provide documentation to the

Employer upon reemployment that would confirm eligibility. This protection applies to the Employee

upon reemployment, as well as to any Dependent who has become covered under the Plan by reason of

the Employee’s reinstatement of coverage.

Life Events and Your Coverage In general, once you enroll in dental plan benefits, you cannot make changes to your elections until the

next Annual Enrollment period. However, certain events in your life — such as a marriage, divorce or

birth of a child — may warrant mid-year changes that are due to and consistent with the event.

Remember — if you do not make your change within 31 days of the event (or as otherwise specified

below in certain circumstances), you may not change your elections until the next Annual Enrollment

period.

You Begin Working at AEP As a new employee of a Participating Company, you must indicate your dental plan election within

31 days of your hire date. If you do not enroll within 31 days, you will not have coverage. Unless you

experience a qualifying change in family or employment status, you will not be able to make changes to

your benefit elections until the next Annual Enrollment period.

Coverage begins on your first day of work, if you enroll within 31 days of your date of hire.

You Get Married Your marriage is considered a qualifying change in family status which allows you to adjust your

participation in the dental plan. You must contact the AEP Benefits Center in order to make benefit

changes when you marry. All changes must be made within 31 days of the date of your marriage. A copy

of the certified marriage certificate will be requested by the AEP Benefits Center in order to enroll your

new spouse. A marriage event does NOT allow you to change your dental plan option.


Coverage is effective on the date of your marriage if you enroll yourself, your spouse and/or your eligible

dependents within 31 days of the date of your marriage.

Your Marriage Ends It’s important to keep the AEP Benefits Center informed of loss of dependent eligibility due to the end of

your marriage. The AEP Benefits Center can help you make appropriate benefits changes. If you have

spouse or family dental coverage, coverage for your former spouse (and any stepchildren) ends on the last

day of the month in which your marriage ends.

You are required to notify the AEP Benefits Center to remove the names of former dependents from

your dental plan.

Your former spouse and any stepchildren may continue the group coverage for 36 months through

COBRA.

If you have eligible children, you may wish to retain Participant + Child(ren) dental coverage even if

you do not have custody of your child(ren). If you drop dependent coverage, you may not resume

coverage for these dependents until the next Annual Enrollment period.

If you were covered under your spouse’s dental plan, you have 31 days from the date your marriage

ends to apply for AEP dental coverage in your own name.

An event ending your marriage event does NOT allow you to change your dental plan option.

Your Domestic Partnership Ends You must notify the AEP Benefits Center of the loss of dependent eligibility due to termination of a

domestic partnership. The AEP Benefits Center can help you make changes to your dental coverage. You

will need to supply a “Declaration of Termination of Domestic Partnership” form to the AEP Benefits

Center in order to change your dental coverage.

If you have domestic partner or family dental coverage, coverage for your former domestic partner

(and any children of your domestic partner) ends on the last day of the month of the end of your

partnership.

You are required to notify the AEP Benefits Center to remove the names of former dependents from

your dental coverage.

Your former domestic partner (and any children of your domestic partner) may continue the group

coverage for up to 36 months, based on the manner the Company is currently offering COBRA

continuation coverage.

If you were covered under your domestic partner’s dental coverage, you have 31 days from the date

of the end of the partnership to apply for AEP dental coverage.

The termination of your domestic partnership does NOT allow you to change your dental plan option.

You Are Unable to Work Due to an Illness or Injury If you are unable to work due to illness or injury while covered under the AEP Comprehensive Dental

Plan, your coverage and obligation to make contributions continue while you are receiving sick pay and

for as long thereafter as you are receiving benefits under AEP’s Long-term Disability (LTD) plan.

You Die In the event you die, your survivors must contact the AEP Benefits Center to:

Make decisions about whether to continue dental coverage for themselves if they were enrolled in

dental coverage at the time of your death.


If you die while employed at AEP, your eligible surviving dependents can continue dental plan coverage

if all required contributions are paid up to date. Please refer to the “Eligibility” section for additional

information about who is eligible to be covered as a surviving dependent and for how long.

If a surviving dependent enrolls in the AEP Comprehensive Dental Plan but later disenrolls from the plan,

he or she may not elect to re-enroll later.

Your survivors will need to submit a copy of your Death Certificate to the AEP Benefits Center prior to

enrollment in coverage.

Your survivors must enroll within 31 days of your death, or such longer period as may be required by

COBRA.

Your survivors will need to submit a copy of your Death Certificate to the AEP Benefits Center prior to

enrollment in coverage.

Your death does NOT allow your surviving dependents to change the dental plan option in which they

were enrolled

A Covered Family Member Dies The death of a family member who is eligible for AEP benefits is considered a qualifying change in

family status which allows you to adjust your participation in the dental plan. Remember that any changes

must be made within 31 days of the death.

Review your dental coverage, and contact the AEP Benefits Center to adjust your coverage level, as

appropriate, for the surviving family members The death of a covered dependent does NOT allow you to

change your dental plan option..

Your Child Loses Dependent Status Your child loses eligibility to be covered as your dependent at the end of the month in which he or she

turns age 26.

If your child is disabled when coverage would otherwise end, you may be able to keep him or her covered

under your plan. Consult the AEP Benefits Center for requirements to continue coverage during the

child’s disability.

Dental coverage also ends for your dependent on the last day of the month in which he or she no longer

meets any other requirement to be considered an eligible dependent. The child may continue coverage

through COBRA.

Birth, Adoption, Placement for Adoption or Legal Guardianship Your newborn child will be eligible for coverage on the date of birth. If a child is placed with you for

adoption, he or she will be eligible for coverage on the date of the placement for adoption as long as the

child satisfies the eligibility requirements of this plan.

To enroll a newborn or other dependent child in dental coverage, you must notify the AEP Benefits

Center within 90 days of the birth, adoption, or the date the child was legally placed in your care in

anticipation of adoption. You must provide the dependent’s Social Security number or tax-identification

number for non-USA citizens, within six months of adding a dependent. The AEP Benefits Center will

request a copy of the birth certificate to validate their eligibility.


Change in Your Spouse's/Domestic Partner’s Employment If your spouse’s/domestic partner’s coverage is affected by a change in his or her employment or benefits

eligibility with his or her current employer, you may be eligible to begin, change, or discontinue coverage

under the AEP Comprehensive Dental Plan to the extent that would be consistent with the events

affecting your spouse/domestic partner. You may not change your dental plan option if you are already

enrolled in the AEP Dental Plan.

You must contact the AEP Benefits Center within 31 days of your spouse’s/domestic partner’s loss/gain

of coverage.

You Begin a Family Medical Leave of Absence (FMLA) If you are on an approved Family Medical Leave of Absence (FMLA), your benefits may be affected.

You may be on a paid or unpaid leave of absence under FMLA.

Under a paid FMLA absence, your dental coverage continues as normal and your dental plan

contributions continue to be taken from your first and second paychecks of the month.

If your FMLA is unpaid, you have the following options:

Revoke Coverages during the Leave. In order to take advantage of this option, then within 31 days

after your leave begins, you must notify the AEP Benefits Center of the specific coverages that you

want to discontinue during the period of your unpaid FMLA leave. You will be entitled to reinstate

the discontinued coverages upon your return to work following your leave.

Continue Your Coverages by Making Payments. Unless you notify the AEP Benefits Center

otherwise, it will be assumed that this is the option that you select. Under this option, you would pay

for your coverage by the first of each month during the leave. When the leave ends, your salary

reduction election that had been in effect at the beginning of your leave will be given effect for the

duration of the calendar year unless you would make an election change upon returning from the

leave, as permitted under the terms of our plan (e.g., for changes in status). If you would stop making

contributions for your coverage during the leave, AEP will continue your coverage, and AEP will

recoup your missed payments upon your return.

COBRA eligibility does not begin until your FMLA leave ends.

You Begin an Unpaid Leave of Absence (non-FMLA) In certain situations, you may need to take more time off from work than your available vacation time

allows. In such cases, you may be eligible for an unpaid leave of absence.

Your dental contributions from your paycheck stop when your unpaid leave begins.

Coverage ends at the end of the month in which your unpaid Leave of Absence begins. You will be

offered the option to continue dental coverage through COBRA.

You Begin a Paid Military Leave of Absence Serving on active duty in the Armed Forces of our country can have an effect on your AEP benefits.

Generally, all benefit coverage levels will continue for up to 24 months at the level in effect immediately

before your paid military leave begins. You have the option to maintain some or all of your benefits

during your paid military leave.


If you elect to continue your dental coverage, your contribution continues at the active employee rate for

as long as you receive pay differential, for up to 24 months and your contributions will be withheld from

your paycheck. If you don’t have enough net pay to take all of your deductions, you will be billed on a

monthly basis. If you elect to discontinue dental coverage during your paid military leave of absence,

your coverage will end at the end of the month in which your paid military leave began.

If you go onto an unpaid Military Leave of Absence, see “Continuation of Coverage During Military

Leave (USERRA),” and “You Begin an Unpaid Leave of Absence (non-FMLA)” for information

regarding your dental coverage.

You Terminate Employment Before Qualifying for AEP Retiree Benefits If your employment with a Participating Company terminates for any reason prior to both reaching age 55

and at least 10 years of service, your dental coverage ends on the last day of the month in which your

employment ends.

You and your dependents may be eligible to continue dental coverage through COBRA. Under COBRA

you pay the full cost of that coverage, plus an administrative charge.

You Terminate Employment After Becoming Retiree Benefits Eligible If you are age 55 or older with at least 10 years of service when your employment with a Participating

AEP system company ends, you may be considered an AEP “retiree.”

See the “Enrolling for Coverage” section.

If you elect retiree dental coverage, premiums will either be deducted from your monthly pension check

or you will be billed monthly for your premiums.

You Are Rehired at AEP As a rehired employee of a Participating Company, you must indicate your dental care election within

31 days of your rehire date. If you do not enroll within 31 days, you will not have dental coverage. Unless

you experience a qualifying change in family or employment status, you will not be able to make changes

to your benefit elections until the next Annual Enrollment period.

You and your eligible dependents are covered from your first day of work, if you enroll within 31 days of

your rehire date.

You Return from an Unpaid Leave of Absence After returning from an approved leave of absence, you may resume participation in benefits that you

may have stopped during your leave or benefits that you may have elected under COBRA.

You may continue, add, or discontinue dental coverage for yourself and your eligible dependents, within

31 days of your return from leave. If you resume participation in the dental plan when you return from

your unpaid leave, your contributions will begin coming out of your paycheck again.


You Return After Retirement If you return to work with a Participating AEP Company after retirement and are only returning for a

temporary length of time (less than 1 year), you may be eligible to be considered a “rehired retiree” or

you can also return to work for AEP as a regular full-time or part-time employee. If you return as a

“rehired retiree,” you retain your retiree dental coverage at the applicable retiree contribution rate while

you work. Your dental contributions will be deducted from your paycheck.

Coverage or Employer Contributions Lost Under Another Dental Plan A Special Enrollment Period is available to you (if you are an eligible Employee or Retiree) and your

eligible Dependents who:

lost eligibility under a prior dental plan for reasons other than non-payment of premium or due to

fraud or intentional misrepresentation of a material fact;

exhausted COBRA benefits or stopped receiving group contributions toward the cost of the prior

dental plan; or

lost Employer contributions towards the cost of the other coverage.

Notice of a requested change must be made to the AEP Benefits Center within 31 days of the event (or

within 90 days of a birth or adoption). You also may be required to provide proof of the qualifying status

change(s).

Newly Eligible Because of Change in AEP Employment Status If your AEP employment status would change from one not eligible to participate (such as if you had

been classified as a contractor, temporary employee, or leased employee) to one that is, you may be able

to enroll in the dental plan within 31 days of the change in employment status. Notice of a requested

change must be made to the AEP Benefits Center within 31 days of the change in your status.

How Your Aetna Dental Plan Works

Understanding Your Aetna Dental Plan It is important that you have the information and useful resources to help you get the most out of your

Aetna dental plan. This Summary Plan Description (“SPD”) explains:

Definitions you need to know;

How to access care, including procedures you need to follow;

What services and supplies are covered and what limits may apply;

What services and supplies are not covered by the plan;

How you share the cost of your covered services and supplies; and

Other important information such as eligibility, complaints and appeals, termination, continuation of

coverage and general administration of the plan.

Important Notes: Unless otherwise indicated, “you” refers to you and your covered dependents. You can refer to the

“Eligibility” section for a complete definition of “you.”

This SPD applies to coverage only and does not restrict your ability to receive covered expenses that are

not or might not be covered expenses under this dental plan.

Store this SPD in a safe place for future reference.


Getting Started: Common Terms Many terms throughout this SPD are defined in the Glossary Section at the back of this document.

Defined terms appear in bolded print. Understanding these terms will also help you understand how your

plan works and provide you with useful information regarding your coverage.

About the Managed Dental Plan Under the Managed Dental Plan, you access care through the primary care dentists (PCD) you select

when you enroll. Each covered family member may select a different PCD. Your PCD provides basic

and routine dental services and supplies, and will refer you to other dental providers in the network.

You may select a PCD from the Aetna network provider directory or by logging on to Aetna’s website

at www.Aetna.com. You can search Aetna’s online directory, DocFind, for names and locations of

network providers.

Out-of-network services and supplies are not covered, except in the event of a dental emergency.

Accessing Network Providers The plan pays a higher level of benefits when your PCD provides your care or refers you to a

specialist dentist.

You must pay a copay for certain types of services and supplies.

You have no further out-of-pocket expenses after you pay all applicable copays, as shown in the

Schedule of Benefits.

You will not have to submit dental claims for treatment received from network providers. Your

network provider will take care of claim submission. Aetna will directly pay the network

providers less any cost sharing required by you. You will be responsible for coinsurance and

copayments, if any.

If you need a service that is not available from a network provider, your PCD may refer you to an out-

of-network provider. You will receive the network level of coverage if your PCD gets approval from

Aetna for this referral.

Changing Your PCD You may change your PCD at any time on Aetna’s website, www.Aetna.com, or by writing to Aetna or

calling the Member Services toll-free number on your identification card. The change will be effective as

follows:

If Aetna receives a request on or before the 15th day of the month, the change will be effective on the

first day of the next month.

If Aetna receives a request after the 15th day of the month, the change will be effective on the first

day of the month following the next month.

Availability of Providers Aetna cannot guarantee the availability or continued participation of a particular provider. Either Aetna

or any network provider may terminate the provider contract or limit the number of patients accepted

in a practice. If the PCD initially selected cannot accept additional patients, you will be notified and

given an opportunity to make another selection. If the agreement between Aetna and your selected PCD

is terminated, Aetna will notify you of the termination and request you to select another PCD.

Important Reminder You must have a referral from your PCD in order to receive coverage for any services a specialist

dentist provides. Please refer to the “Referral Process” section.




Using Your Dental Plan

The Referral Process There may be times when you need services and supplies that only a dental specialist can provide. In

these cases, your PCD will make a referral to a specialist dentist. A PCD referral is not required for

any orthodontic services.

Having a referral from your PCD keeps your out-of-pocket expenses lower for services of a specialist

dentist and any necessary follow-up treatment. The referral is important because it is how your PCD

arranges for you to receive care and follow-up treatment.

How Referrals Work Here are some important points to remember:

When your PCD determines that your treatment should be provided by a specialist dentist, you'll receive

a written or electronic referral. The referral will be good for 90 days, as long as you remain covered

under the plan.

Go over the referral with your PCD. Make sure you understand what types of services have been

recommended and why.

When you visit the specialist dentist, bring the referral (or check in advance to verify that they have

received the electronic referral). Without it, you'll receive out-of-network benefits – even if you receive

your treatment from a network provider.

You cannot request a referral from your PCD after you have received services from a specialist dentist.

If a service you need isn't available from a network provider, your PCD may refer you to an out-of-

network provider. Your PCD must get precertification from Aetna and issue a special out-of-network

referral for services from out-of-network providers to be covered at the network level of coverage.

When You Do Not Need a PCD Referral You do not need a PCD referral for:

Emergency care. Please refer to the “In the case of a Dental Emergency” section.

Direct Access Services. Orthodontic services and supplies do not require a referral.

Important Reminder Refer to the “Schedule of Benefits” for details about any applicable deductibles, copayments,

coinsurance and maximums. There is a separate deductible and maximum that applies to

orthodontic treatment.

Important Reminder You must have a referral from your PCD in order to receive the network level of coverage for any

services received from a specialist dentist.


In Case of a Dental Emergency If you need dental care for the palliative treatment (pain relieving, stabilizing) of a dental emergency,

you are covered 24 hours a day, 7 days a week.

A dental emergency is any dental condition which:

Occurs unexpectedly;

Requires immediate diagnosis and treatment in order to stabilize the condition; and

Is characterized by symptoms such as severe pain and bleeding.

Follow the guidelines below when you believe you have a dental emergency.

If you have a dental emergency, call your PCD. If you cannot reach your PCD or are away from home,

you may get treatment from any dentist. You may also call Member Services for help in finding a

dentist. The care must be for the temporary relief of the dental emergency until you can be seen by your

PCD. The care provided must be a covered service or supply. You must submit a claim to Aetna

describing the care given.

The plan pays a benefit up to the dental emergency maximum. All follow-up care should be provided by

your PCD.

If you seek care from an out-of-network provider for a non-emergency dental condition (that is, one that

does not meet the definition above), no benefit will be payable.

What the Plan Covers

Managed Dental Plan Managed Dental Plan is merely a name of the benefits in this section. The plan does not pay a benefit for

all dental expenses you incur.

Covered expenses include charges made by a dental provider only for the services and supplies that are

listed in the dental care schedule that applies. See “Schedule of Benefits.”

The next sentence applies 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.

In that case, the charge will be considered to have been made for a service in the list that Aetna

determines would have produced a professionally acceptable result.

Coverage is also provided for a dental emergency. For additional information, please refer to “In Case of

a Dental Emergency.”

Important Reminder Your dental services and supplies must meet the following rules to be covered by the plan:

The services and supplies must be medically necessary.

The service and supplies must be listed in the dental care schedule.

You must be covered by the plan when you incur the expense.


Schedule of Benefits

This Schedule Applies To Covered Expenses Provided By Network Providers. 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.

If:


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.

This Schedule Applies to Services Provided by Network Providers Primary Care Dentist Services

Visits and Exams Oral examination (limited to total of 4 visits per calendar year)

Copayment Amount $0

Emergency palliative treatment $10

Prophylaxis (cleaning), (limited to 2 treatments per calendar year)

Adult $0

Child $0

Topical application of fluoride (limited to 1 treatment per calendar year and

to covered persons under age 16) $0 Oral hygiene instruction $0 Sealants, per tooth (limited to 1 application every 3 rolling years for permanent molars only and covered persons to age 16) $5 Pulp vitality test $0 Consultation $0 Diagnostic casts $0

X-Rays and Pathology Bitewing x-rays (limited to 1 set per calendar year) $0

Entire series, including bitewings, or panoramic film, (limited to 1 set every 3 rolling years) $0

Vertical bitewing X-rays (limited to 1 set every 3 rolling years) $0

Periapical x-ray $0 Intra-oral, occlusal view, maxillary or mandibular $0 Extra-oral upper or lower jaw $0 Biopsy and histopathologic examination of oral tissue $75

Important Reminder

The copays that apply to each type of dental care are shown in the “Schedule of Benefits.”


Space Maintainers - (only when needed to preserve space resulting from premature loss

of primary teeth) Includes all adjustments within six months after installation Fixed $75 Removable $70 Recement space maintainer $12 Remove fixed space maintainer (by dentist who did not place appliance) $12

Endodontics Pulp cap $0

Pulpotomy $22 Root canal therapy, including necessary x-rays

Anterior $70 Bicuspid $109

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

Resin-based composite restoration (anterior) 1 surface $0 2 surfaces $0 3 surfaces $0

4 or more surfaces or incisal angle $45 Resin-based composite crown, anterior $50 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 $40

Stainless steel crowns, prefabricated, permanent tooth $50 Recementing inlays or crowns $10 Recementing bridges $15 Sedative filling $3

Inlays and Onlays, metallic* $195 Crowns

Porcelain $255 Porcelain with metal (includes abutments)* $255 Metallic (full cast) (includes abutments)* $255 Metallic (3/4 cast)* $255 Cast post and core* $112

Prefabricated post and core $74

Core buildup including pins $80


Pontics Metallic (full cast)* $255 Porcelain with metal* $255

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 $350

Immediate, upper or lower (does not include charge for reline) $315 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 $20 Repair acrylic, 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) $45

Reline, partial denture, upper or lower (chairside) $45 Reline, complete denture, upper or lower (laboratory) $102 Reline, partial denture, upper or lower (laboratory) $102 Interim partial denture, upper or lower (stayplate), anterior only $90 Tissue conditioning for dentures $40

Periodontics

Scaling and root planning, per quadrant (limited to 4 separate quadrants every

2 rolling years) $62

Scaling and root planning -1 to 3 teeth per quadrant (limited to once per site every

2 rolling years) $37

Periodontal maintenance procedures following surgical therapy (limited to 2 per

calendar year) $45 Full mouth debridement (once per lifetime) $60 Occlusal guard (for bruxism only), limited to 1 every 3 rolling years $100

Oral Surgery - Includes local anesthetics and routine post-operative care Extraction - exposed root or erupted tooth $0

Extraction - coronal remnants $0 Surgical removal of erupted tooth $28 Surgical removal of impacted tooth (soft tissue) $46 Incision and drainage of intraoral abscess $20 Surgical exposure of impacted or unerupted tooth to aid eruption. $30


Specialty Services Copayment Amount

Endodontics - Includes local anesthetics where necessary Apicoectomy/periradicular surgery

Anterior $92 Bicuspid, first root $92 Molar, first root $90 Each additional root $55

Retrograde filling, per root $40 Root amputation, per root $70 Molar root canal therapy $280

Retreatment of previous root canal therapy Anterior

$170 Bicuspid $209

Molar Oral Surgery - Includes local anesthetics where necessary and post-operative care

$380

Surgical removal of root tip, root recovery $25 Frenectomy $34 Alveoplasty in conjunction with extractions – per quadrant $25 Alveoplasty not in conjunction with extractions – per quadrant $40 Surgical removal of impacted tooth

Partially bony $58 Completely bony $117 Completely bony with unusual surgical complications

Periodontics $117

Gingivectomy or gingivoplasty - per quadrant, limited to 1 per quadrant, every 3 rolling years

$133

Gingivectomy or gingivoplasty – 1–3 teeth, limited to 1 per site, every 3 rolling years $57 Gingival flap procedure – per quadrant $134 Gingival flap procedure – 1–3 teeth one per quadrant $80

Occlusal adjustment (other than with an appliance or restoration) Limited

$20 Complete

Osseous surgery (including flap entry and closure) - per quadrant, limited to 1 per $80

quadrant, every 3 rolling years Osseous surgery (including flap entry and closure) – 1–3 teeth, limited to once per site

$300

every 3 rolling years $180 Surgical revision procedure, per tooth $120 Pedicle soft tissue graft $230 Free soft tissue graft (including donor site surgery) $245 Subepithelial connective tissue graft $275 Soft tissue allograft $275 Combined connective tissue and double pedicle graft $303 Clinical crown lengthening – hard tissue Orthodontics

$180

Orthodontic screening exam (when no Orthodontic Procedure is performed) $30 Orthodontic diagnostic records $150 Comprehensive orthodontic treatment of adolescent and adult dentition $1,945 Orthodontic retention $275


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

This Schedule Applies to Covered Expenses Provided by Out-of-Network Providers Dental Care Schedule

Out-of-Network Deductible $100

Copayment The copayment is the amount of charges that exceeds the benefits payable under this coverage.

This dental care schedule shows services that are covered and maximum charge eligible under the plan for

each service. Dental services that are considered covered expenses as shown in the dental care schedule

must be given by a licensed dentist, at the dental office location. You are responsible for any amount

above the Amount Payable shown.

The next sentence applies if:


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 a

professionally acceptable result, as determined by Aetna.

Primary Care Services Schedule

Type A Services

Visits and Exams

Out-of-Network maximum Amount

Payable by Aetna Office visit for oral examination (limited to 4 visits per year) $12 Emergency palliative treatment Prophylaxis (cleaning) (limited to 2 treatments per year)

$12

Adult $26 Child $14

Topical application of fluoride (limited to 1 treatment per year and to covered persons under age 16)

$16 Oral hygiene instruction $12

Sealants; per tooth (limited to 1 application every 3 years for permanent molars and to covered persons under age 16)

$10 Pulp vitality test $8 Consultation $12 Diagnostic casts $20


X-Ray and Pathology Bitewing x-rays (limited to 1 set per year) $8 Entire series; including bitewings; or panoramic film (limited to 1 set every 3 years) $14

Vertical bitewing x-rays (limited to 1 set every 3 years) $12 Periapical x-rays $6 Intra-oral; occlusal view; maxillary or mandibular $8 Extra-oral upper or lower jaw $12 Biopsy and histopathologic examination of oral tissue $27

Space Maintainers - Includes all adjustments within six months after installation.

Fixed; band type $40 Removable acrylic with round wire clasp $32 Recement space maintainer $10 Removal of fixed space maintainer (by dentist who did not place appliance) $10

Type B Services Endodontics Pulp cap $3 Pulpotomy $27 Root canal therapy; including necessary x-rays

Anterior $80

Bicuspid $96

Restorations and Repairs Amalgam restoration

1 surface $12 2 surfaces $16 3 surfaces $24 4 or more surfaces $26

Resin restoration (other than for molars)

1 surface $12 2 surfaces $16 3 surfaces $26 4 or more surfaces or incisal angle $30

Retention pins $14 Sedative filling $12

Stainless steel crowns $26

Prefabricated resin crowns (excluding temporary crowns) $60 Recementing inlays or crowns $16 Recementing bridges $16 Tissue conditioning for dentures $26

Periodontics Emergency treatment (abscess; acute periodontitis; etc.) $26 Subgingival curettage (limited to 4 separate quadrants; every 2 years) $40

Scaling and root planning (limited to 4 separate quadrants every 2 years) $40

Periodontal maintenance procedures following surgical therapy (limited to 2 per year) $40

Oral Surgery - Includes local anesthetics and routine post-operative care. Extraction, coronal remnants $14 Extraction - exposed root or erupted tooth $27 Surgical removal of erupted tooth $32


Surgical removal of impacted tooth (soft tissue) $40

Excision of hyperplastic tissue $32 Excision of pericoronal gingival $40 Incision and drainage of abscess $20

Crown exposure to aid eruption $26

Removal of foreign body from soft tissue $20 Suture of soft tissue injury $20

Type C Services Restorations Inlays

1 surface $60 2 or more surfaces $80

Onlays 2 surfaces $80 3 or more surfaces $80

Crowns (including build-ups when necessary)

Resin $120

Resin with noble metal $120 Resin with base metal $120 Porcelain $120 Porcelain with noble metal $120 Porcelain with base metal $120 Base metal (full cast) $120 Noble metal (full cast) $120

Metallic (3/4 cast) $120 Post and core $27

Pontics Base metal (full cast) $20 Noble metal (full cast) $20 Porcelain with noble metal $20 Porcelain with base metal $20 Resin with noble metal $20 Resin with base metal $20

Dentures and Partials - (includes relines; rebases and adjustments within six months

after installation) Full (Upper or Lower) $120 Partial $120

Stress breakers (per unit) $40

Interim partial denture; (stayplates); anterior only $40

Crown and bridge repairs $27 Adding teeth to an existing denture $40 Full and partial denture repairs $27 Relining/rebasing dentures (includes adjustments with six months after installation) $40 Occlusal

guard (for bruxism only); (limited to 1 every 3 years) $40


Specialty Care Dental Services

Type B Services Endodontics - Includes local anesthetics where necessary.

Apexification/recalcification - per visit $32

Apicoectomy First root $60 Each additional root $40

Retrograde Filling $14 Root Amputation $27 Hemisection $27

Oral Surgery - Includes local anesthetics where necessary and post-operative care.

Removal of residual root $27 Removal of odontogenic cyst $40 Closure of oral fistula $48 Removal of foreign body from bone $20 Sequestrectomy $20 Frenectomy $40

Transplantation of tooth or tooth bud $48

Alveoplasty in conjunction with extractions - per quadrant $27 Alveoplasty not in conjunction with extractions - per quadrant $40 Removal of exostosis $60 Sialolithotomy; removal of salivary calculus $36 Closure of salivary fistula $36

Periodontics Gingivectomy or gingivoplasty - per quadrant (limited to 1 quadrant; every 3 years) $40

Gingivectomy or gingivoplasty - per tooth (limited to 1 per site; every 3 years) $20

Gingival flap procedure - per quadrant $60 Occlusal adjustment (other than with an appliance or by restoration)

Limited $20 Entire Mouth $40

Type C Services

Endodontics - Includes local anesthetics where necessary. Complex Molar Root Canal Therapy $120

Intravenous Sedation and General Anesthesia - per 15-minute segment. $20

Oral Surgery - Includes local anesthetics where necessary and post-operative

care. Surgical removal of impacted tooth Partially bony $53 Completely bony $60 Completely bony with unusual surgical complications $64

Periodontics Osseous surgery (including flap entry and closure) – per quadrant (limited to 1 per

quadrant; every 3 years) $80 Osseous surgery (including flap entry and closure) – 1–3 teeth per quadrant (limited to 1 per site every 3 years) $40 Clinical crown lengthening – hard tissue $40


Orthodontics Comprehensive orthodontic treatment of adolescent dentition

Comprehensive orthodontic treatment of adult dentition

Post Treatment Stabilization

Lifetime Maximum: $400

Expense Provisions 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.

Deductible Provisions 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.

Copayments and Benefit Deductible Provisions Copayment, Copay

This is a specified dollar amount or percentage of the negotiated charge required to be paid by you at the

time you receive a covered service from a network provider. It represents a portion of the applicable

expense.

Maximum Benefit Provisions Lifetime Maximum Benefit

The most the plan will pay for covered expenses incurred by any one covered person during their lifetime

is called the Lifetime Maximum Benefit.

The Lifetime Maximum Benefit applies to network and out-of-network expenses combined. The

Lifetime Maximum Benefit will not deny benefits for certain covered expenses.

General 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. Coverage is underwritten by Aetna Life Insurance Company.

Managed Dental Expense Coverage Plan The following additional dental expenses will be considered covered expenses for you and your covered

dependent if you have medical coverage insured or administered by Aetna and have at least one of the

following conditions:

Pregnancy;

Coronary artery disease/cardiovascular disease;

Cerebrovascular disease; or

Diabetes


Additional Covered Dental Expenses

One additional prophylaxis (cleaning) per year.

Scaling and root planing, (4 or more teeth); per quadrant;

Scaling and root planing (limited to 1–3 teeth); per quadrant;

Full mouth debridement;

Periodontal maintenance (one additional treatment per year); and

Localized delivery of antimicrobial agents. (Not covered for pregnancy)

Payment of Benefits

The additional prophylaxis, the benefit will be payable the same as other prophylaxis under the plan.

The plan coinsurance applied to the other covered dental expenses above will be 100%. These additional

benefits will not be subject to any frequency limits except as shown above.

Aetna will reimburse the provider directly, or you may pay the provider directly and then submit a claim

for reimbursement for covered expenses.

Rules and Limits That Apply to the Dental Plan Several rules apply to the dental plan. Following these rules will help you use the plan to your advantage

by avoiding expenses that are not covered by the plan.

Orthodontic Treatment Rule The plan does not cover the following orthodontic services and supplies:

Replacement of broken appliances;

Re-treatment of orthodontic cases;

Changes in treatment necessitated by an accident;

Maxillofacial surgery;

Myofunctional therapy;

Treatment of micrognathia;

Treatment of cleft palate;

Treatment of macroglossia;

Treatment of primary dentition;

Treatment of transitional dentition;

Lingually placed direct bonded appliances and arch wires (i.e. “invisible braces”); or

Removable acrylic aligners (i.e. “invisible aligners”).

The plan will not cover the charges for an orthodontic procedure if an active appliance for that procedure

was installed before you were covered by the plan.

Replacement Rule Crowns, inlays, onlays and veneers, complete dentures, removable partial dentures, fixed partial dentures

(bridges) and other prosthetic services are subject to the plan's replacement rule. That means certain

replacements of, or additions to, existing crowns, inlays, onlays, veneers, dentures or bridges are covered

only when you give proof to Aetna that:

While you were covered by the plan, you had a tooth (or teeth) extracted after the existing denture or

bridge was installed. As a result, you need to replace or add teeth to your denture or bridge.

The present crown, inlay and onlay, veneer, complete denture, removable partial denture, fixed partial

denture (bridge), or other prosthetic service was installed at least 5 years before its replacement and

cannot be made serviceable.


You had a tooth (or teeth) extracted while you were covered by the plan. Your present denture is an

immediate temporary one that replaces that tooth (or teeth). A permanent denture is needed, and the

temporary denture cannot be used as a permanent denture. Replacement must occur within 12 months

from the date that the temporary denture was installed.

Tooth Missing but Not Replaced Rule The first installation of complete dentures, removable partial dentures, fixed partial dentures (bridges),

and other prosthetic services will be covered if:

The dentures, bridges or other prosthetic services are needed to replace one or more natural teeth that

were removed while you were covered by the plan; and

The tooth that was removed was not an abutment to a removable or fixed partial denture installed

during the prior 5 years. 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 Sometimes there are several ways to treat a dental problem, all of which provide acceptable results. When

alternate services or supplies can be used, the plan's coverage will be limited to the cost of the least

expensive service or supply that is:

Customarily used nationwide for treatment, and

Deemed by the dental profession to be appropriate for treatment of the condition in question. The

service or supply must meet broadly accepted standards of dental practice, taking into account your

current oral condition.

You should review the differences in the cost of alternate treatment with your dental provider. Of course,

you and your dental provider can still choose the more costly treatment method. You are responsible for

any charges in excess of what the plan will cover.

Coverage for Dental Work Begun Before You Are Covered by the Plan The plan does not cover dental work that began before you were covered by the plan. This means that the

following dental work is not covered:

An appliance, or modification of an appliance, if an impression for it was made before you were

covered by the plan;

A crown, bridge, or cast or processed restoration, if a tooth was prepared for it before you were

covered by the plan; or

Root canal therapy, if the pulp chamber for it was opened before you were covered by the plan.

Coverage for Dental Work Completed After Termination of Coverage Your dental coverage may end while you or your covered dependent is in the middle of treatment. The

plan does not cover dental services that are given after your coverage terminates. There is an exception.

The plan will cover the following services if they are ordered while you were covered by the plan, and

installed within 30 days after your coverage ends.

Inlays;

Onlays;

Crowns;

Removable bridges;

Cast or processed restorations;

Dentures;

Fixed partial dentures (bridges); and

Root canals.


“Ordered” means:

For a denture: the impressions from which the denture will be made were taken.

For a root canal: the pulp chamber was opened.

For any other item: the teeth which will serve as retainers or supports, or the teeth which are being

restored:

Must have been fully prepared to receive the item; and

Impressions have been taken from which the item will be prepared.

What the Managed Dental Plan Does Not Cover Not every dental care service or supply is covered by the plan, even if prescribed, recommended, or

approved by your physician or dentist. The plan covers only those services and supplies that are

medically necessary and included in the “What the Plan Covers” section. Charges made for the

following are not covered except to the extent listed under the “ What the Plan Covers” section or by

amendment attached to this SPD. In addition, some services are specifically limited or excluded. This

section describes expenses that are not covered or subject to special limitations.

These dental exclusions are in addition to the exclusions that apply to health coverage.

Any instruction for diet, plaque control and oral hygiene.

Cosmetic services and supplies including plastic surgery, reconstructive surgery, cosmetic surgery,

personalization or characterization of dentures or other services and supplies which improve alter or

enhance appearance, augmentation and vestibuloplasty, and other substances to protect, clean, whiten

bleach or alter the appearance of teeth; whether or not for psychological or emotional reasons; except to

the extent coverage is specifically provided in the “What the Plan Covers” section. Facings on molar

crowns and pontics will always be considered cosmetic.

Crown, inlays and onlays, and veneers unless:

It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material; or

The tooth is an abutment to a covered partial denture or fixed bridge.

Dental implants, braces, mouth guards, and other devices to protect, replace or reposition teeth and

removal of implants.

Dental services and supplies that are covered in whole or in part:

Under any other part of this plan; or

Under any other plan of group benefits provided by the policyholder.

Dentures, crowns, inlays, onlays, bridges, or other appliances or services used for the purpose of

splinting, to alter vertical dimension, to restore occlusion, or correcting attrition, abrasion, or erosion.

Except as covered in the “What the Plan Covers” section, treatment of any jaw joint disorder and

treatments to alter bite or the alignment or operation of the jaw, including temporomandibular joint

disorder (TMJ) treatment, orthognathic surgery, and treatment of malocclusion or devices to alter bite or

alignment.

First installation of a denture or fixed bridge, and any inlay and crown that serves as an abutment to

replace congenitally missing teeth or to replace teeth all of which were lost while the person was not

covered.

General anesthesia and intravenous sedation.


Orthodontic treatment except as covered in the “What the Plan Covers” section.

Pontics, crowns, cast or processed restorations made with high noble metals (gold or titanium).

Prescribed drugs; pre-medication; or analgesia.

Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of appliances

that have been damaged due to abuse, misuse or neglect and for an extra set of dentures.

Services and supplies done where there is no evidence of pathology, dysfunction, or disease other than

covered preventive services.

Services and supplies provided for your personal comfort or convenience, or the convenience of any other

person, including a provider.

Services and supplies provided in connection with treatment or care that is not covered under the plan.

Space maintainers except when needed to preserve space resulting from the premature loss of deciduous

teeth. Surgical removal of impacted wisdom teeth only for orthodontic reasons.

Treatment by other than a dentist. However, the plan will cover some services provided by a licensed

dental hygienist under the supervision and guidance of a dentist. These are:

Scaling of teeth; and

Cleaning of teeth.

Additional Items Not Covered by a Health Plan Not every health service or supply is covered by the plan, even if prescribed, recommended, or approved

by your physician or dentist. The plan covers only those services and supplies that are medically

necessary and included in the “What the Plan Covers” section. Charges made for the following are not

covered except to the extent listed under the “What the Plan Covers” section or by amendment attached

to this SPD.

Acupuncture, acupressure and acupuncture therapy, except as provided in the “What the Plan Covers”

section.

Any charges in excess of the benefit, dollar, day, visit or supply limits stated in this SPD.

Charges submitted for services by an unlicensed hospital, physician or other provider or not within the

scope of the provider’s license.

Charges submitted for services that are not rendered, or rendered to a person not eligible for coverage

under the plan. Court ordered services, including those required as a condition of parole or release.


Examinations:

Any dental examinations:

required by a third party, including examinations and treatments required to obtain or maintain

employment, or which an employer is required to provide under a labor agreement;

required by any law of a government, securing insurance or school admissions, or professional or

other licenses;

required to travel, attend a school, camp, or sporting event or participate in a sport or other

recreational activity; and

any special medical reports not directly related to treatment except when provided as part of a

covered service.

Experimental or investigational drugs, devices, treatments or procedures, except as described in the

“What the Plan Covers” section.

Medicare: Payment for that portion of the charge for which Medicare or another party is the primary

payer.

Miscellaneous charges for services or supplies including:

Cancelled or missed appointment charges or charges to complete claim forms;

Charges the recipient has no legal obligation to pay; or the charges would not be made if the recipient

did not have coverage (to the extent exclusion is permitted by law) including:

Care in charitable institutions;

Care for conditions related to current or previous military service; or

Care while in the custody of a governmental authority.

Non-medically necessary services, including but not limited to, those treatments, services, prescription

drugs and supplies which are not medically necessary, as determined by Aetna, for the diagnosis and

treatment of illness, injury, restoration of physiological functions, or covered preventive services. This

applies even if they are prescribed, recommended or approved by your physician or dentist.

Routine dental exams and other preventive services and supplies, except as specifically provided in the

“What the Plan Covers” section.

Services rendered before the effective date or after the termination of coverage, unless coverage is

continued under the “Continuation of Coverage” section of this SPD.

Work related: Any illness or injury related to employment or self-employment including any injuries

that arise out of (or in the course of) any work for pay or profit, unless no other source of coverage or

reimbursement is available to you for the services or supplies. Sources of coverage or reimbursement

may include your employer, workers’ compensation, or an occupational illness or similar program under

local, state or federal law. A source of coverage or reimbursement will be considered available to you

even if you waived your right to payment from that source. If you are also covered under a workers’

compensation law or similar law, and submit proof that you are not covered for a particular illness or

injury under such law, that illness or injury will be considered “non-occupational” regardless of cause.


Coordination of Benefits – What Happens When There Is More Than One Health Plan

When Coordination of Benefits Applies

General A. This coordination of benefits (“COB”) provision applies to This Plan when an employee or the

employee's covered dependent has health care coverage under more than one plan. “Plan” and

“This Plan” are defined below.

B. If this COB provision applies, you should look first at the order of benefit determination rules. Those

rules determine whether the benefits of This Plan are determined before or after those of another

plan. The benefits of This Plan:

Shall not be reduced when, under the order of benefit determination rules, This Plan determines

its benefits before another plan; but

May be reduced when, under the order of benefits determination rules, another plan determines its

benefits first.

Getting Started – Important Terms A. Plan means any of the following which provides benefits or services for, or because of, medical or

dental care or treatment:

Group insurance or group-type coverage, whether insured or uninsured. This includes

prepayment, group practice or individual practice coverage. It also includes coverage other than

school accident-type coverage.

Coverage under a governmental plan, or coverage required or provided by law. This does not

include a state plan under Medicaid (Title XIX, Grants to States for Medical Assistance

Programs, of the United States Social Security Act, as amended from time to time).

Plan does not include school accident-type coverage, individual contracts of coverage, or some

supplemental sickness and accident policies.

Each contract or other arrangement for coverage under (1) or (2) is a separate plan. If an

arrangement has two parts and COB rules apply only to one of the two, each part is a separate

plan.

B. This Plan is the part of this group contract that provides benefits for health care expenses.

C. “Primary Plan/Secondary Plan”: the order of benefit determination rules state whether This Plan is

a Primary Plan or Secondary Plan as to another plan covering the person. When This Plan is a

Primary Plan, its benefits are determined before those of the other plan and without considering the

other plan’s benefits. When This Plan is a Secondary Plan, its benefits are determined after those

of the other plan and may be reduced because of the other plan’s benefits. When there are more

than two plans covering the person, This Plan may be a Primary Plan as to one or more other plans

and may be a Secondary Plan as to a different plan or plans.

D. “Allowable Expense” means a necessary, reasonable and customary item of expense for health care

when the item of expense is covered by this plan. However, This Plan is not required to pay for an

item, service, or benefit which is not a part of this Plan’s contract. When a plan provides benefits

in the form of services, the reasonable cash value of each service rendered will be considered both

an allowable expense and a benefit paid.

Which Plan Pays First A. When there is a basis for a claim under This Plan and another plan, This Plan is a Secondary Plan

whose benefits are determined after those of the other plan, unless: 1) The other plan has rules coordinating its benefits with those of This Plan; and


2) Both those rules and this plan's rules, in subsection below, require that this plan's benefits

be determined before those of the other plan.

B. This Plan determines its order of benefits using the first of the following rules which applies:

1) The benefits of the plan which covers the person as an employee, member, insured, or

subscriber (that is, other than as a dependent) are determined before those of the plan which

covers the person as a dependent; except that: if the person is also a Medicare beneficiary, and

as a result of the rule established by Title XVIII of the Social Security Act and implementing

regulations, Medicare is;

Secondary to the plan covering the person as a dependent and

Primary to the plan covering the person as other than a dependent (e.g. a retired employee).

2) Benefits for a dependent child whose parents are not separated or divorced shall be determined as follows:

The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but

If both parents have the same birthday, the benefits of the plan which covered one parent longer are determined before those of the plan which has covered the other parent for a shorter period of time.

However, if the other plan does not have the rules described in (A) above, but instead has a rule based upon the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the

rule in the other plan will determine the order of benefits. 3) Benefits for a dependent child whose parents are divorced or separated shall be determined as

follows. To the extent the plan has been notified by receiving a copy of the court decree:

If the specific terms of the court decree state that one of the parents is responsible for the

health care expenses of the child, the benefits of the plan of that parent are determined

first. The plan of the other parent shall be the Secondary Plan.

If the specific terms of the court decree state that the parents shall share joint custody,

without stating that one of the parents is responsible for the health care expenses of the

child, the plans covering the child shall be subject to the order of benefit determination

contained in subdivision (B)(2) of this section.

If neither subdivision (A) nor (B) applies, the order of benefits shall be determined in the following order:

1) The plan of the parent with custody of the child;

2) The plan of the spouse of the parent with the custody of the child; 3) The plan of the parent not having custody of the child; and 4) The plan of the spouse of the parent not having custody of the child. 5) The benefits of a plan which covers a person as an employee who is neither laid off not retired (or as

that employee's dependent) are determined before the benefits of a plan which covers that person as

a laid off or retired employee (or as that employee’s dependent). If the other plan does not have this

rule and if, as a result, the plans do not agree on the order of benefits, this paragraph shall be

ignored.

6) Continuation Coverage. If a person whose coverage is provided under a right of continuation pursuant to federal law (i.e., COBRA) or state law also is covered under another plan, the benefits

of the plan covering the person as employee, member or subscriber (or that person’s dependent)

shall be determined before the benefits under the continuation coverage. If the other plan does not

have this rule and if, as a result, the plans do not agree on the order of benefits, this paragraph shall

be ignored.

7) Longer/shorter length of coverage. If none of the above rules determines the order of benefits, the

benefits of the plan which covered an employee, member or subscriber longer are determined before

those of the plan which covered that person for the shorter term.


How Coordination of Benefits Works A. This section applies when, in accordance with the “Order of Benefit Determination Rules,” This

Plan is a Secondary Plan as to one or more other plans. In that event, the benefits of This Plan

may be reduced under this section. Such other plan or plans are referred to as “the other plans” in

(B) below.

B. Reduction in This Plan’s benefits. The benefits of This Plan will be reduced to the extent that the sum of:

The benefits that would be payable for the allowable expense under This Plan in the absence of

this COB provision; and

The benefits that would be payable for the allowable expenses under the other plans, in the

absence of provisions with a purpose like that of this COB provision, whether or not claim is

made, exceeds those allowable expenses.

If the allowable expense under This Plan is lower than the primary plan’s, Aetna will use the primary

plan’s allowable expense. That may be lower than the actual bill.

Right to Receive and Release Needed Information Certain facts are needed to apply these COB rules. Aetna has the right to decide which facts it needs. It

may get needed facts from or give them to any other organization or person. Aetna need not tell, or get

the consent of, any person to do this. Each person claiming benefits under This Plan must give Aetna any

facts it needs to pay the claim.

Facility of Payment A payment made under another plan may include an amount which should have been paid under This

Plan. If it does, Aetna may pay that amount to the organization which made that payment. That amount

will then be treated as though it were a benefit paid under This Plan. Aetna will not have to pay that

amount again. The term “payment made” includes providing benefits in the form of services, in which

case “payment made” means reasonable cash value of the benefits provided in the form of services.

Right of Recovery If the amount of the payments made by Aetna is more than it should have paid under this COB provision,

it may recover the excess from one or more of:

The persons it has paid or for whom it has paid;

Another plan; or

The provider of service.

The “amount of the payments made” includes the reasonable cash value of any benefits provided in the

form of services.

Coordination Disputes If you believe that we have not paid a claim properly, you should first attempt to resolve the problem by

contacting us. If you are still not satisfied, you may call the Ohio Department of Insurance for

instructions on filing a consumer complaint. Call (614) 644-2673 or 1-800-686- 1526.

When You Have Medicare Coverage This section explains how the benefits under This Plan interact with benefits available under Medicare.

Medicare, when used in this SPD, means the health insurance provided by Title XVIII of the Social

Security Act, as amended. It includes Health Maintenance Organization (HMO) or similar coverage that

is an authorized alternative to Parts A and B of Medicare.


You are eligible for Medicare if you are:

Covered under it by reason of age, disability, or

End Stage Renal Disease; or

Not covered under it because you:

1. Refused it; 2. Dropped it; or 3. Failed to make a proper request for it.

If you are eligible for Medicare, the plan coordinates the benefits it pays with the benefits that Medicare

pays. Sometimes, the plan is the primary payor, which means that the plan pays benefits before

Medicare pays benefits. Under other circumstances, the plan is the secondary payor, and pays benefits

after Medicare.

Which Plan Pays First The plan is the primary payor when your coverage for the plan’s benefits is based on current employment

with your employer. The plan will act as the primary payor for the Medicare beneficiary who is eligible

for Medicare:

Solely due to age if the plan is subject to the Social Security Act requirements for Medicare with

respect to working aged (i.e., generally a plan of an employer with 20 or more employees);

Due to diagnosis of end stage renal disease, but only during the first 30 months of such eligibility for

Medicare benefits. This provision does not apply if, at the start of eligibility, you were already

eligible for Medicare benefits, and the plan’s benefits were payable on a secondary basis;

Solely due to any disability other than end stage renal disease; but only if the plan meets the

definition of a large group health plan as outlined in the Internal Revenue Code (i.e., generally a plan

of an employer with 100 or more employees).

The plan is the secondary payor in all other circumstances.

How Coordination With Medicare Works

When the Plan is Primary The plan pays benefits first when it is the primary payor. You may then submit your claim to Medicare

for consideration.

When Medicare is Primary Your health care expense must be considered for payment by Medicare first. You may then submit the

expense to Aetna for consideration.

Aetna will calculate the benefits the plan would pay in the absence of Medicare:

The amount will be reduced so that when combined with the amount paid by Medicare, the total benefits

paid or provided by all plans for the claim do not exceed 100 % of the total allowable expense.

This review is done on a claim-by-claim basis.

Charges used to satisfy your Part B deductible under Medicare will be applied under the plan in the

order received by Aetna. Aetna will apply the largest charge first when two or more charges are received

at the same time.

Aetna will apply any rule for coordinating health care benefits after determining the benefits payable.


Right to Receive and Release Required Information Certain facts about health care coverage and services are required to apply coordination of benefits (COB)

rules to determine benefits under This Plan and other plans. Aetna has the right to obtain or release any

information, and make or recover any payments it considers necessary, in order to administer this

provision.

General Provisions

Type of Coverage Coverage under this plan is non-occupational. Only non-occupational accidental injuries and non-

occupational illnesses are covered. This plan covers charges made for services and supplies only while

the person is covered under this plan.

Physical Examinations Aetna will have the right and opportunity to examine and evaluate any person who is the basis of any

claim at all reasonable times while a claim is pending or under review. This will be done at no cost to

you.

Legal Action No legal action can be brought to recover payment under any benefit after 3 years from the deadline for

filing claims.

Aetna will not try to reduce or deny a benefit payment on the grounds that a condition existed before your

coverage went into effect, if the loss occurs more than 2 years from the date coverage commenced. This

will not apply to conditions excluded from coverage on the date of the loss.

Confidentiality Information contained in your medical records and information received from any provider incident to the

provider- patient relationship shall be kept confidential in accordance with applicable law. Information

may be used or disclosed by Aetna when necessary for your care or treatment, the operation of the plan

and administration of this Booklet- Certificate, or other activities, as permitted by applicable law. You

can obtain a copy of Aetna’s Notice of Information Practices by calling Aetna’s toll-free Member Service

telephone.

Additional Provisions The following additional provisions apply to your coverage.

This SPD applies to coverage only, and does not restrict your ability to receive health care services

that are not, or might not be, covered.

You cannot receive multiple coverage under the plan because you are connected with more than one

employer.

In the event of a misstatement of any fact affecting your coverage under the plan, the true facts will

be used to determine the coverage in force.

This document describes the main features of the plan. Additional provisions are described elsewhere

in the group policy. If you have any questions about the terms of the plan or about the proper

payment of benefits, contact your employer or Aetna.

Your employer hopes to continue the plan indefinitely but, as with all group plans, the plan may be

changed or discontinued with respect to your coverage.


Assignments Coverage may be assigned only with the written consent of Aetna. To the extent allowed by law, Aetna

will not accept an assignment to an out-of-network provider, including but not limited to, an assignment

of:

The benefits due under this group insurance policy;

The right to receive payments due under this group insurance policy; or

Any claim you make for damages resulting from a breach or alleged breach, of the terms of this group

insurance policy.

Misstatements If any fact as to the Policyholder or you is found to have been misstated, a fair change in premiums may

be made. If the misstatement affects the existence or amount of coverage, the true facts will be used in

determining whether coverage is or remains in force and its amount.

All statements made by the Policyholder or you shall be deemed representations and not warranties. No

written statement made by you shall be used by Aetna in a contest unless a copy of the statement is or has

been furnished to you or your beneficiary, or the person making the claim.

Aetna’s failure to implement or insist upon compliance with any provision of this policy at any given

time or times, shall not constitute a waiver of Aetna’s right to implement or insist upon compliance with

that provision at any other time or times. This includes, but is not limited to, the payment of premiums.

This applies whether or not the circumstances are the same.

Incontestability As to Accident and Health Benefits:

Except as to a fraudulent misstatement, or issues concerning Premiums due:

No statement made by the Policyholder or you or your dependent shall be the basis for voiding

coverage or denying coverage or be used in defense of a claim unless it is in writing after it has been

in force for 2 years from its effective date.

No statement made by the Policyholder shall be the basis for voiding this Policy after it has been in

force for 2 years from its effective date.

No statement made by you, an eligible employee or your dependent shall be used in defense of a

claim for loss incurred or starting after coverage as to which claim is made has been in effect for

2 years.

Recovery of Overpayments

Health Coverage If a benefit payment is made by Aetna, to or on your behalf, which exceeds the benefit amount that you

are entitled to receive, Aetna has the right:

To require the return of the overpayment; or

To reduce by the amount of the overpayment, any future benefit payment made to or on behalf of that

person or another person in his or her family.

Such right does not affect any other right of recovery Aetna may have with respect to such overpayment.


Reporting of Claims A claim must be submitted to Aetna in writing. It must give proof of the nature and extent of the loss.

Your employer has claim forms.

All claims should be reported promptly. The deadline for filing a claim is 90 days after the date of the

loss.

If, through no fault of your own, you are not able to meet the deadline for filing claim, your claim will

still be accepted if you file as soon as possible. Unless you are legally incapacitated, late claims for health

benefits will not be covered if they are filed more than 2 years after the deadline.

Payment of Benefits Benefits will be paid as soon as the necessary proof to support the claim is received. Written proof must

be provided for all benefits.

All covered health benefits are payable to you. However, Aetna has the right to pay any health benefits to

the service provider. This will be done unless you have told Aetna otherwise by the time you file the

claim.

Aetna will notify you in writing, at the time it receives a claim, when an assignment of benefits to a

health care provider or facility will not be accepted.

Any unpaid balance will be paid within 30 days of receipt by Aetna of the due written proof.

Aetna may pay up to $1,000 of any other benefit to any of your relatives whom it believes are fairly

entitled to it. This can be done if the benefit is payable to you and you are a minor or not able to give a

valid release. It can also be done if a benefit is payable to your estate.

Records of Expenses Keep complete records of the expenses of each person. They will be required when a claim is made. Very

important are:

Names of dentists who furnish services.

Dates expenses are incurred.

Copies of all bills and receipts.

Contacting Aetna If you have questions, comments or concerns about your benefits or coverage, or if you are required to

submit information to Aetna, you may contact Aetna’s Home Office at:

Aetna Life Insurance Company

151 Farmington Avenue

Hartford, CT 06156

You may also use Aetna’s toll free Member Services phone number on your ID card or visit Aetna’s web

site at www.aetna.com.



Effect of Benefits Under Other Plans

Effect of a Health Maintenance Organization Plan (HMO Plan) on Coverage If you are in an eligible class and have chosen dental coverage under an HMO Plan offered by your

employer, you will be excluded from dental expense coverage on the date of your coverage under such

HMO Plan.

If you are in an eligible class and are covered under an HMO Plan providing dental coverage, you can

choose to change to coverage for yourself and your covered dependents under this plan. If you:

Live in an HMO Plan enrollment area and choose to change dental coverage during an open

enrollment period, coverage will take effect on the group policy anniversary date after the open

enrollment period. There will be no rules for waiting periods or preexisting conditions.

Live in an HMO Plan enrollment area and choose to change dental coverage when there is not an

open enrollment period, coverage will take effect only if and when Aetna gives its written consent.

Move from an HMO Plan enrollment area or if the HMO discontinues and you choose to change

dental coverage within 31 days of the move or the discontinuance, coverage will take effect on the

date you elect such coverage. There will be no restrictions for waiting periods or preexisting

conditions. If you choose to change coverage after 31 days, coverage will take effect only if and

when Aetna gives its written consent.

Any extension of dental benefits under this plan will not apply on or after the date of a change to an HMO

Plan. No benefits will be paid for any charges for services rendered or supplies furnished under an HMO

Plan.

Incentives In order to encourage you to access certain medical services when deemed appropriate by you in

consultation with your physician or other service providers, we may, from time to time, offer to waive or

reduce a member’s copayment, coinsurance, and/or a deductible otherwise required under the plan or

offer coupons or other financial incentives. We have the right to determine the amount and duration of

any waiver, reduction, coupon, or financial incentive and to limit the covered persons to whom these

arrangements are available.

Appeals Procedure

Definitions

Adverse Benefit Determination (Decision) means:

A decision by Aetna:

To deny, reduce, terminate or fail to provide or make payment in whole or in part, for a service,

supply or Benefit. Such adverse benefit determination may include all of the following:

Your eligibility for coverage.

A determination that the health care services does not meet the plan's requirements for medical

necessity, appropriateness, health care setting, level of care, or effectiveness, including

experimental or investigational treatments.

A determination of your eligibility for individual health insurance coverage, including coverage

offered through a non-employer group, to participate in a plan or health insurance coverage.

The results of any Utilization Review activities.

A determination that a health care service is not a covered benefit.

The imposition of an exclusion, including exclusions for pre-existing conditions, source of injury,

network, or any other limitation on benefits that would otherwise be covered.


Not to issue individual health insurance coverage to you, including coverage offered through a non-

employer group.

As to medical and prescription drug claims only, an adverse benefit determination also means the

termination of your coverage back to the original effective date (rescission) as it applies under any

rescission of coverage provision of the Policy or the SPD.

Appeal: An oral or written request to Aetna to reconsider an adverse benefit determination.

Authorized Representative: An individual who represents you in an internal appeal or external review

process of an adverse benefit determination who is any of the following:

A person to whom you have given express, written consent to represent you in an internal appeals

process or external review process of an adverse benefit determination;

A person authorized by law to provide substituted consent for you;

A family member or a treating health care professional, but only when you are unable to provide

consent.

Complaint: Any oral or written expression of dissatisfaction about quality of care or the operation of the

Plan.

Concurrent Care Claim Extension: A request to extend a course of treatment that was previously

approved.

Concurrent Care Claim Reduction or Termination: A decision to reduce or terminate a course of

treatment that was previously approved.

Covered Benefits or Benefits: Those health care services to which a covered person is entitled under the

terms of a health benefit plan.

Covered Person: Policyholder, subscriber, enrollee, member, or individual covered by a health benefit

plan. “Covered person” does include the covered person’s authorized representative with regard to an

internal appeal or external review.

Emergency Services:

A medical screening examination, as required by federal law, that is within the capability of the

emergency department of a hospital, including ancillary services routinely available to the emergency

department, to evaluate an emergency medical condition;

Such further medical examination and treatment that are required by federal law to stabilize an

emergency medical condition and are within the capabilities of the staff and facilities available at the

hospital, including any trauma and burn center of the hospital.

External Review: A review of an adverse benefit determination or a final adverse benefit

determination by an Independent Review Organization/External Review Organization (ERO) assigned

by the State Insurance Commissioner and made up of physicians or other appropriate health care

providers. The ERO must have expertise in the problem or question involved.

Final Adverse Benefit Determination: An adverse benefit determination that has been upheld by

Aetna at the exhaustion of the appeals process.

Health Benefit Plan: A policy, contract, certificate, or agreement offered by a health plan issuer to

provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.


Health Care Services: Services for the diagnosis, prevention, treatment, cure, or relief of a health

condition, illness, injury, or disease.

Health Plan Issuer: An entity subject to the insurance laws and rules of this state, or subject to the

jurisdiction of the superintendent of insurance, that contracts, or offers to contract to provide, deliver,

arrange for, pay for, or reimburse any of the costs of health care services under a health benefit plan,

including a sickness and accident insurance company, a health insuring corporation, a fraternal benefit

society, a self-funded multiple employer welfare arrangement, or a nonfederal, government health plan.

“Health Plan Issuer” includes a third party administrator to the extent that the benefits that such an entity

is contracted to administer under a health benefit plan are subject to the insurance laws and rules of this

state or subject to the jurisdiction of the superintendent.

Independent Review Organization: An entity that is accredited to conduct independent external reviews

of adverse benefit determinations.

Pre-service Claim: Any claim for medical care or treatment that requires approval before the medical

care or treatment is received.

Post-Service Claim: Any claim that is not a “Pre-Service Claim.”

Rescission or to rescind: A cancellation or discontinuance of coverage that has a retroactive effect.

“Rescission” does not include a cancellation or discontinuance of coverage that has only a prospective

effect or a cancellation or discontinuance of coverage that is effective retroactively to the extent it is

attributable to a failure to timely pay required premiums or contributions towards the cost of coverage.

Stabilize: The provision of such medical treatment as may be necessary to assure, within reasonable

medical probability that no material deterioration of a covered person’s medical condition is likely to

result from or occur during a transfer, if the medical condition could result in any of the following:

Placing the health of the covered person or, with respect to a pregnant woman, the health of the

woman or her unborn child, in serious jeopardy;

Serious impairment to bodily functions;

Serious dysfunction of any bodily organ or part.

In the case of a woman having contractions, “stabilize” means such medical treatment as may be

necessary to deliver, including the placenta.

Superintendent: The Superintendent of Insurance.

Urgent Care Claim: Any claim for medical care or treatment in which a delay in treatment could:

Seriously jeopardize your life or health;

Jeopardize your ability to regain maximum function;

Cause you to suffer severe pain that cannot be adequately managed without the requested medical

care or treatment; or

In the case of a pregnant woman, cause serious jeopardy to the health of the fetus.

Full and Fair Review of Claim Determinations and Appeals As to medical and prescription drug claims and appeals only, Aetna will provide you with any new or

additional evidence considered and rationale, relied upon, or generated by us in connection with the claim

at issue. This will be provided to you in advance of the date on which the notice of the final adverse

benefit determination is required to be provided so that you may respond prior to that date.


Prior to issuing a final adverse benefit determination based on a new or additional rationale, you must

be provided, free of charge, with the rationale; the rationale must be provided as soon as possible and

sufficiently in advance of the date on which notice of final adverse determination is required.

Claim Determinations Notice of a claim benefit decision will be provided to you in accordance with the guidelines and timelines

provided below. As to medical and prescription drug claims only, if Aetna makes an adverse benefit

determination, written notice will be provided to you, or in the case of a concurrent care claim, to your

provider.

Urgent Care Claims Aetna will notify you of an urgent care claim decision as soon as possible, but not later than 72 hours

after the claim is made.

If more information is needed to make an urgent claim decision, Aetna will notify the claimant within

72 hours of receipt of the claim. The claimant has 48 hours after receiving such notice to provide Aetna

with the additional information. Aetna will notify the claimant within 48 hours of the earlier to occur:

The receipt of the additional information; or

The end of the 48 hour period given the physician to provide Aetna with the information.

If the claimant fails to follow the procedures for filing a claim, the plan will notify the claimant within

24 hours following the failure to comply.

Pre-Service Claims Aetna will notify you of a pre-service claim decision as soon as possible, but not later than 15 calendar

days after the claim is made. Aetna may determine that due to matters beyond its control an extension of

this 15 calendar day claim decision period is required. Such an extension, of not longer than 15 additional

calendar days, will be allowed if Aetna notifies you within the first 15 calendar day period. If this

extension is needed because Aetna needs more information to make a claim decision, the notice of the

extension shall specifically describe the required information. You will have 45 calendar days, from the

date of the notice, to provide Aetna with the required information.

Post-Service Claims Aetna will notify you of a post-service claim decision as soon as possible, but not later than 30 calendar

days after the claim is made. Aetna may determine that due to matters beyond its control an extension of

this 30 calendar day claim decision period is required. Such an extension, of not longer than 15 additional

calendar days, will be allowed if Aetna notifies you within the first 30 calendar day period. If this

extension is needed because Aetna needs more information to make a claim decision, the notice of the

extension shall specifically describe the required information. The patient will have 45 calendar days,

from the date of the notice, to provide Aetna with the required information.

Concurrent Care Claim Extension Following a request for a concurrent care claim extension, Aetna will notify you of a claim

determination for emergency or urgent care as soon as possible, but not later than 24 hours with respect

to emergency care or urgent care, provided the request is received at least 24 hours prior to the expiration

of the approved course of treatment and 15 calendar days with respect to all other care, following a

request for a concurrent care claim extension.

Concurrent Care Claim Reduction or Termination Aetna will notify you of a claim determination to reduce or terminate a previously approved course of

treatment with enough time for you to file an appeal.


If you file an appeal, coverage under the plan will continue for the previously approved ongoing course

of treatment until a final appeal decision is rendered. During this continuation period, you are responsible

for any copayments; coinsurance; and deductibles; that apply to the services; supplies; and treatment;

that are rendered in connection with the claim that is under appeal. If Aetna's initial claim decision is

upheld in the final appeal decision, you will be responsible for all charges incurred for services; supplies;

and treatment; received during this continuation period.

Complaints If you are dissatisfied with the service you receive from the Plan or want to complain about a provider

you must call or write Member Services within 30 calendar days of the incident. The complaint must

include a detailed description of the matter and include copies of any records or documents that you think

are relevant to the matter. Aetna will review the information and provide you with a written response

within 30 calendar days of the receipt of the complaint, unless more information is needed and it cannot

be obtained within this period. The notice of the decision will tell you what you need to do to seek an

additional review.

Notice of an Adverse Determination When Aetna notifies you of an adverse benefit determination in writing, you will also be notified of

your right to an external review. As part of the written notice, the Plan will include the following:

Sufficient information to identify the claim or health care service involved, including the health care

provider, and the date of service and claim amount, if applicable;

A description of the reason or reasons for the adverse benefit determination, including the denial

code, such as the claim adjustment reason code and the remittance advice remark code, and each

code's corresponding meaning;

A description of the available internal appeals and external review processes, including information

regarding how to initiate an appeal and an external review; and

Disclosure of the availability of assistance from the superintendent with the internal appeals and

external review processes, including the web site, telephone number, and mailing address of the

superintendent's Office of Consumer Services.

Appeals of Adverse Benefit Determinations You may submit an appeal if Aetna gives notice of an adverse benefit determination. This Plan

provides for two levels of appeal. A final adverse benefit determination notice will also provide an

option to request an External Review if the services are eligible for external review.

You have 180 calendar days with respect to Group Health Claims following the receipt of notice of an

adverse benefit determination to request your Level One Appeal. Your appeal may be submitted

orally or in writing and must include:

Your name.

The employer's name.

A copy of Aetna’s notice of an adverse benefit determination.

Your reasons for making the appeal.

Any other information you would like to have considered.

Send your written appeal to Member Services at the address shown on your ID Card.

You may also choose to have another person (an authorized representative) make the appeal on your

behalf. You must provide written consent to Aetna if you decide to choose an authorized representative.

You may also supply additional information that you would like us to consider regarding your appeal. In

addition, you may request copies of documents relevant to your claim (free of charge) by contacting us at

the number on your member identification card.


You may be allowed to provide evidence or testimony during the appeal process in accordance with the

guidelines established by the Federal Department of Health and Human Services.

Level One Appeal A review of a Level One Appeal of an adverse benefit determination shall be provided by Aetna

personnel. They shall not have been involved in making the adverse benefit determination.

Urgent Care Claims (May Include Concurrent Care Claim Reduction or Termination) Aetna shall

issue a decision within 36 hours of receipt of the request for an appeal.

Pre-Service Claims (May Include Concurrent Care Claim Reduction or Termination) Aetna shall

issue a decision within 15 calendar days of receipt of the request for an appeal.

Post-Service Claims Aetna shall issue a decision within 30 calendar days of receipt of the request for an appeal.

Level Two Health Appeal If Aetna upholds an adverse benefit determination at the first level of appeal, and the reason for the

decision was based on medical necessity or experimental or investigational reasons, you or your

authorized representative have the right to file a Level Two Appeal. The appeal must be submitted

within 60 calendar days following the receipt of a decision of a Level One Appeal.

Review of a Level Two Appeal of an adverse benefit determination of an urgent care claim, a Pre-

Service Claim, or a Post-Service Claim shall be provided by Aetna personnel. They shall not have been

involved in making the adverse benefit determination.

Urgent Care Claims (May Include Concurrent Care Claim Reduction or Termination). Aetna shall

issue a decision within 36 hours of receipt of the request for a Level Two Appeal.

Pre-Service Claims (May Include Concurrent Care Claim Reduction or Termination). Aetna shall

issue a decision within 15 calendar days of receipt of the request for a Level Two Appeal.

Post-Service Claims. Aetna shall issue a decision within 30 calendar days of receipt of the request for a

Level Two Appeal.

Exhaustion of Process You must exhaust the applicable Level One and Level Two processes of the Appeal Procedure before

you:

Contact the Ohio Department of Insurance to request an investigation of a complaint or appeal; or

File a complaint or appeal with the Ohio Department of Insurance; or

Establish any:

Litigation;

Arbitration; or

Administrative proceeding;

regarding an alleged breach of the policy terms by Aetna or any matter within the scope of the Appeals

Procedure.


Exceptions to the exhaustion of the Level One and Level Two processes of the Appeals procedure may

occur in the following instances:

a) Aetna agrees to waive the Exhaustion requirement;

b) You did not receive a written decision of Aetna’s internal appeal within the required timeframe; c) Aetna fails to meet all requirements of the internal appeals process unless the failure:

was de minimis;

does not cause or is not likely to cause prejudice or harm to you;

was for good cause and beyond the control of the Plan; or

is not reflective of a pattern or practice of non-compliance. d) An expedited external review is sought simultaneously with an expedited internal review.

An internal appeal process shall be considered exhausted if you have requested an internal appeal and

have not received a written decision from Aetna at each level of appeal within the timeframes listed

above and Aetna fails to adhere to all requirements of the internal appeals process.

You may not request an external review of an adverse benefit determination involving a retrospective

utilization review decision until Aetna’s internal appeal process has been exhausted unless the Aetna

agrees to waive the exhaustion requirement

Under certain circumstances, you may seek simultaneous review through the internal Appeals Procedure

and External Review processes—these include Urgent Care Claims and situations where you are

receiving an ongoing course of treatment. Exhaustion of the applicable process of the Appeal Procedure

is not required under these circumstances.

Important Note: If Aetna does not adhere to all claim determination and appeal requirements of the Federal

Department of Health and Human Services, you are considered to have exhausted the appeal

requirements and may proceed with External Review or any of the actions mentioned above. There

are limits, though, on what sends a claim or appeal straight to an External Review.

Your claim or internal appeal will not go straight to External Review if:

a rule violation was minor and isn’t likely to influence a decision or harm you;

it was for a good cause or was beyond Aetna’s control; and

it was part of an ongoing, good faith exchange between you and Aetna.

Opportunity for External Review An external review may be conducted by an Independent Review Organization (IRO) or by the Ohio

Department of Insurance. You do not pay for the external review. There is no minimum cost of health

care services denied in order to qualify for an external review. However, you must generally exhaust the

health Plan issuer’s internal appeal process before seeking an external review. Exceptions to this

requirement will be included in the notice of the adverse benefit determination.


External Review by an IRO You are entitled to an external review by an IRO in the following instances:

The adverse benefit determination involves a medical judgment or is based on any medical

information

The adverse benefit determination indicates the requested service is experimental or

investigational, the requested health care service is not explicitly excluded in your health benefit

Plan, and the treating physician certifies at least one of the following:

Standard health care services have not been effective in improving your condition.

Standard health care services are not medically appropriate for you.

No available standard health care service covered by the Plan is more beneficial than the

requested health care service.

There are two types of IRO reviews, standard and expedited. A standard review is normally completed

within 30 days. An expedited review for urgent medical situations is normally completed within 72 hours

and can be requested if any of the following applies:

Your treating physician certifies that the adverse benefit determination involves a medical

condition that could seriously jeopardize your life or health or would jeopardize your ability to regain

maximum function if treatment is delayed until after the time frame of an expedited internal appeal.

Your treating physician certifies that the final adverse benefit determination involves a medical

condition that could seriously jeopardize your life or health or would jeopardize your ability to regain

maximum function if treatment is delayed until after the time frame of a standard external review.

The final adverse benefit determination concerns an admission, availability of care, continued stay,

or health care service for which you received emergency services, but has not yet been discharged

from a facility.

An expedited internal appeal is already in progress for an adverse benefit determination of

experimental or investigational treatment and your treating physician certifies in writing that the

recommended health care service or treatment would be significantly less effective if not promptly

initiated.

Note: An expedited external review is not available for retrospective final adverse benefit determinations

(meaning the health care service has already been provided to you.)

External Review by the Ohio Department of Insurance You are entitled to an external review by the Department in the either of the following instances:

The adverse benefit determination is based on a contractual issue that does not involve a medical

judgment or medical information.

The adverse benefit determination for an emergency medical condition indicates that medical

condition did not meet the definition of emergency AND the Plan’s decision has already been upheld

through an external review by an IRO.

Request for External Review Regardless of whether the external review case is to be reviewed by an IRO or the Department of

Insurance, you or an authorized representative, must request an external review through Aetna within

180 days of the date of the notice of final adverse benefit determination issued by their Plan.

All requests must be in writing, except for a request for an expedited external review. Expedited

external reviews may be requested electronically or orally; however written confirmation of the request

must be submitted to Aetna no later than five (5) days after the initial request. You will be required to

consent to the release of applicable medical records and sign a medical records release authorization.


If the request is complete Aetna will initiate the external review and notify you in writing, or

immediately in the case of an expedited review, that the request is complete and eligible for external

review. The notice will include the name and contact information for the assigned IRO or the Ohio

Department of Insurance (as applicable) for the purpose of submitting additional information. When a

standard review is requested, the notice will inform you that, within 10 business days after receipt of the

notice, you may submit additional information in writing to the IRO or the Ohio Department of Insurance

(as applicable) for consideration in the review. Aetna will also forward all documents and information

used to make the adverse benefit determination to the assigned IRO or the Ohio Department of

Insurance (as applicable).

If the request is not complete Aetna will inform you in writing and specify what information is needed to

make the request complete. Aetna determines that the adverse benefit determination is not eligible for

external review, Aetna must notify you in writing and provide you with the reason for the denial and

inform you that the denial may be appealed to the Ohio Department of Insurance.

The Ohio Department of Insurance may determine the request is eligible for external review regardless

of the decision by Aetna and require that the request be referred for external review. The Department’s

decision will be made in accordance with the terms of the health benefit Plan and all applicable

provisions of the law.

IRO Assignment When the Plan initiates an external review by an IRO, the Ohio Department of Insurance web based

system randomly assigns the review to an accredited IRO that is qualified to conduct the review based on

the type of health care service. An IRO that has a conflict of interest with Aetna, you, the health care

provider or the health care facility will not be selected to conduct the review.

IRO Review and Decision The IRO must consider all documents and information considered by Aetna in making the adverse

benefit determination, any information submitted by you and other information such as; your medical

records, the attending health care professional’s recommendation, consulting reports from appropriate

health care professionals, the terms of coverage under the health benefit Plan, the most appropriate

practice guidelines, clinical review criteria used by the health Plan issuer or its utilization review

organization, and the opinions of the IRO’s clinical reviewers.

The IRO will provide a written notice of its decision within 30 days of receipt by the plan of a request for

a standard review or within 72 hours of receipt by the Plan of a request for an expedited review. This

notice will be sent to you, Aetna and the Ohio Department of Insurance and must include the following

information:

A general description of the reason for the request for external review.

The date the independent review organization was assigned by the Ohio Department of Insurance to

conduct the external review.

The dates over which the external review was conducted.

The date on which the independent review organization's decision was made.

The rationale for its decision.

References to the evidence or documentation, including any evidence-based standards, which was

used or considered in reaching its decision.

Note: Written decisions of an IRO concerning an adverse benefit determination that involves a health

care treatment or service that is stated to be experimental or investigational also includes the principle

reason(s) for the IRO’s decision and the written opinion of each clinical reviewer including their

recommendation and their rationale for the recommendation.


Binding Nature of External Review Decision An external review decision is binding on Aetna except to the extent that Aetna has other remedies

available under state law. The decision is also binding on you except to the extent that you have other

remedies available under applicable state or federal law.

You may not file a subsequent request for an external review involving the same adverse benefit

determination that was previously reviewed unless new medical or scientific evidence is submitted to the

Plan.

If You Have Questions About Your Rights or Need Assistance You may contact the Plan:

Aetna

National External Review Unit

11675 Great Oaks Way

Alpharetta, GA 30022

Toll Free # (877) 848-5855

Fax #: (860) 975-1526

You may also contact the Ohio Department of Insurance:

Ohio Department of Insurance

ATTN: Consumer Affairs

50 West Town Street, Suite 300,

Columbus, OH 43215

800-686-1526 / 614-644-2673

614-644-3744 (fax)

614-644-3745 (TDD)

Contact ODI Consumer Affairs:

https://secured.insurance.ohio.gov/ConsumServ/ConServComments.asp

File a Consumer Complaint: http://insurance.ohio.gov/Consumer/OCS/Pages/ConsCompl.aspx

Your Legal Rights Participants in the AEP Comprehensive Dental Plan are entitled to certain rights and protections under the

Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants

shall be entitled to.

Receive Information about Your Plans and Benefits Examine, without charge, at the plan administrator’s office and other specified locations, such as

worksites and union halls, all documents governing the plan, including insurance contracts, and a copy of

the latest annual report (Form 5500 series) filed by the plan with the U.S. Department of Labor and

available at the Public Disclosure Room of the Employee Benefits Security Administration.

Obtain, upon written request to the plan administrator, copies of documents governing the operation of

the plan, including insurance contracts, and copies of the latest annual report (Form 5500 Series), and

updated Summary Plan Description. The plan administrator may charge a reasonable fee for the copies.

Receive a summary of the plan’s annual financial report. The plan administrator is required by law to

furnish each participant a copy of this summary annual report.

https://secured.insurance.ohio.gov/ConsumServ/ConServComments.asp

http://insurance.ohio.gov/Consumer/OCS/Pages/ConsCompl.aspx


Continue Group Health Plan Coverage Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the

plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review

this Summary Plan Description and the documents governing the plan on the rules governing your

COBRA continuation coverage rights.

Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are

responsible for the operation of the employee benefit plan.

The people who operate your plan, called “fiduciaries” of the plan, have a duty to do so prudently and in

the interest of you and other plan participants and beneficiaries. No one, including your employer or any

other person may fire you or otherwise discriminate against you in any way to prevent you from obtaining

a benefit or exercising your rights under ERISA.

Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why

this was done, to obtain copies of documents relating to the decision without charge, and to appeal any

denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy

plan documents or the latest annual report from the plan and do not receive them within 30 days, you may

file suit in a Federal court. In such a case, the court may require the plan administrator to provide the

materials and pay up to $110 a day until you receive the materials, unless the materials were not sent due

to reasons beyond the control of the plan administrator. If you have a claim for benefits which is ignored

or denied, in whole or in part, you may file suit in Federal or state court. In addition, if you disagree with

the plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a

medical child support order, you may file suit in a Federal court.

If it should happen that plan fiduciaries misuse the plan’s money, or if you are discriminated against for

asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in

a Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the

court may order the person you have sued to pay these costs and fees. If you lose, the court may order you

to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance with Your Questions If you have any questions about your plans, you should contact the plan administrator. If you have any

questions about this statement or about your rights under ERISA or if you need assistance in obtaining

documents from the plan administrator, you should contact the nearest Office of the Employee Benefits

Security Administration, U.S. Department of Labor listed in your telephone directory or the Division of

Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of

Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also obtain certain

publications about your rights and responsibilities under ERISA by calling the publications hotline of the

Employee Benefits Security Administration.


Plan Documents This AEP Comprehensive Dental Plan Summary Plan Description (SPD) provides a summary of the

dental benefits available to eligible employees. In some instances, full details of the plan are contained in

the official plan documents and/or insurance contracts. If a provision described in this SPD differs from

the provision of the applicable plan document and/or insurance contract, the plan document and/or

insurance contract prevails.

Transfer of Benefits Your dental plan benefits belong to you and, in certain cases, to members of your family. Your benefits

may not be sold, assigned, transferred, pledged, or garnished. In addition, a Qualified Medical Child

Support Order (QMCSO) may require you to provide coverage for a dependent under your dental plan.

In the event that you or your beneficiary is unable to attend to legal or financial affairs, benefits may be

paid to a guardian, relative or other third party appointed on your behalf. If benefits are paid to a third

party in good faith, benefits will not be paid again.

Plan Amendment or Termination The Company reserves the right to change or end the AEP Comprehensive Dental Plan, in whole or in

part, at any time and for any reason, which could result in modification or termination of benefits to

employees, retirees or other participants. The Company’s decision to amend, replace, or terminate a plan

may be due to changes in federal law or state laws governing welfare benefits, the requirements of the

Internal Revenue Service, ERISA or any other reason. If the Company does make a change or decides to

end the plan, it may decide to set up a different plan providing similar or identical benefits. The Company

has the right to change the amount of participant contributions to these plans.

If the AEP Comprehensive Dental Plan is terminated, you will not receive any further benefits under the

plan other than payment for losses or expenses incurred before the plan was terminated.

Administrative Information This section provides details about the way the AEP Comprehensive Dental Plan is administered, the way

claims are processed and related topics. If you have questions about your dental benefits that are not

answered below, please contact the AEP Benefits Center toll-free at 1-888-237-2363.

Plan Name: American Electric Power System Comprehensive Dental Plan

Type of Plan: Welfare benefit group health plan that provides dental benefits

Type of Administration: The Dental Maintenance Organization (DMO) option is insured through a

contract with Aetna. Aetna sets the premiums, administers claims and is solely responsible for providing

benefits.

The Dental Preferred Provider Organization (DPPO) option is self-insured by AEP through contributions

made solely by the Company and Plan participants. Benefits are paid either directly by the Company or

through trusts administered by the Company. AEP contracts with Aetna to administer claims under the

plan DPPO option (i.e., process claims, pay providers), but AEP bears the risk associated with offering

DPPO benefits.


Plan Sponsor and Administrator: The Plan sponsored by American Electric Power Service

Corporation (AEP) and AEP is also the plan administrator. AEP’s address is:

American Electric Power Service Corporation (AEP)

1 Riverside Plaza

Columbus, OH 43215

(614) 716-1000

The plan administrator has the authority to control, administer and manage the operation of all plans. The

rights to carry out responsibilities and use maximum discretionary authority permitted by law are assigned

to the plan administrator and any representative it chooses for self-insured options, and to the claims

administrator appointed by insurer for insured options. These rights and responsibilities include the

following:

Interpret, construe and administer the plans,

Make determinations regarding plan participation, enrollment and eligibility for benefits,

Evaluate and determine the validity of benefit claims, and

Resolve any and all claims and disputes regarding the rights and entitlements of individuals to

participate in the plans and to receive benefits and payments pursuant to the plans.

The decisions of these parties are final and binding.

Plan Numbers: Plans are identified by the United States Department of Labor by reference to two

numbers: the Plan Sponsor’s Employer Identification Number (EIN) and the Plan Number. The EIN for

AEP is 13-4922641.Three-Digit Plan Identification Number: 503.

Plan Type: Fully Insured

Plan Year: January 1 through December 31.

Agent for Service of Legal Process: Legal process may be served on the plan administrator at the

address listed under section titled “Plan Sponsor and Administrator.”

Glossary In this section, you will find definitions for the words and phrases that appear in bold type throughout the

text of this SPD.

Aetna Aetna Life Insurance Company, an affiliate, or a third party vendor under contract with Aetna.

Coinsurance Coinsurance is both the percentage of 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 “plan coinsurance”

and varies by the type of expense. Please refer to the “Schedule of Benefits” for specific information on

coinsurance amounts.

Copay or Copayment The specific dollar amount or percentage required to be paid by you or on your behalf. The plan includes

various copayments, and these copayment amounts or percentages are specified in the Schedule of

Benefits.


Cosmetic Services or supplies that alter, improve or enhance appearance.

Covered Expenses Medical, dental, vision or hearing services and supplies shown as covered under this SPD.

Deductible The part of your covered expenses you pay before the plan starts to pay benefits. Additional information

regarding deductibles and deductible amounts can be found in the “Schedule of Benefits.”

Dental Provider This is:

Any dentist;

Group;

Organization;

Dental facility; or

Other institution or person.

legally qualified to furnish dental services or supplies.

Dental Emergency Any dental condition that:

Occurs unexpectedly;

Requires immediate diagnosis and treatment in order to stabilize the condition; and

Is characterized by symptoms such as severe pain and bleeding.

Dentist A legally qualified dentist, or a physician licensed to do the dental work he or she performs.

Directory A listing of all network providers serving the class of employees to which you belong. The policyholder

will give you a copy of this directory. Network provider information is available through Aetna's

online provider directory, DocFind®. You can also call the Member Services phone number listed on

your ID card to request a copy of this directory.

Experimental or Investigational A drug, a device, a procedure, or treatment will be determined to be experimental or investigational if:

There are insufficient outcomes data available from controlled clinical trials published in the peer-

reviewed literature to substantiate its safety and effectiveness for the illness or injury involved; or

Approval required by the U. S. Food and Drug Administration (FDA) has not been granted for

marketing; or

A recognized national medical or dental society or regulatory agency has determined, in writing, that

it is experimental or investigational, or for research purposes; or

It is a type of drug, device, procedure or treatment that is the subject of a Phase I or Phase II clinical

trial or the experimental or research arm of a Phase III clinical trial, using the definition of “phases”

indicated in regulations and other official actions and publications of the FDA and Department of

Health and Human Services; or


The written protocol or protocols used by the treating facility, or the protocol or protocols of any

other facility studying substantially the same:

drug;

device;

procedure; or

treatment, or the written informed consent used by the treating facility or by another facility

studying the same drug, device, procedure, or treatment states that it is experimental or

investigational, or for research purposes.

Hospital An institution that:

Is primarily engaged in providing, on its premises, inpatient medical, surgical and diagnostic services;

Is supervised by a staff of physicians;

Provides twenty-four (24) hour-a-day R.N. service,

Charges patients for its services;

Is operating in accordance with the laws of the jurisdiction in which it is located; and

Does not meet all of the requirements above, but does meet the requirements of the jurisdiction in

which it operates for licensing as a hospital and is accredited as a hospital by the Joint Commission

on the Accreditation of Healthcare Organizations.

Illness A pathological condition of the body that presents a group of clinical signs and symptoms and laboratory

findings peculiar to the findings set the condition apart as an abnormal entity differing from other normal

or pathological body states.

Injury An accidental bodily injury that is the sole and direct result of:

An unexpected or reasonably unforeseen occurrence or event; or

The reasonable unforeseeable consequences of a voluntary act by the person.

An act or event must be definite as to time and place.

Jaw Joint Disorder This is:

A Temporomandibular Joint (TMJ) dysfunction or any alike disorder of the jaw joint; or

A Myofacial Pain Dysfunction (MPD); or

Any alike disorder in the relationship of the jaw joint and the related muscles and nerves.

Lifetime Maximum This is the most the plan will pay for covered expenses incurred by any one covered person in their

lifetime.

In no event does hospital include a convalescent nursing home or any institution or part of one which is

used principally as a convalescent facility, rest facility, nursing facility, facility for the aged, extended care

facility, intermediate care facility, skilled nursing facility, hospice, rehabilitative hospital or facility

primarily for rehabilitative or custodial services.


Medically Necessary or Medical Necessity These are health care or dental services, and supplies or prescription drugs that a physician, other health

care provider or dental provider, exercising prudent clinical judgment, would give to a patient for the

purpose of:

preventing;

evaluating;

diagnosing; or

treating:

an illness;

an injury;

a disease; or

its symptoms.

The provision of the service, supply or prescription drug must be: a) In accordance with generally accepted standards of medical or dental practice; b) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered

effective for the patient's illness, injury or disease; and c) Not mostly for the convenience of the patient, physician, other health care or dental provider; and d) And do not cost more than an alternative service or sequence of services at least as likely to

produce the same therapeutic or diagnostic results as to the diagnosis or treatment of that patient's

illness, injury, or disease.

For these purposes “generally accepted standards of medical or dental practice” means standards that are

based on credible scientific evidence published in peer-reviewed literature. They must be generally

recognized by the relevant medical or dental community. Otherwise, the standards are consistent with

physician or dental specialty society recommendations. They must be consistent with the views of

physicians or dentists practicing in relevant clinical areas and any other relevant factors.

Negotiated Charge The maximum charge a network provider has agreed to make as to any service or supply for the purpose

of the benefits under this plan.

Network Provider A dental provider who has contracted to furnish services or supplies for this plan; but only if the provider is, with Aetna's consent, included in the directory as a network provider for:

The service or supply involved; and

The class of employees to which you belong.

Network Service(s) or Supply(ies) Health care service or supply that is:

Furnished by a network provider; or

Furnished or arranged by your PCD.

Non-Occupational Illness A non-occupational illness is an illness that does not:

Arise out of (or in the course of) any work for pay or profit; or

Result in any way from an illness that does.


An illness will be deemed to be non-occupational regardless of cause if proof is furnished that the person:

Is covered under any type of workers' compensation law; and

Is not covered for that illness under such law.

Non-Occupational Injury A non-occupational injury is an accidental bodily injury that does not:

Arise out of (or in the course of) any work for pay or profit; or

Result in any way from an injury which does.

Occupational Injury or Occupational Illness An injury or illness that:

Arises out of (or in the course of) any activity in connection with employment or self-employment

whether or not on a full time basis; or

Results in any way from an injury or illness that does.

Occurrence This means a period of disease or injury. An occurrence ends when 60 consecutive days have passed

during which the covered person:

Receives no medical treatment; services; or supplies; for a disease or injury; and

Neither takes any medication, nor has any medication prescribed, for a disease or injury.

Orthodontic Treatment

This is any:

Medical service or supply; or

Dental service or supply;

furnished to prevent or to diagnose or to correct a misalignment:

Of the teeth; or

Of the bite; or

Of the jaws or jaw joint relationship; whether or not for the purpose of relieving pain.

Out-of-Network Service(s) and Supply(ies)

Health care service or supply that is:

Furnished by an out-of network provider; or

Not furnished or arranged by your PCD.

Out-of-Network Provider A dental provider who has not contracted with Aetna, an affiliate, or a third party vendor, to furnish

services or supplies for this plan.

Physician A duly licensed member of a medical profession who:

Has an M.D. or D.O. degree;

Is properly licensed or certified to provide medical care under the laws of the jurisdiction where the

individual practices; and

Provides medical services which are within the scope of his or her license or certificate. This also

includes a health professional who:


Is properly licensed or certified to provide medical care under the laws of the jurisdiction where he or

she practices;

Provides medical services which are within the scope of his or her license or certificate;

Under applicable insurance law is considered a “physician” for purposes of this coverage;

Has the medical training and clinical expertise suitable to treat your condition;

Specializes in psychiatry, if your illness or injury is caused, to any extent, by alcohol abuse,

substance abuse or a mental disorder; and

A physician is not you or related to you.

For the purposes of Short Term Disability coverage, regular care of a physician means you are attended

by a physician who:

Is not you or related to you;

Has the medical training and clinical expertise suitable to treat your disabling condition;

Specializes in psychiatry, if your disability is caused, to any extent, by a mental health or psychiatric

condition; and

Whose treatment is:

Consistent with the diagnosis of the disabling condition;

According to guidelines established by medical, research and rehabilitative organizations; and

Administered as often as needed.

Precertification or Precertify A process where Aetna is contacted before certain services are provided, such as hospitalization or

outpatient surgery, or prescription drugs are prescribed to determine whether the services being

recommended or the drugs prescribed are considered covered expenses under the plan. It is not a

guarantee that benefits will be payable.

Prescriber Any physician or dentist, acting within the scope of his or her license, who has the legal authority to

write an order for a prescription drug.

Prescription An order for the dispensing of a prescription drug by a prescriber. If it is an oral order, it must be

promptly put in writing by the pharmacy.

Prescription Drug A drug, biological, or compounded prescription which, by State and Federal Law, may be dispensed only by prescription and which is required to be labeled “Caution: Federal Law prohibits dispensing

without prescription.” This includes:

An injectable drug prescribed to be self-administered or administered by any other person except one

who is acting within his or her capacity as a paid healthcare professional. Covered injectable drugs

include injectable insulin.

Primary Care Dentist (PCD) This is the network provider who:

Is selected by a person from the list of Primary Care Dentists in the directory;

Supervises, coordinates and provides dental services to a person;

Initiates referrals for specialist dentist care and maintains continuity of patient care; and

Is shown on Aetna's records as the person's primary care dentist.


If you do not choose a PCD, Aetna will have the right to make a selection for you. You will be notified

of the selection.

Recognized Charge The amount of an out-of-network provider’s charge that is eligible for coverage. You are responsible for

all amounts above the recognized charge. The recognized charge may be less than the provider’s full

charge.

Your plan’s recognized charge applies to all out-of-network covered expenses. In all cases, the

recognized charge is determined based on the Geographic Area where you receive the service or

supply.

For dental expenses:

80th percentile of the Prevailing Charge Rate

We have the right to apply Aetna reimbursement policies. Those policies may further reduce the

recognized charge.

These policies take into account factors such as:

The duration and complexity of a service;

When multiple procedures are billed at the same time, whether additional overhead is required;

Whether an assistant surgeon is necessary for the service;

If follow up care is included;

Whether other characteristics modify or make a particular service unique;

When a charge includes more than one claim line, whether any services described by a claim line are

part of or incidental to the primary service provided and

The educational level, licensure or length of training of the provider.

Aetna reimbursement policies are based on our review of:

The Centers for Medicare and Medicaid Services’ (CMS) National Correct Coding Initiative (NCCI)

and other external materials that say what billing and coding practices are and are not appropriate

Generally accepted standards of medical and dental practice and

The views of physicians and dentists practicing in the relevant clinical areas.

We use commercial software to administer some of these policies. Some policies are different for

professional services than for facility services.

Special terms used Geographic Area and Prevailing Charge Rates are defined as follows:

Geographic Area

The Geographic Area is made up of the first three digits of the U.S. Postal Service zip code. If we

determine we need more data for a particular service or supply, we may base rates on a wider Geographic

Area such as an entire state.

Prevailing Charge Rates The percentile value reported in a database prepared by FAIR Health, a nonprofit company. FAIR Health

changes these rates periodically. Aetna updates its systems with these changes within 180 days after

receiving them from FAIR Health. If the FAIR Health database becomes unavailable, Aetna has the right

to substitute an alternative database that Aetna believes is comparable.


Additional Information: Get the most value out of your benefits. Use the “Estimate the Cost of Care” tool on Aetna Navigator to help decide whether to get care in network or out-of-network. Aetna’s secure member website at www.aetna.com may contain additional information which may help you determine the cost of a service or supply. Log on to Aetna Navigator to access the “Estimate the Cost of Care” feature. Within this feature, view our “Cost of Care” and “Member Payment Estimator” tools.

Referral This is a written or electronic authorization made by your primary care physician (PCP) or primary

care dentist (PCD) to direct you to a network provider, for medically necessary services or supplies

covered under the plan.

Referral Care Covered services given to you by a specialist dentist who is a network provider after referral by your

primary care dentist and providing that Aetna approves coverage for the treatment.

R.N. A registered nurse.

Skilled Nursing Facility An institution that meets all of the following requirements:

It is licensed to provide, and does provide, the following on an inpatient basis for persons

convalescing from illness or injury:

Professional nursing care by an R.N., or by a L.P.N. directed by a full-time R.N.; and

Physical restoration services to help patients to meet a goal of self-care in daily living activities.

Provides 24 hour a day nursing care by licensed nurses directed by a full-time R.N.

Is supervised full-time by a physician or an R.N.

Keeps a complete medical record on each patient.

Has a utilization review plan.

Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, for mental retardates, for

custodial or educational care, or for care of mental disorders.

Charges patients for its services.

An institution or a distinct part of an institution that meets all of the following requirements:

It is licensed or approved under state or local law.

Is primarily engaged in providing skilled nursing care and related services for residents who

require medical or nursing care, or rehabilitation services for the rehabilitation of injured,

disabled, or sick persons.

Qualifies as a skilled nursing facility under Medicare or as an institution accredited by:

The Joint Commission on Accreditation of Health Care Organizations;

The Bureau of Hospitals of the American Osteopathic Association; or

The Commission on the Accreditation of Rehabilitative Facilities

Skilled nursing facilities also include rehabilitation hospitals (all levels of care, e.g. acute) and portions

of a hospital designated for skilled or rehabilitation services.



Skilled nursing facility does not include:

Institutions which provide only:

Minimal care;

Custodial care services;

Ambulatory; or

Part-time care services.

Institutions which primarily provide for the care and treatment of alcoholism, substance abuse or mental disorders.

Specialist A physician who practices in any generally accepted medical or surgical sub-specialty.

Specialist Dentist Any dentist who, by virtue of advanced training is board eligible or certified by a Specialty Board as

being qualified to practice in a special field of dentistry.

Specialty Care Health care services or supplies that require the services of a specialist.


Confidentiality Notice Aetna considers personal information to be confidential and has policies and procedures in place to

protect it against unlawful use and disclosure. By "personal information," we mean information that

relates to a member's physical or mental health or condition, the provision of health care to the member,

or payment for the provision of health care or disability or life benefits to the member. Personal

information does not include publicly available information or information that is available or reported in

a summarized or aggregate fashion but does not identify the member.

When necessary or appropriate for your care or treatment, the operation of our health, disability or life

insurance plans, or other related activities, we use personal information internally, share it with our

affiliates, and disclose it to health care providers (doctors, dentists, pharmacies, hospitals and other

caregivers), payors (health care provider organizations, employers who sponsor self-funded health plans

or who share responsibility for the payment of benefits, and others who may be financially responsible

for payment for the services or benefits you receive under your plan), other insurers, third party

administrators, vendors, consultants, government authorities, and their respective agents. These parties

are required to keep personal information confidential as provided by applicable law. In our health plans,

participating network providers are also required to give you access to your medical records within a

reasonable amount of time after you make a request.

Some of the ways in which personal information is used include claim payment; utilization review and

management; medical necessity reviews; coordination of care and benefits; preventive health, early

detection, vocational rehabilitation and disease and case management; quality assessment and

improvement activities; auditing and anti- fraud activities; performance measurement and outcomes

assessment; health, disability and life claims analysis and reporting; health services, disability and life

research; data and information systems management; compliance with legal and regulatory requirements;

formulary management; litigation proceedings; transfer of policies or contracts to and from other

insurers, HMOs and third party administrators; underwriting activities; and due diligence activities in

connection with the purchase or sale of some or all of our business. We consider these activities key for

the operation of our health, disability and life plans. To the extent permitted by law, we use and disclose

personal information as provided above without member consent. However, we recognize that many

members do not want to receive unsolicited marketing materials unrelated to their health, disability and

life benefits. We do not disclose personal information for these marketing purposes unless the member

consents. We also have policies addressing circumstances in which members are unable to give consent.

To obtain a copy of our Notice of Privacy Practices, which describes in greater detail our practices

concerning use and disclosure of personal information, please call the toll-free Member Services number

on your ID card or visit our Internet site at www.aetna.com.


AEP Benefits Center

1-888-237-2363