Aetna Dental Preferred Provider Organization (PPO) Plan

Transcription

1 Aetna Dental Preferred Prvider Organizatin (PPO) Plan This dcument is a Summary Plan Descriptin (SPD), as defined by the Emplyee Retirement Incme Security Act f 1974 (ERISA), f the Tys R Us, Inc. Aetna Dental Preferred Prvider Organizatin (PPO) Plan ( Plan ). This SPD is a summary f the main features f the Plan in effect as f July 1, If there is any discrepancy between the infrmatin cntained in this SPD and the Plan dcuments, the Plan dcuments will always gvern. If there are legal rules that require changes that are nt yet written int the Plan dcument, the Plan dcument will be interpreted by the Plan Administratr as including thse legal rules. Please nte that nthing in this SPD is meant t imply a cntract r guarantee f emplyment. Participatin in the Plan des nt preclude the Cmpany frm terminating yur emplyment at any time, whether r nt fr cause, with r withut ntice. Please read this SPD carefully and share the infrmatin with yur family. If yu have any questins abut this Plan, please cntact the R Benefits Service Center at TRU BENS. This Summary Plan Descriptin supersedes and replaces any previus SPDs yu have received describing the Aetna Dental PPO Plan. Tys R Us, Inc. Aetna Dental PPO Plan 1 July 1, 2017

2 Cntents The Aetna Dental PPO Plan at a Glance... 3 The Aetna Dental PPO Plan... 4 ID Cards... 4 Cvered Expenses... 4 Preventive and Diagnstic Services... 4 Basic Services... 5 Majr Services... 7 Orthdntics... 8 Emergency Care... 8 Dental Medical Integratin (DMI)... 8 Maximum Benefits... 9 Tth Missing but Nt Replaced Rule... 9 Exclusins Pre-treatment Review Effect f Benefits under Other Plans Recvery f Overpayment Qualified Medical Child Supprt Order (QMCSO) In the Event f Yur Death Terminatin f Cverage Cntinuatin f Cverage (COBRA) Glssary f Key Terms Tys R Us, Inc. Aetna Dental PPO Plan 2 July 1, 2017

3 The Aetna Dental PPO Plan at a Glance Here are the highlights f the Aetna Dental PPO Plan. Benefits may be subject t certain limits and restrictins. Be sure t review the rest f this Summary Plan Descriptin fr a mre cmplete descriptin f Plan benefits. Fr infrmatin abut participatin requirements, see Eligibility and Enrllment; see Administrative and Legal Infrmatin fr hw t file a claim, cntinuatin cverage, legal ntices and where t btain additinal infrmatin. Aetna Dental PPO Plan In-netwrk (Benefits are based n negtiated charge) Out-f-netwrk (Benefits are based n the recgnized charge) Plan Year Deductible Preventive and Diagnstic Services, including: $50 fr each cvered persn 100% n deductible 100% n deductible Rutine ral exams Cleaning and scaling f teeth X-rays Fluride treatment Space maintainers Sealants Basic Services, including: 80% after deductible 70% after deductible Fillings Extractins Enddntics Peridntics Osseus surgery Oral surgery Majr Services, including: 50% after deductible 50% after deductible Crwns Bridgewrk and dentures Inlays and nlays Orthdntic Care 50% up t a $1,500, after deductible Individual lifetime maximum Nt cvered Plan Year Maximum Benefit $1,500 fr each cvered persn Tys R Us, Inc. Aetna Dental PPO Plan 3 July 1, 2017

4 The Aetna Dental PPO Plan The Aetna Dental PPO Plan prmtes gd dental health by prviding cverage fr a brad range f dental services and supplies. Plan benefits are highest and yu pay less ut f yur wn pcket whenever yu use an in-netwrk dentist. If yu chse t see an ut-f-netwrk dentist, rthdntic care is nt cvered and Plan benefits are generally less. While in-netwrk dentists agree t a cntracted rate, charges fr ut-f-netwrk dentists will be based n recgnized charge rates as determined by Aetna. T lcate a participating Aetna dentist near yu, cntact Aetna Member Services. ID Cards Yu will nt receive an ID card when yu enrll in the Aetna Dental PPO Plan. If yu want t print an ID card, frm Aetna s website, g t (yu must register and lg n t Aetna Navigatr t access this feature). Yu r yur prvider can als cntact Aetna Member Services t verify yur cverage. Cvered Expenses The Plan cvers nly the dental services listed belw, prvided they are necessary, custmarily used natinwide, prfessinally apprpriate and meet bradly accepted natinal standards f dental practice fr the cnditin being treated. Preventive and Diagnstic Services The PPO pays the fllwing benefits fr Preventive and Diagnstic services with n deductible: The PPO pays 100% f the negtiated charge fr in-netwrk cverage If Preventive and Diagnstic services are prvided by An in-netwrk and ut-f-netwrk dentist 100% f the recgnized charge fr ut-fnetwrk cverage Cvered Preventive and Diagnstic services include: Visits and Exams Rutine ral exams limited t nce every six mnths Prphylaxis (cleaning and scaling f teeth) limited t nce every six mnths Tpical applicatin f sdium r stannus fluride fr cvered individuals under age 17 limited t ne treatment per plan year Sealants fr cvered dependent children under age 16 limited t ne applicatin every three years fr permanent mlars nly Space maintainers, including all adjustments within the first six mnths fllwing installatin (fr cvered dependents under age 17): fixed, band type remvable acrylic with rund wire clasp Tys R Us, Inc. Aetna Dental PPO Plan 4 July 1, 2017

5 X-rays Full muth series r panramic film limited t nce every 5 years Bitewing X-rays limited t ne set every 12 mnths Vertical bitewing X-rays Periapical X-rays Intra-ral X-rays, cclusal view, maxillary r mandibular Extra-ral X-rays f the upper r lwer jaw. Basic Services The PPO pays the fllwing benefits fr Basic services: The PPO pays If Basic services are prvided by 80% f the discunted rate after the deductible An in-netwrk dentist 70% f recgnized charges after the deductible An ut-f-netwrk dentist Cvered Basic services include: Restratins and Repairs Amalgam fillings Resin fillings Retentin pins Sedative fillings Prefabricated resin crwns (but nt temprary crwns) Recementing inlays, crwns, bridges and space maintainers Tissue cnditining fr dentures Emergency palliative treatment (emergency relief f pain) Crwn and bridge repairs Full and partial denture repairs, including relining, rebasing and adjustments within six mnths after installatin. Adding teeth t an existing denture Tys R Us, Inc. Aetna Dental PPO Plan 5 July 1, 2017

6 Enddntics (Rt Canal) Pulp capping Pulptmy Surgical expsure fr rubber dam islatin Rt canal therapy, including necessary X-rays Apexificatin/recalcificatin Apicetmy (per tth) first rt Apicetmy (per tth) Retrgrade filling Rt amputatin Hemisectin Peridntics Scaling and rt planing Peridntal maintenance prcedures fllwing active peridntal therapy Gingivectmy r gingivplasty per tth r per quadrant Gingival flap prcedure per quadrant Peridntics fr sseus surgery (including flap entry and clsure). Oral Surgery including lcal anesthetics and rutine pst-perative care Simple extractins (nn-surgical) Surgical remval f: erupted tth tth impacted in sft tissue tth impacted in bne (partially bny, cmpletely bny, and cmpletely bny with unusual surgical cmplicatins) hyperplastic tissue pericrnal gingiva Intravenus sedatin and general anesthesia, nly when medically necessary and prvided in cnjunctin with a cvered surgery Remval f residual rt Clsure f ral fistula Frenectmy Transplantatin f tth r tth bud Alveplasty in cnjunctin with extractins per quadrant Alveplasty nt in cnjunctin with extractins per quadrant Remval f exstsis. Tys R Us, Inc. Aetna Dental PPO Plan 6 July 1, 2017

7 Majr Services The PPO pays the fllwing benefits fr Majr services: The PPO pays If Majr services are prvided by 50% f the discunted rate after the deductible An in-netwrk dentist 50% f recgnized charges after the deductible An ut-f-netwrk dentist Cvered Majr services include: Restratins Inlays Onlays Implants, including prsthetic replacement Crwns (including build-ups when necessary) Stainless steel crwns Prcelain with nble metal, base metal, base metal (full cast), nble metal (full cast), metallic (3/4 cast), pst and cre Pntics with base metal (full cast), nble metal (full cast), prcelain with nble metal, prcelain with base metal, resin with nble metal, resin with base metal Dentures and partials T be eligible fr reimbursement, Aetna must receive satisfactry prf f the fllwing: The remvable denture, fixed bridgewrk r ther prsthetic service is needed t replace ne r mre natural teeth remved while the individual was cvered under the Plan and The remvable denture, fixed bridgewrk r ther prsthetic service is nt an abutment t an existing partial denture, remvable bridge r fixed bridge installed during the prir five years. T be eligible fr replacement, Aetna must receive satisfactry prf f the fllwing: The replacement, additin r mdificatin is necessary t replace teeth extracted while the individual was cvered under the Plan, and after the denture, bridge r ther prsthetic was installed The existing denture, bridgewrk r ther prsthetic is at least five years ld and cannt be made serviceable and The existing denture: is temprary t replace ne r mre natural teeth extracted while the patient was a Plan participant cannt be made permanent and replacement by a permanent denture is needed is replaced within 12 mnths after the temprary was first installed. Tys R Us, Inc. Aetna Dental PPO Plan 7 July 1, 2017

8 Orthdntics The PPO pays 50% f the cst f services and supplies fr Orthdntic treatment fr dependent children and adults. Benefits are prvided nly if yu use an in-netwrk rthdntist. If yu use an ut-f-netwrk rthdntist, n benefits will be paid by the Plan. Cvered Orthdntic expenses include: Cmprehensive rthdntic treatment Remvable appliance t crrect habits Fixed r cemented appliance t crrect habits Occlusal guard fr bruxism. Emergency Care The Plan prvides cverage fr any emergency which: Occurs unexpectedly Requires immediate diagnsis and treatment and Invlves severe pain and bleeding due t an abscess, infectin r chewing incident Fr emergency care the Plan pays up t $75 fr the initial visit. It desn t matter if yu receive the service frm an in-netwrk r ut-f-netwrk dentist. Fr any fllw-up care, the Plan pays its regular benefits. Dental Medical Integratin (DMI) The fllwing additinal dental expenses will be cnsidered cvered expenses fr yu and yur cvered dependent if yu r yur cvered dependent have medical cverage insured r administered by Aetna and have at least ne f the fllwing cnditins: Pregnancy; Crnary artery disease/cardivascular disease; Cerebrvascular disease; r Diabetes Additinal Cvered Dental Expenses One additinal prphylaxis (cleaning) per year. Scaling and rt planing, (4 r mre teeth); per quadrant; Scaling and rt planing (limited t 1-3 teeth); per quadrant; Full muth debridement; Peridntal maintenance (ne additinal treatment per year); and Lcalized delivery f antimicrbial agents. (Nt cvered fr pregnancy) Payment f Benefits The additinal prphylaxis, the benefit will be payable the same as ther prphylaxis under the plan. The payment percentage applied t the ther cvered dental expenses abve will be 100% fr netwrk expenses and 100% fr ut-f-netwrk expenses. These additinal benefits will nt be subject t any frequency limits except as shwn abve r any Plan Year maximum. Tys R Us, Inc. Aetna Dental PPO Plan 8 July 1, 2017

9 Aetna will reimburse the prvider directly, r yu may pay the prvider directly and then submit a claim fr reimbursement fr cvered expenses. Maximum Benefits Yu and each cvered dependent can receive up t $1,500 in benefits each plan year fr Preventive and Diagnstic, Basic and Majr services cmbined whether care is received in-netwrk r ut-f-netwrk. Hwever, frequency f treatment and/r age limitatins may apply, as described in the list f cvered dental services and supplies. Orthdntic care has a separate individual lifetime maximum benefit f $1,500 fr each eligible member. Tth Missing but Nt Replaced Rule Replacement Rule Crwns, inlays, nlays and veneers, cmplete dentures, remvable partial dentures, fixed partial dentures (bridges) and ther prsthetic services are subject t the plan's replacement rule. That means certain replacements f, r additins t, existing crwns, inlays, nlays, veneers, dentures r bridges are cvered nly when yu give prf t Aetna that: While yu were cvered by the plan, yu had a tth (r teeth) extracted after the existing denture r bridge was installed. As a result, yu need t replace r add teeth t yur denture r bridge. The present crwn, inlay and nlay, veneer, cmplete denture, remvable partial denture, fixed partial denture (bridge), r ther prsthetic service was installed at least 5 years befre its replacement and cannt be made serviceable. Yu had a tth (r teeth) extracted while yu were cvered by the plan. Yur present denture is an immediate temprary ne that replaces that tth (r teeth). A permanent denture is needed, and the temprary denture cannt be used as a permanent denture. Replacement must ccur within 12 mnths frm the date that the temprary denture was installed. The first installatin f cmplete dentures, remvable partial dentures, fixed partial dentures (bridges), and ther prsthetic services will be cvered if: The dentures, bridges r ther prsthetic services are needed t replace ne r mre natural teeth that were remved while yu were cvered by the plan; and The tth that was remved was nt an abutment t a remvable r fixed partial denture installed during the prir 5 years. The extractin f a third mlar des nt qualify. Any such appliance r fixed bridge must include the replacement f an extracted tth r teeth. Tys R Us, Inc. Aetna Dental PPO Plan 9 July 1, 2017

10 Exclusins Nt every dental care service r supply is cvered by the plan, even if prescribed, recmmended, r apprved by yur physician r dentist. The plan cvers nly thse services and supplies that are medically necessary and included in the Cvered Expenses sectin. Charges made fr the fllwing are nt cvered except t the extent listed under the Cvered Expenses sectin. In additin, sme services are specifically limited r excluded. This sectin describes expenses that are nt cvered r subject t special limitatins. These dental exclusins are in additin t the exclusins that apply t health cverage. Any instructin fr diet, plaque cntrl and ral hygiene. Csmetic services and supplies including plastic surgery, recnstructive surgery, csmetic surgery, persnalizatin r characterizatin f dentures r ther services and supplies which imprve alter r enhance appearance, augmentatin and vestibulplasty, and ther substances t prtect, clean, whiten bleach r alter the appearance f teeth; whether r nt fr psychlgical r emtinal reasns; except t the extent cverage is specifically prvided in the What the Plan Cvers sectin. Facings n mlar crwns and pntics will always be cnsidered csmetic. Crwn, inlays and nlays, and veneers unless: It is treatment fr decay r traumatic injury and teeth cannt be restred with a filling material; r The tth is an abutment t a cvered partial denture r fixed bridge. Dental implants, braces, muth guards, and ther devices t prtect, replace r repsitin teeth and remval f implants. Dental services and supplies that are cvered in whle r in part: Under any ther part f this plan; r Under any ther plan f grup benefits prvided by the cntract hlder. Dentures, crwns, inlays, nlays, bridges, r ther appliances r services used fr the purpse f splinting, t alter vertical dimensin, t restre cclusin, r crrecting attritin, abrasin, r ersin. Except as cvered in the Cvered Expenses sectin, treatment f any Jaw Jint Disrder and treatments t alter bite r the alignment r peratin f the jaw, including temprmandibular jint disrder (TMJ) treatment, rthgnathic surgery, and treatment f malcclusin r devices t alter bite r alignment. First installatin f a denture r fixed bridge, and any inlay and crwn that serves as an abutment t replace cngenitally missing teeth r t replace teeth all f which were lst while the persn was nt cvered. General anesthesia and intravenus sedatin, unless specifically cvered and nly when dne in cnnectin with anther necessary cvered service r supply. Orthdntic treatment except as cvered in the Cvered Expenses sectin. Pntics, crwns, cast r prcessed restratins made with high nble metals (gld r titanium). Prescribed drugs; pre-medicatin; r analgesia. Replacement f a device r appliance that is lst, missing r stlen, and fr the replacement f appliances that have been damaged due t abuse, misuse r neglect and fr an extra set f dentures. Services and supplies dne where there is n evidence f pathlgy, dysfunctin, r disease ther than cvered preventive services. Services and supplies prvided fr yur persnal cmfrt r cnvenience, r the cnvenience f any ther persn, including a prvider. Tys R Us, Inc. Aetna Dental PPO Plan 10 July 1, 2017

11 Services and supplies prvided in cnnectin with treatment r care that is nt cvered under the plan. Space maintainers except when needed t preserve space resulting frm the premature lss f deciduus teeth. Surgical remval f impacted wisdm teeth nly fr rthdntic reasns. Treatment by ther than a dentist. Hwever, the plan will cver sme services prvided by a licensed dental hygienist under the supervisin and guidance f a dentist. These are: Scaling f teeth; Cleaning f teeth; and Tpical applicatin f fluride. Pre-treatment Review Whenever yur dentist estimates that his r her services will exceed $350, yu shuld have yur dentist file an advance claim review with Aetna. Aetna will estimate the benefits and let yu and yur dentist knw befre the wrk begins. Effect f Benefits under Other Plans Sme persns have health r dental cverage in additin t cverage under this Plan. Under these circumstances, it is nt intended that a plan prvide duplicate benefits. Fr this reasn, many plans, including this Plan, have a "crdinatin f benefits" prvisin. Under the crdinatin f benefits prvisin f this Plan, the amunt nrmally reimbursed under this Plan is reduced t take int accunt payments made by "ther plans". When this and anther health expenses cverage plan applies, the rder in which the varius plans will pay benefits must be figured. This will be dne as fllws using the first rule that applies: 1. A plan with n rules fr crdinatin with ther benefits will be deemed t pay its benefits befre a plan which cntains such rules. 2. A plan which cvers a persn ther than as a dependent will be deemed t pay its benefits befre a plan which cvers the persn as a dependent; except that if the persn is als a Medicare beneficiary and as a result f the Scial Security Act f 1965, as amended, Medicare is: secndary t the plan cvering the persn as a dependent; and primary t the plan cvering the persn as ther than a dependent; The benefits f a plan which cvers the persn as a dependent will be determined befre the benefits f a plan which: cvers the persn as ther than a dependent; and is secndary t Medicare. 3. Except in the case f a dependent child whse parents are divrced r separated; the plan which cvers the persn as a dependent f a persn whse birthday cmes first in a calendar year will be primary t the plan which cvers the persn as a dependent f a persn whse birthday cmes later in that calendar year. If bth parents have the same birthday, the benefits f a plan which cvered ne parent lnger are determined befre thse f a plan which cvered the ther parent fr a shrter perid f time. If the ther plan des nt have the rule described in this prvisin (3) but instead has a rule based n the gender f the parent and if, as a result, the plans d nt agree n the rder f benefits, the rule in the ther plan will determine the rder f benefits. Tys R Us, Inc. Aetna Dental PPO Plan 11 July 1, 2017

12 4. In the case f a dependent child whse parents are divrced r separated: a. If there is a curt decree which states that the parents shall share jint custdy f a dependent child, withut stating that ne f the parents is respnsible fr the health care expenses f the child, the rder f benefit determinatin rules specified in (3) abve will apply. b. If there is a curt decree which makes ne parent financially respnsible fr the medical, dental r ther health care expenses f such child, the benefits f a plan which cvers the child as a dependent f such parent will be determined befre the benefits f any ther plan which cvers the child as a dependent child. c. If there is nt such a curt decree: If the parent with custdy f the child has nt remarried, the benefits f a plan which cvers the child as a dependent f the parent with custdy f the child will be determined befre the benefits f a plan which cvers the child as a dependent f the parent withut custdy. If the parent with custdy f the child has remarried, the benefits f a plan which cvers the child as a dependent f the parent with custdy shall be determined befre the benefits f a plan which cvers that child as a dependent f the stepparent. The benefits f a plan which cvers that child as a dependent f the stepparent will be determined befre the benefits f a plan which cvers that child as a dependent f the parent withut custdy. 5. If 1, 2, 3 and 4 abve d nt establish an rder f payment, the plan under which the persn has been cvered fr the lngest will be deemed t pay its benefits first; except that: The benefits f a plan which cvers the persn n whse expenses claim is based as a: laid-ff r retired emplyee; r the dependent f such persn; Shall be determined after the benefits f any ther plan which cvers such persn as: an emplyee wh is nt laid-ff r retired; r a dependent f such persn. If the ther plan des nt have a prvisin: regarding laid-ff r retired emplyees; and as a result, each plan determines its benefits after the ther; then the abve paragraph will nt apply. The benefits f a plan which cvers the persn n whse expenses claim is based under a right f cntinuatin pursuant t federal r state law shall be determined after the benefits f any ther plan which cvers the persn ther than under such right f cntinuatin. If the ther plan des nt have a prvisin: regarding right f cntinuatin pursuant t federal r state law; and as a result, each plan determines its benefits after the ther; then the abve paragraph will nt apply. The general rule is that the benefits therwise payable under this Plan fr all expenses incurred in a plan year will be reduced by all "ther plan" benefits payable fr thse expenses. When the crdinatin f benefits rules f this Plan and an "ther plan" bth agree that this Plan determines its benefits befre Tys R Us, Inc. Aetna Dental PPO Plan 12 July 1, 2017

13 such ther plan, the benefits f the ther plan will be ignred in applying the general rule abve t the claim invlved. In rder t administer this prvisin, Aetna can release r btain data. Aetna can als make r recver payments. When this prvisin perates t reduce the ttal amunt f benefits therwise payable as t a persn cvered under this Plan during a plan year, each benefit that wuld be payable in the absence f this prvisin will be reduced prprtinately. Such reduced amunt will be charged against any applicable benefit limit f this Plan. Other Plan This means any ther plan f health expense cverage under: Grup insurance. Any ther type f cverage fr persns in a grup. This includes plans that are insured and thse that are nt. N-fault aut insurance required by law and prvided n ther than a grup basis. Only the level f benefits required by the law will be cunted. Claiming Benefits Aetna administers all Aetna Dental PPO claims. Dental services yu receive frm an in-netwrk dentist generally require n claim frms. As a curtesy, all in-netwrk dentists are required t submit dental frms fr yu. If yu receive care frm an ut-f-netwrk dentist yu will need t file a claim frm fr reimbursement. Submit the cmpleted frm t Aetna at the address shwn n the frm. Be sure t include all f the necessary dcumentatin. Recvery f Overpayment If yu receive a benefit payment fr mre than it shuld be, the Claims Administratr reserves the right t have the extra amunt returned r reduce any future payments t make up the difference. Qualified Medical Child Supprt Order (QMCSO) Federal law requires grup health plans t hnr qualified medical child supprt rders (QMCSOs) which apply t the Aetna Dental PPO Plan. In general, a QMCSO is a state rder requiring a parent t prvide medical supprt t a child in case f separatin r divrce and under certain statutry cnditins. Upn receipt f a medical child supprt rder (MCSO), yu and the affected child will receive ntice that the rder is being reviewed by the Plan t determine if it is qualified and the prcedures being used t d s. If the Plan determines that the rder is qualified, it will pay benefits directly t the child, the child s custdial parent r legal guardian. The child as well as yu will be enrlled in the Plan autmatically. In the Event f Yur Death If yu die while yu are an active team member cvered under the Aetna Dental PPO Plan, yur cvered dependents can receive 60 days f cntinued cverage under COBRA (see Cntinuatin f Cverage n next page) at n cst. At the end f the 60 days, cntinued cverage is available fr up t an additinal 34 mnths at full COBRA rates. In rder t receive this cverage yu must apply fr and elect COBRA cntinuatin cverage fr dental benefits. See the Administratin and Legal SPD fr mre infrmatin n electing COBRA cverage. Tys R Us, Inc. Aetna Dental PPO Plan 13 July 1, 2017

14 Terminatin f Cverage Cverage under yur plan can end fr a variety f reasns. In this sectin, yu will find details n hw and why cverage ends, and hw yu may still be able t cntinue cverage. Yur Aetna Dental benefits cverage will end if: The Aetna Dental benefits plan is discntinued; Yu vluntarily stp yur cverage; Yu are n lnger eligible fr cverage; Yu d nt make any required cntributins; Yu becme cvered under anther dental plan ffered by yur emplyer; Yu have exhausted yur verall maximum annual r lifetime benefit under yur dental plan, if yur plan cntains such a maximum benefit; r Yur emplyer ntifies Aetna that yur emplyment is ended (unless COBRA is elected). It is yur emplyer s respnsibility t let Aetna knw when yur emplyment ends. Tys R Us, Inc. Aetna Dental PPO Plan 14 July 1, 2017

15 When Cverage Ends fr Dependents Cverage fr yur dependents will end if: Yu are n lnger eligible fr dependents cverage; Yu d nt make yur cntributin fr the cst f dependents cverage; Yur wn cverage ends fr any f the reasns listed under When Cverage Ends fr Emplyees. (This des nt apply if yu use up yur verall annual r lifetime maximum, if included); Yur dependent is n lnger eligible fr cverage. Cverage ends the last day f the pay perid fllwing the date yur dependent is n lnger eligible fr cverage. r; As permitted under applicable federal and state law, yur dependent becmes eligible fr like benefits under this r any ther grup plan ffered by yur emplyer. In additin, a "dmestic partner" will n lnger be cnsidered t be a defined dependent n the earlier t ccur f: The date this plan n lnger allws cverage fr dmestic partners. The date f terminatin f the dmestic partnership. Cverage fr handicapped dependents may cntinue after they reach any limiting age. See Cntinuatin f Cverage fr mre infrmatin. Cntinuatin f Cverage (COBRA) Federal law (the Cnslidated Omnibus Budget Recnciliatin Act f 1985, cmmnly knwn as COBRA) requires that the Aetna Dental PPO Plan ffer team members and their cvered family members the pprtunity fr a temprary extensin f cverage (called cntinuatin cverage ) when cverage under the Aetna Dental PPO Plan wuld therwise end. Please refer t the Administratin and Legal SPD fr yur rights and bligatins under the cntinuatin cverage prvisins f the law. Tys R Us, Inc. Aetna Dental PPO Plan 15 July 1, 2017

16 Glssary f Key Terms T help yu understand hw the Aetna Dental PPO Plan wrks, yu shuld familiarize yurself with the fllwing key terms. Aetna Member Services Call r lg n t Plan year The 12-mnth perid beginning n July 1 and ending n June 30, used t determine annual dental plan benefit limitatins (deductible, annual maximum benefit and frequency f certain dental services). Claims Administratr Aetna Inc. Cpay r Cpayment - The specific dllar amunt r percentage required t be paid by yu r n yur behalf. The plan includes varius cpayments, and these cpayment amunts r percentages are specified in the Schedule f Benefits. Csmetic - Services r supplies that alter, imprve r enhance appearance Cvered Expenses - dental, services and supplies shwn as cvered under this Bklet-Certificate Deductible The amunt yu must pay each plan year befre the Aetna Dental PPO Plan pays any benefits. Dental Emergency - Any dental cnditin that: Occurs unexpectedly; Requires immediate diagnsis and treatment in rder t stabilize the cnditin; and Is characterized by symptms such as severe pain and bleeding. Dentist An individual hlding a degree f Dctr f Dental Surgery (DDS) r Dctr f Dental Medicine (DMD) wh practices within the scpe f his r her license under the laws f the state r jurisdictin in which services are prvided. Directry - A listing f all netwrk prviders serving the class f emplyees t which yu belng. The cntract hlder will give yu a cpy f this directry. Netwrk prvider infrmatin is als available thrugh Aetna's nline prvider directry, DcFind. Dctr (r physician) An individual hlding a degree f Dctr f Medicine (MD), Dctr f Ostepathy (DO), Dctr f Dental Surgery (DDS), Dctr f Dental Medicine (DMD), Dctr f Pdiatric Medicine (DPM) r Dctr f Chirpractic (DC), wh practices within the scpe f his r her license under the laws f the state r jurisdictin in which the services are prvided. Experimental r Investigatinal - A drug, a device, a prcedure, r treatment will be determined t be experimental r investigatinal if: There are insufficient utcmes data available frm cntrlled clinical trials published in the peer-reviewed literature t substantiate its safety and effectiveness fr the illness r injury invlved; r Apprval required by the U. S. Fd and Drug Administratin (FDA) has nt been granted fr marketing; r A recgnized natinal medical r dental sciety r regulatry agency has determined, in writing, that it is experimental r investigatinal, r fr research purpses; r It is a type f drug, device, prcedure r treatment that is the subject f a Phase I r Phase II clinical trial r the experimental r research arm f a Phase III clinical trial, using the definitin Tys R Us, Inc. Aetna Dental PPO Plan 16 July 1, 2017

17 f phases indicated in regulatins and ther fficial actins and publicatins f the FDA and Department f Health and Human Services; r The written prtcl r prtcls used by the treating facility, r the prtcl r prtcls f any ther facility studying substantially the same: drug; device; prcedure; r treatment, r the written infrmed cnsent used by the treating facility r by anther facility studying the same drug, device, prcedure, r treatment states that it is experimental r investigatinal, r fr research In-netwrk dentist A state licensed dentist wh has a written agreement with Aetna t perfrm services and receive payment at a discunted rate under this prgram. Jaw Jint Disrder - A Temprmandibular Jint (TMJ) dysfunctin r any alike disrder f the jaw jint; r A Myfacial Pain Dysfunctin (MPD); r Any alike disrder in the relatinship f the jaw jint and the related muscles and nerves. Out-f-netwrk dentist A state licensed dentist wh des nt have an agreement with Aetna. Medically Necessary r Medical Necessity - These are health care r dental services, and supplies r prescriptin drugs that a physician, ther health care prvider r dental prvider, exercising prudent clinical judgment, wuld give t a patient fr the purpse f: preventing; evaluating; diagnsing; r treating: an illness; an injury; a disease; r its symptms. The prvisin f the service, supply r prescriptin drug must be: a) In accrdance with generally accepted standards f medical r dental practice; b) Clinically apprpriate, in terms f type, frequency, extent, site and duratin, and cnsidered effective fr the patient's illness, injury r disease; and c) Nt mstly fr the cnvenience f the patient, physician, ther health care r dental prvider; and d) And d nt cst mre than an alternative service r sequence f services at least as likely t prduce the same therapeutic r diagnstic results as t the diagnsis r treatment f that patient's illness, injury, r disease. Fr these purpses generally accepted standards f medical r dental practice means standards that are based n credible scientific evidence published in peer-reviewed literature. They must be generally recgnized by the relevant medical r dental cmmunity. Otherwise, the standards are cnsistent with physician r dental specialty sciety recmmendatins. They must be cnsistent with the views f physicians r dentists practicing in relevant clinical areas and any ther relevant factrs. Tys R Us, Inc. Aetna Dental PPO Plan 17 July 1, 2017

18 Negtiated Charge The maximum amunt the Plan will cnsider fr a service r supply. The Claims Administratr determines the negtiated charge taking int cnsideratin the usual amunt charged fr such a service in a given lcality. If yu receive ut-f-netwrk care, amunts in excess f the Recgnized charges are nt cvered by the Plan. Orthdntic Treatment This is any: Medical service r supply; r Dental service r supply; furnished t prevent r t diagnse r t crrect a misalignment: Of the teeth; r Of the bite; r Of the jaws r jaw jint relatinship; whether r nt fr the purpse f relieving pain. R Benefits Service Center Call TRU-BENS, Mnday thrugh Friday frm 8:00 a.m. t 8:00 p.m. Eastern Time fr assistance with benefit-related questins. If yu r yur dependent experiences a COBRA qualifying event, cntact ADP COBRA Services at TRU-BENS. Recgnized Charge - The amunt f an ut-f-netwrk prvider s charge that is eligible fr cverage. Yu are respnsible fr all amunts abve the recgnized charge. The recgnized charge may be less than the prvider s full charge. Yur plan s recgnized charge applies t all ut-f-netwrk cvered expenses. In all cases, the recgnized charge is determined based n the Gegraphic Area where yu receive the service r supply. Except as therwise specified belw, the recgnized charge fr each service r supply is the lesser f what the prvider bills and: Fr dental expenses, the recgnized charge fr a service r supply is the lesser f: What the prvider bills r submits fr that service r supply; and the 80th percentile f the Prevailing Charge Rate We have the right t apply Aetna reimbursement plicies. Thse plicies may further reduce the recgnized charge. These plicies take int accunt factrs such as: The duratin and cmplexity f a service; When multiple prcedures are billed at the same time, whether additinal verhead is required; Whether an assistant surgen is necessary fr the service; If fllw up care is included; Whether ther characteristics mdify r make a particular service unique; When a charge includes mre than ne claim line, whether any services described by a claim line are part f r incidental t the primary service prvided and The educatinal level, licensure r length f training f the prvider. Aetna reimbursement plicies are based n ur review f: The Centers fr Medicare and Medicaid Services (CMS) Natinal Crrect Cding Initiative (NCCI) and ther external materials that say what billing and cding practices are and are nt apprpriate Generally accepted standards f medical and dental practice and Tys R Us, Inc. Aetna Dental PPO Plan 18 July 1, 2017

19 The views f physicians and dentists practicing in the relevant clinical areas. We use cmmercial sftware t administer sme f these plicies. Sme plicies are different fr prfessinal services than fr facility services. Prevailing Charge Rates - The percentile value reprted in a database prepared by FAIR Health, a nnprfit cmpany. FAIR Health changes these rates peridically. Aetna updates its systems with these changes within 180 days after receiving them frm FAIR Health. If the FAIR Health database becmes unavailable, Aetna has the right t substitute an alternative database that Aetna believes is cmparable.. Tys R Us, Inc. Aetna Dental PPO Plan 19 July 1, 2017