SPE's Aetna Dental(R) PPO Max Plan
Your dental health is an important part of caring for your body. That's why dental insurance is an important part of your family's overall healthcare coverage. The SPE Dental Insurance Plan—Aetna Dental® PPO Max Plan offers you and your family a great combination of quality benefits, guaranteed acceptance, and a network of participating dentists, all backed by a commitment to providing exceptional personal service.
One of the important benefits the Dental Insurance Plan offers is preventive care. This Plan will cover you and your family for routine exams and preventive care (such as oral exams, cleanings, bitewing x-rays, and full-mouth x-rays) as soon as your coverage goes into effect.
*The PPO Plan is referred to as the Participating Dental Network (PDN) in Texas.
You are eligible to apply for the SPE Dental Insurance Plan regardless of your age if you are a member of the Society of Petroleum Engineers; you are a United States resident but are not a resident of Alaska, Arkansas, Massachusetts, Maine, North Carolina, or Oregon; and you have not been covered under the SPE Dental Plan in the past two years.
You can also request coverage for your spouse and all unmarried dependent children under age 19**, or 25 if a full-time student. Dependents who are not enrolled at the time of the member enrollment may be subject to services not being covered during the first 12 months of coverage.
**Under age 25 for Texas residents with no full-time student requirement.
Aetna Dental® PPO Max Benefits Summary
|Preventive Service Payment %||100%|
|Benefits begin immediately|
|Basic Service Payment %||80%|
|Benefits begin immediately|
|Major Service Payment %||50%|
|Benefits begin after 12 months of continuous coverage under the GeoCare Dental Insurance Plans|
|Calendar Year Maximum||$1000|
|Orthodontic Services||Not Covered|
Under this Plan, you may choose at the time of service either a dentist who participates in Aetna's dental PPO network or a nonparticipating dentist. With this Plan, savings are possible because the participating dentists have agreed to provide care at negotiated rates. Benefits for care from non-participating dentists will be paid based on the standard Aetna negotiated rates for participating dentists in the same geographic area. The non-participating dentist may balance bill you for the difference up to the submitted fee.
To find a participating dentist near you, visit www.aetna.com/docfind. Select Dental PPO/PDN with PPO II Network from the list of plans.
Partial List of Plan Provisions
|Oral examinations (a)||100%|
|Cleanings, Adult/Child (a)||100%|
|Sealants (permanent molars only) (a)||100%|
|Bitewing X-rays (a)||100%|
|Full-mouth series X-rays (a)||100%|
|Amalgam (silver) fillings||80%|
|Composite fillings (anterior teeth only)||80%|
|Stainless steel crowns||80%|
|Incision and drainage of abscess||80%|
|Surgical removal of erupted tooth||80%|
|Surgical removal of impacted tooth (soft tissue)||80%|
|Root canal therapy (Anterior teeth/Bicuspid teeth)||80%|
|Scaling and root planing (a)||80%|
|Crowns (non-stainless steel)||50%|
|Full & partial dentures||50%|
|Root canal therapy (Molar teeth)||50%|
|Osseous surgery (a)*||50%|
|Surgical removal of impacted tooth (partial bony/full bony)*||50%|
|General anesthesia/intravenous sedation||50%|
|(a) Frequency and/or age limitations may apply to these services. These limits are described in the Certificate of Insurance.|
Important note: Benefits for care from non-participating dentists will be paid based on the standard Aetna negotiated rate for participating dentists in the same geographical area. The non-participating dentist may balance bill you for the difference up to the submitted fee.
To find a participating dentist near you, visit http://www.aetna.com/docfind. Select Dental PPO/PDN with PPO II Network from the list of plans.
Emergency Dental Care
If you need emergency dental care for the palliative treatment (pain relieving, stabilizing) of a dental emergency, you are covered 24 hours a day, 7 days a week. When emergency services are provided by a participating PPO dentist, your coinsurance amount will be based on a negotiated fee schedule. When emergency services are provided by a non-participating dentist, you will be responsible for the difference between the plan payment and the dentist’s usual charge. Covered emergency services may vary based on state law. Out of area emergency dental care may be reviewed by Aetna's dental consultants to verify appropriateness of treatment.
Your coverage becomes effective immediately upon receipt of your enrollment form and premium.
Termination of Coverage
Coverage terminates on the earliest of the following dates:
- the first of the month following the date you cease to be eligible for coverage,
- the first of the month following the date your dependent is no longer a dependent as defined,
- the premium due date on which you fail to pay the required premium,
- the date the group insurance policy terminates
About the Insurance Program's Administrator
AGIA is recognized as a leader in association group insurance because their approach is simple - they take care of the details so their clients don't have to. The secret to AGIA's customer service is what happens behind the scenes.
Some Services Not Covered Under the Plan Are:
- Services or supplies that are covered in whole or in part: a) under any other part of this Dental Care Plan; or b) under any other plan of group benefits provided by or through your employer;
- Services and supplies to diagnose or treat a disease or injury that is not: a) a non-occupational disease; or b) a non-occupational injury.
- Services not listed in the Dental Care Schedule that applies.
- Those for replacement of a lost, missing or stolen appliance, and those for replacement of appliances that have been damaged due to abuse, misuse, or neglect.
- Those for plastic, reconstructive or cosmetic surgery, or other dental services or supplies that are primarily intended to improve, alter or enhance appearance. This applies whether or not the services and supplies are for psychological or emotional reasons. Facings on molar crowns and pontics will always be considered cosmetic.
- Those for or in conjunction with services, procedures, drugs or other supplies that are determined by Aetna to be experimental or still under clinical investigation by health professionals.
- Those for dentures, crowns, inlays, onlays, bridgework, or other appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or to correct attrition, abrasion or erosion.
- Those for any of the following services: a) an appliance or modification of one if an impression for it was made before the person became a covered person; b) a crown, bridge, or cast or processed restoration if a tooth was prepared for it before the person became a covered person; or c) root canal therapy if the pulp chamber for it was opened before the person became a covered person.
- Services that Aetna defines as not necessary for the diagnosis, care or treatment of the condition involved. This applies even if they are prescribed, recommended, or approved by the attending physician or dentist.
- Those for services intended for treatment of any jaw disorder unless otherwise specified in the booklet/certificate.
- Those for space maintainers, except when needed to preserve space resulting from the premature loss of deciduous teeth.
- Those for orthodontic treatment.
- Those for general anesthesia and intravenous sedation, unless specifically covered. For plans that cover these services, they will not be eligible for benefits unless done in conjunction with another necessary covered service.
- Those for treatment by other than a dentist, except that scaling or cleaning of teeth and topical application of flouride may be done by a licensed dental hygienist. In this case, the treatment must be given under the supervision and guidance of a dentist.
- Those in connection with a service given to a person age 5 or older if that dependent becomes a covered dependent, other than: (a) during the first 31 days the dependent is eligible for this coverage, or (b) as prescribed for any period of open enrollment agreed to by the Plan Sponsor and Aetna. This does not apply to charges incurred: (i) after the end of the 12-month period starting on the date the dependent became a covered dependent; of (ii) as a result of accidental injuries sustained while the dependent was a covered dependent; or (iii) for a primary care service in the Dental Care Schedule that applies as shown under the headings Visits and Exams, and X-rays and Pathology.
- Services given by a non-participating dental provider to the extent that the charges exceed the amount payable for the services shown in the Dental Care Schedule that applies.
- Those for a crown, cast or processed restoration unless: a) it is treatment for decay or traumatic injury, and teeth cannot be restored with a filling material; or b) the tooth is an abutment to a covered partial denture or fixed bridge.
- Those for pontics, crowns, cast or processed restorations made with high-noble metals, unless otherwise specified in the Certificate.
- Those for surgical removal of impacted wisdom teeth only for orthodontic reasons, unless otherwise specified in the Certificate.
- Services needed solely in connection with non-covered services.
- Services done where there is no evidence of pathology, dysfunction or disease other than covered preventive services.
Any exclusion above will not apply to the extent that coverage of the charges is required under any law that applies to the coverage.
This is a partial list of exclusions and limitations; others may apply. Please check your plan booklet/certificate for details.
Dental Insurance Area Number Chart & Monthly Premium Rates
|State||Zip Codes||Area||State||Zip Codes||Area||State||Zip Codes||Area|
|AL||All||1||LA||700,701||1||OK||730-731, 740-741, 748||1|
|AR||Not available||n/a||All other||2||All other||2|
|AZ||850-853, 856-857||3||MA||Not available||n/a||OR||Not available||n/a|
|CA||919-921||5||ME||Not available||n/a||All other||2|
|All other||6||MN||550-551, 553-555||3||SC||All||1|
|DC||All||3||All other||2||TX||750-753, 760-762||3|
|All other||2||NC||Not available||n/a||All other||2|
(Use your area number from the Area Chart above.)
Monthly Premium Rates* by Area
Effective January 1, 2012
|Area 1||Area 2||Area 3||Area 4||Area 5||Area 6||Area 7|
*This material is for informational purposes only and is not a contract of dental insurance. Please note that rates and benefits are subject to change on the plan renewal dates. An enrollment form must be completed and approved by Aetna, and initial premium paid before coverage is made effective. These insurance plans contain exclusions and limitations and may not cover all of your dental care expenses. Please note: A $2.00 administrative fee is added by AGIA (the Program Administrator) for billing modes other than annual.
Other Important Information
Rules Governing Coverage Under This Dental Plan
The replacement of, addition to, or modification of existing dentures, crowns, casts or processed restorations, removable denture, fixed bridgework, or other prosthetic devices is covered only if one of the following terms is met:
- The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or bridgework was installed. This coverage must have been in force for the covered person when the extraction took place.
- The existing denture, crown, cast or processed restoration, removable denture, bridgework, or other prosthetic device cannot be made serviceable, and was installed at least 8 years before its replacement.
- The existing denture is an immediate temporary one to replace one or more natural teeth extracted while the person is covered, cannot be made permanent, and replacement by permanent denture is required. The replacement must take place within 12 months from the date of initial installation of the immediate temporary denture.
Tooth Missing, But Not Replaced Rule
Coverage for the first installation of removable dentures, fixed bridgework and other prosthetic services is subject to the requirements that such removable dentures, fixed bridgework and other prosthetic services are (i) needed to replace one or more natural teeth that were removed while this policy was in force for the covered person, and (ii) are not abutments to a partial denture, removable bridge, or fixed bridge installed during the prior 8 years.
Alternate Treatment Rule
If more than one service can be used to treat a covered person’s dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that all of the following terms are met: a) the service must be listed in the Dental Care Schedule, b) the service selected must be deemed by the dental profession to be an appropriate method of treatment, and c) the service selected must meet broadly-accepted national standards of dental practice.
If treatment is being given by a participating dental provider and the covered person asks for a more costly covered service than that for which coverage is approved, the specific coinsurance for such service will consist of: a) the coinsurance for the approved less costly service plus b) the difference in cost between the approved less costly service and the more costly covered service.
Reinstatement of Coverage
Members who terminate their coverage or who terminate the coverage of their covered dependents may not re-enroll in the Dental Plan for a period of 24 months from the date the coverage is terminated.
Finding Participating Providers
Consult Aetna Dental’s online provider directory, DocFind ® for the most current provider listings. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna. The availability of any particular provider cannot be guaranteed and provider network composition is subject to change without notice. For the most current information, please contact the selected provider or Aetna Member Services at the toll-free number on your ID card, or use Aetna’s Internet-based provider directory (DocFind) available at http://www.aetna.com/docfind.
This material is for information only and is not an offer or invitation to contract. Dental insurance plans contain exclusions and limitations. Dental information programs provide general dental information and are not a substitute for diagnosis or treatment by a dentist or other dental care professional. Dental providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide or guarantee access to dental services. Not all dental services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. Policy forms issued in Oklahoma include GR-9 and/or GR-23, GR-29 and/or GR-29N.
Understanding Your Certificate of Insurance-30 Day Free Look
This website contains only a partial description of the provisions of this insurance coverage. When you become insured, you will be sent a Certificate of Insurance as evidence of coverage underwritten by Aetna Life Insurance Company. Please read your Certificate thoroughly when it arrives and contact the Administrator with any questions. If you are not completely satisfied with the terms of your Certificate, you may return it, without claim, within 30 days for a full premium refund. No questions asked.
How to Apply for Coverage
It is important to read the General Information section of this website before applying for coverage. To download a paper application and complete application instructions, click here. Online enrollment is not available for this Plan.
The information on this website is subject to change without notice. In case of a conflict between your plan documents and this information, the plan documents will govern. All member care and related decisions are the sole responsibility of participating providers. Aetna is not a provider of dental care services and therefore cannot guarantee any results or outcomes.
PPO Dental Insurance Plans are underwritten and administered by Aetna Life Insurance Company, Hartford, CT.
The Dental PPO Plan is referred to as the Participating Dental Network (PDN) in Texas.
This information contains only a partial, general description of plan or program benefits and does not constitute a contract. The availability of a plan or program may vary by geographical service area. Consult your Certificate to determine governing contractual provisions, including procedures, exclusions and limitations relating to your plan.