44 45 What is Covered provider is not in the contracted Aetna network the eli gible charge for such service or supply shall be limited to the amount that would have been eligible for the service ID: 828292
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1 44 45 SECTION II: UNDERSTANDING WHAT IS
44 45 SECTION II: UNDERSTANDING WHAT IS COVERED | Wh
2 at is Covered provider is not in the con
at is Covered provider is not in the contracted Aetna networ
3 k, the eli - gible charge for such servi
k, the eli - gible charge for such service or supply shall b
4 e limited to the amount that would have
e limited to the amount that would have been eligible for t
5 he service or supply that would have be
he service or supply that would have been covered by the Pl
6 an had the service been performed or th
an had the service been performed or the supply provided by
7 an Aetna contracted network dentist wh
an Aetna contracted network dentist who was quali ed t
8 o perform the eligible work in the geog
o perform the eligible work in the geographic area in which
9 it was performed or supplied. Dental B
it was performed or supplied. Dental Bene t Payable Un
10 der the Plan The following bene ts w
der the Plan The following bene ts will be payable for c
11 overed services under the Plan. The e
overed services under the Plan. The eligible charge will
12 be limited to the lesser of (1) the act
be limited to the lesser of (1) the actual charge made by t
13 he dentist for the service or supply an
he dentist for the service or supply and (2) the eligible c
14 ontracted charge. The eligible contract
ontracted charge. The eligible contracted charge will be ba
15 sed on whether the service had been per
sed on whether the service had been performed or the supply
16 had been provided by a contracted netw
had been provided by a contracted network dentist who was
17 quali ed to perform the eligible wo
quali ed to perform the eligible work in the geographic
18 area in which it was performed or supp
area in which it was performed or supplied. Calendar Yea
19 r Deductible . A calendar year deductibl
r Deductible . A calendar year deductible shall be paid by
20 the participant for all covered Basic R
the participant for all covered Basic Restorative Care and
21 Major Restorative Care Services before
Major Restorative Care Services before any such bene ts
22 will be payable. The deduct - ible will
will be payable. The deduct - ible will not apply to Diagno
23 stic and Preventive Care and Orthodonti
stic and Preventive Care and Orthodontic Care. The deductib
24 le is $25 per individual per calendar y
le is $25 per individual per calendar year. No more than an
25 aggre - gate family limit of $75 in ded
aggre - gate family limit of $75 in deductible expenses wil
26 l be charged to the family during a cal
l be charged to the family during a calendar year, regard -
27 less of the number of family members wh
less of the number of family members who incur such expens
28 es. It is not necessary that any individ
es. It is not necessary that any individual sat - isfy an in
29 dividual deductible if the family r
dividual deductible if the family rst incurs the famil
30 y limit of deductible expenses. Diagnos
y limit of deductible expenses. Diagnostic and Preventive C
31 are Coinsurance . Expenses incurred for
are Coinsurance . Expenses incurred for Diagnostic and Preve
32 ntive Care shall be reimbursed at 100%
ntive Care shall be reimbursed at 100% but no more than th
33 e Plan’s maximum bene t will be
e Plan’s maximum bene t will be paid for expenses
34 incurred during the calendar year. Bas
incurred during the calendar year. Basic Restorative and M
35 ajor Restorative Care Coinsurance . Exp
ajor Restorative Care Coinsurance . Expenses incurred for B
36 asic Restor - ative Care and Major Resto
asic Restor - ative Care and Major Restorative Care shall be
37 reimbursed at 85% but no more than the
reimbursed at 85% but no more than the Plan’s maximu
38 m bene t will be paid for expenses i
m bene t will be paid for expenses incurred during the
39 calendar year. Orthodontic Care Coinsu
calendar year. Orthodontic Care Coinsurance . Expenses inc
40 urred for Orthodontic Care shall be rei
urred for Orthodontic Care shall be reimbursed at 85% but
41 no more than the Plan’s maximum lif
no more than the Plan’s maximum lifetime bene t
42 will be paid for expenses incurred durin
will be paid for expenses incurred during the individual&
43 #146;s lifetime. Maximum Dental Plan B
#146;s lifetime. Maximum Dental Plan Bene t . The Plan
44 shall pay no more than $2,500 in reimb
shall pay no more than $2,500 in reimbursement for Preven
45 - tive, Basic and Major dental expenses
- tive, Basic and Major dental expenses incurred by an indi
46 vidual during a calendar year. In additi
vidual during a calendar year. In addition, the Plan shall
47 pay no more than $1,500 in reimbursement
pay no more than $1,500 in reimbursement for Orthodontic de
48 ntal expenses that are incurred by an i
ntal expenses that are incurred by an individual during tha
49 t individual’s lifetime. Covered De
t individual’s lifetime. Covered Dental Services The fo
50 llowing services or supplies shall be el
llowing services or supplies shall be eligible under the Pl
51 an, subject to the limitations and exclu
an, subject to the limitations and exclusions set forth on
52 pages 49-51 and 61-62. Further, for a se
pages 49-51 and 61-62. Further, for a service or supply t
53 o be covered: It must be a covered expe
o be covered: It must be a covered expense as listed in thi
54 s Plan; its provision must not be exclu
s Plan; its provision must not be excluded as provided in
55 this Plan; its cost must not exceed the
this Plan; its cost must not exceed the aggregate amount av
56 ailable for such service as provided in
ailable for such service as provided in this Plan; and it m
57 ust be obtained in accordance with all
ust be obtained in accordance with all the terms, policies
58 and procedures provided for such servic
and procedures provided for such service or supply in this
59 Plan. The service or supply must be pro
Plan. The service or supply must be provided while coverage
60 under this Plan is in effect. The servi
under this Plan is in effect. The services and supplies mus
61 t be Medically Neces - sary. Dental serv
t be Medically Neces - sary. Dental services or supplies wil
62 l be considered Medically Necessary if
l be considered Medically Necessary if they meet all of the
63 follow - ing conditions: (1) they are p
follow - ing conditions: (1) they are provided by a license
64 d provider who is quali ed to perfo
d provider who is quali ed to perform the service or to
65 provide the supply; (2) the provider e
provide the supply; (2) the provider exercises prudent cl
66 inical judgment in selecting the service
inical judgment in selecting the service or supply for the
67 purpose of preventing, evaluating, diagn
purpose of preventing, evaluating, diagnosing or treating a
68 n illness, injury, disease or its sympto
n illness, injury, disease or its symptoms in the judgment
69 of the Claims Administrator and the ser
of the Claims Administrator and the service or supply must
70 meet the following conditions in the ju
meet the following conditions in the judgment of the Claims
71 Administrator: It must be provided in a
Administrator: It must be provided in accordance with gener
72 ally- accepted standards of dental pract
ally- accepted standards of dental practice; oIt must be cli
73 nically appropriate in terms of type, f
nically appropriate in terms of type, frequency, extent, si
74 te and duration, and it must be conside
te and duration, and it must be considered effective for th
75 e patient’s illness, injury or dis
e patient’s illness, injury or disease; It must not ha
76 ve been provided primarily for the conv
ve been provided primarily for the convenience of the patie
77 nt, the physician or dental provider or
nt, the physician or dental provider or other health care p
78 rovider; and oIt must not be more costly
rovider; and oIt must not be more costly than an alternative
79 service or sequence of services that w
service or sequence of services that would likely have pr
80 oduced an equivalent therapeutic or d
oduced an equivalent therapeutic or diagnostic result in
81 light of the patient’s illness, in
light of the patient’s illness, injury or disease. Al
82 l prescription drugs and Specialty Drugs
l prescription drugs and Specialty Drugs costing more than
83 $1,000 per supply day. To get approval f
$1,000 per supply day. To get approval for any of the above
84 prescription drugs, your doctor or prov
prescription drugs, your doctor or provider should call CVS
85 Caremark at the toll-free number shown
Caremark at the toll-free number shown on the chart in the
86 Administrative Information section of
Administrative Information section of this SPD. The MILA
87 Prescription Drug Program contains a Co
Prescription Drug Program contains a Coordi - nation of Ben
88 e ts (COB) provision which establish
e ts (COB) provision which establishes the order in whi
89 ch bene t plans will pay for the cos
ch bene t plans will pay for the cost of pre - scription
90 medication. The purpose of this provisi
medication. The purpose of this provision is that you will
91 receive the best coverage provided by e
receive the best coverage provided by either Plan for your
92 prescription drugs while saving MILA ex
prescription drugs while saving MILA expense where possibl
93 e. See pages 63 and 64 for more informat
e. See pages 63 and 64 for more information regarding the o
94 rder of Plan payment. You must tell MILA
rder of Plan payment. You must tell MILA if you have another
95 prescription drug program in order for
prescription drug program in order for this program to ope
96 rate properly. MILA will report to CVS
rate properly. MILA will report to CVS Caremark the order i
97 n which the Plans are to pay for each c
n which the Plans are to pay for each covered person based
98 upon the rules in the Plan referred to
upon the rules in the Plan referred to above. When you subm
99 it a drug for payment to the retail pha
it a drug for payment to the retail pharmacy, give copies o
100 f your drug cards for each Plan to the
f your drug cards for each Plan to the pharmacist. Many re
101 tail pharmacies (including most CVS Reta
tail pharmacies (including most CVS Retail Pharmacies) are
102 equipped to process both Plan bene t
equipped to process both Plan bene ts electronically so
103 that most of the coordination will be i
that most of the coordination will be invisible; you will
104 just pay the lowest copay provided by ei
just pay the lowest copay provided by either Plan when you
105 receive your prescription drug. However,
receive your prescription drug. However, if the pharmacy is
106 not equipped to perform the COB process
not equipped to perform the COB process, it will process th
107 e prescription under the Plan that is p
e prescription under the Plan that is primary and charge th
108 at Plan’s copayments or other cost
at Plan’s copayments or other costs. You should then o
109 btain a receipt just as if you were usi
btain a receipt just as if you were using an “Out-of-N
110 etwork” pharmacy and submit your c
etwork” pharmacy and submit your claim together with y
111 our receipt to the secondary Plan. If t
our receipt to the secondary Plan. If the MILA Plan is seco
112 ndary, you may obtain the claim form on
ndary, you may obtain the claim form online or by calling M
113 ILA. THE MILA DENTAL PLAN Plan bene
ILA. THE MILA DENTAL PLAN Plan bene ts shall be provided
114 through a network of den - tists as con
through a network of den - tists as contracted and administ
115 ered by Aetna, the Claims Administrator
ered by Aetna, the Claims Administrator for the MILA Dental
116 Plan. Bene ts shall be available f
Plan. Bene ts shall be available from any dentist whos