Schedule of Benefits (GR-9N S )
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1 Schedule of Benefits (GR-9N S ) Employer: Group Policy Number: BNSF Railway Company GP Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 1A Cert Base: 1 For: DMO - All Other States This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information. Managed Dental Plan Schedule of Managed Dental Benefits (GR-9N KS) 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: A charge is made for an unlisted service given for the dental care of a specific condition; and The list includes one or more services that, under standard practices, are separately suitable for the dental care of that condition, then the charge will be considered to have been made for a service that would have produced professionally acceptable result, as determined by Aetna. This Schedule Applies to Services Provided by Network Providers Primary Care Dentist Services (GR-9N-S ) Visits and Exams Copayment Amount Oral examination $0 Emergency palliative treatment $10 Prophylaxis (cleaning), (limited to 2 treatments per year) Adult $0 Child $0 Topical application of fluoride $0 Oral hygiene instruction $0 Sealants, per tooth (limited to children under age 15) $0 GR-9N 1
2 Pulp vitality test $0 Consultation $0 Diagnostic casts $0 X-rays and Pathology Bitewing x-rays $0 Entire series, including bitewings, or panoramic film $0 Vertical bitewing X-rays (limited to 1 set every 3 years) $0 Periapical x-ray $0 Intra-oral, occlusal view, maxillary or mandibular $0 Extra-oral upper or lower jaw $0 Accession of oral tissue $0 Endodontics Pulp cap $0 Pulpotomy $0 Root canal therapy, including necessary x-rays Anterior $50 Bicuspid $70 Restorations and Repairs (Copayments for crowns and pontics are per unit.) There will be an additional patient charge for the actual cost of high noble metal ( gold ) when used for services shown with an asterisk. Amalgam restoration 1 surface $0 2 surfaces $0 3 surfaces $0 4 or more surfaces $0 Resin-based composite restoration (other than for molars) 1 surface $0 2 surfaces $0 3 surfaces $0 4 or more surfaces or incisal angle $0 Resin-based composite crown, anterior $40 Retention pins $6 Stainless steel crowns, prefabricated, primary tooth $0 Stainless steel crowns, prefabricated, permanent tooth $40 Recementing inlays or crowns $5 Recementing bridges $15 Sedative filling $0 Inlays, metallic* $160 Crowns Porcelain $185 Porcelain with metal (includes abutments)* $185 Metallic (full cast) (includes abutments)* $185 Metallic (3/4 cast)* $178 Cast post and core* $50 Prefabricated post and core $60 Core buildup including pins $30 Pontics Metallic (full cast)* $185 Porcelain with metal* $185 Full Mouth Rehabilitation, Per Unit (This means 6 or more covered units of crowns and/or pontics under one treatment plan.) $125 GR-9N 2
3 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 $250 Partial, upper or lower Resin base $250 Cast metal base $300 Immediate, upper or lower (does not include charge for reline) $300 Adjust complete denture, upper or lower $10 Adjust partial denture, upper or lower $10 Repair broken acrylic, complete denture, upper or lower $25 Replace one tooth on complete denture $35 Repair resin denture base, cast frame, broken clasp $35 Replace broken tooth, partial $35 Add tooth to existing partial denture $35 Add clasp to existing partial $40 Replace all teeth and acrylic on cast metal framework $86 Rebase, complete denture, upper or lower $86 Rebase, partial denture, upper or lower $40 Reline, complete denture, upper or lower (chairside) $40 Reline, partial denture, upper or lower (chairside) $75 Reline, complete denture, upper or lower (laboratory) $75 Reline, partial denture, upper or lower (laboratory) $60 Interim partial denture, upper or lower (stayplate), anterior only $20 Tissue conditioning for dentures Periodontics Scaling and root planing, per quadrant (limited to 4 separate quadrants per 12 $40 Scaling and root planing -1 to 3 teeth per quadrant (limited to once per site every 12 $24 Periodontal maintenance procedures following surgical therapy (limited to 2 per 12 $20 Occlusal guard (for bruxism only), limited to 1 every 3 years $70 Full mouth debridement - once per listime $60 Oral Surgery - Includes local anesthetics and routine post-operative care Extraction - exposed root or erupted tooth $0 Extraction - coronal remnants - deciduous tooth uncomplicated $0 Surgical removal of erupted tooth $0 Surgical removal of impacted tooth (soft tissue) $0 Incision and drainage of intraoral abscess $10 Mobilization of erupted or malpositioned tooth to aid eruption Biopsy of oral tissue Space Maintainers - (only when needed to preserve space resulting from premature loss of primary teeth) Includes all adjustments within six months after installation Fixed $0 Removable $0 Recement space maintainer $12 Removal of fixed space maintainer (by dentist who did not place appliance) $12 $30 $20 GR-9N 3
4 Specialty Services Copayment Amount Endodontics - Includes local anesthetics where necessary Apicoectomy/periradicular surgery Anterior $60 Bicuspid, first root $60 Molar, first root $80 Each additional root $40 Retrograde filling, per root $20 Root amputation, per root $60 Molar root canal therapy $150 Retreatment of previous root canal therapy Anterior $150 Bicuspid $170 Molar $250 Oral Surgery - Includes local anesthetics where necessary and post-operative care Surgical removal of residual tooth roots $15 Frenectomy $24 Alveoloplasty in conjunction with extractions - per quadrant $18 Alveoloplasty not in conjunction with extractions - per quadrant $25 Surgical removal of impacted tooth Partially bony $45 Completely bony $60 Completely bony with unusual surgical complications $60 Periodontics Gingivectomy or gingivoplasty - per quardrant $75 Gingivectomy or gingivoplasty teeth $20 Gingival flap procedure - per quadrant $90 Gingival flap procedure teeth one per quadrant $54 Occlusal adjustment (other than with an appliance or restoration) Limited $10 Complete $60 Osseous surgery (including flap entry and closure) - per quadrant $250 Osseous surgery (including flap entry and closure) - 1 to 3 teeth $150 Surgical revision procedure, per tooth $100 Pedicle soft tissue graft $190 Free soft tissue graft (including donor site surgery) $205 Subepithelial connective tissue graft $115 Soft tissue allograft $230 Combined connective tissue and double pedicle graft $190 Clinical crown lengthening $150 Orthodontics Orthodontic screening exam (when no Orthodontic Procedure is performed) $30 Orthodontic diagnostic records $150 Comprehensive orthodontic treatment of adolescent and adult dentition $1,545 Orthodontic retention $275 GR-9N 4
5 Expense Provisions (GR-9N S ) The following provisions apply to your health expense plan. This section describes cost sharing features, benefit maximums and other important provisions that apply to your Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the attached health expense sections of this Schedule of Benefits. The insurance described in this Schedule of Benefits will be provided under Aetna Life Insurance Company's policy form GR-29N. Keep This Schedule of Benefits With Your Booklet-Certificate. Copayments and Benefit Deductible Provisions (GR-9N KS) 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. General (GR-9N S ) This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your plan of benefits. Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot be accepted. This Schedule is part of your Booklet-Certificate and should be kept with your Booklet-Certificate form GR-9N. Coverage is underwritten by Aetna Life Insurance Company. GR-9N 5
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