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RCA Benefit Guide

Aetna Dental AETNA

Aetna Dental AETNA DENTAL FREEDOM OF CHOICE With the Aetna Dental Freedom on Choice plan, you get two plans in one, Aetna’s Dental PPO and DMO. You are not locked into one or the other for the entire year. You can switch between the two plans every month, as your needs change. Call Member Services or log into the secure member website at www.aetna.com to change your plan choice. Coverage under both plans include preventive, basic, major and orthodontic services. DMO Out-of-pocket costs are generally lower with this plan. You need to choose a primary care dentist (PCD) who participates in the Aetna DMO network to help guide your care. You need a referral to see most specialists. Benefits are based on copays—a set dollar amount. There are no deductibles or annual dollar maximums. PPO You may choose a PPO participating dentist or any nonparticipating dentist. You will save money when you choose a participating dentist because they have agreed to provide care for covered services at negotiated rates. No referrals are needed. A deductible and coinsurance applies for most benefits. ID CARDS You don’t need a dental ID card to get dental care. When you visit your dentist, simply tell the office your name, date of birth or member ID number. If you want a card, you can print out an ID card for your and your dependents at www.aetna.com. Select “ID Card” and then select “View ID Card.” If your electronic ID card says “No Election” or “Invalid Choice,” then your plan requires you to choose a primary care dentist (PCD) who is in the Aetna network. Until you choose one, your benefits and claims may be affected. FINDING A PARTICIPATING DENTIST To locate an in-network dentist go to www.aetna.com. “Find a Doctor” gives you access to the directory. DMO PPO Benefits Per Plan Year In-Network Only In- & Out-of-Network* Annual Deductible (excludes Class I) None $50/$150 Annual Maximum None $1,500 Office Visit Copay $15 N/A Class I: Diagnostic & Preventive Exams Cleanings X-rays Sealants Class II: Basic Restorative Services Restorative Oral Surgery Denture Repair Endodontics (root canal) Periodontics (gum treatment) Palliative General Anesthesia Class III: Major Restorative Services Inlays, Onlays and Crowns Prosthodontics (bridges, dentures, implants) Class IV: Orthodontics 8 | 2018 Recovery Centers of America Benefit Guide Schedule/Copay 100% Schedule/Copay 80% Schedule/Copay 50% Orthodontics (Dependent children to age 19) $1,500 copay 50% Orthodontics (Adult) $1,500 copay Not covered Orthodontic Lifetime Maximum None $1,500 lifetime maximum *Out-of-Network: Reimbursement is based on the 90 th percentile of prevailing charges for the geographic region. Nonparticipating dentists may balance bill the difference between Aetna’s payment and their usual fee for service.

Aetna Vision The Aetna Vision Preferred plan is a voluntary program with comprehensive coverage at a nationwide network of providers. You can use your lens coverage once every rolling 12 months to purchase either 1 pair of glasses or 1 pair of contact lenses. HEALTHY EYES WITHOUT THE HASSLE You’re covered for one routine eye exam, lenses, contacts and frames, including luxury brands.* Plus, you get: • Freedom to see any provider • Choice of popular retailers like LensCrafters, Pearle Vision, JCPenny Optical, Sears Optical, Target Optical and more • Savings on LASIK surgery, extra pairs of glasses, sunglasses and more • Night, weekend and walk-in appointments You can also buy eyewear at glasses.com, lenscrafterscontacts.com or contactsdirect.com. KEEP YOUR WELCOME MAILING HANDY It’s your ticket to an easy experience. It includes: • Your member ID card • Basic plan details • A list of local providers Bonus: A $20 LensCrafters coupon, too In-Network Out-of-Network Exam Member pays Reimbursement Routine/Comprehensive Eye Exam $10 copay Up to $25 Standard Contact Lens Fit/Follow-up Discounted fee of $40 Not covered Premium Contact Lens Fit/Follow-up 90% of retail Not covered Eyeglass Lenses / Lens Options Standard Plastic Single Vision Lenses $25 copay Up to $10 Standard Plastic Bifocal Vision Lenses $25 copay Up to $25 Standard Plastic Trifocal Vision Lenses $25 copay Up to 55 Standard Plastic Lenticular Vision Lenses $25 copay Up to $55 Standard Progressive Vision Lenses $90 copay Up to $25 Premium Progressive Vision Lenses 20% discount off retail minus $120 Up to $25 Lens Enhancements Discounted fees Not covered Contact Lenses Conventional Contact Lenses $130 allowance, plus 15% off Up to $90 Disposable Contact Lenses $130 allowance Up to $90 Medically Necessary Contact Lenses $0 copay Up to $200 Frames (every 24 months) Any frame, including frames for $130 allowance, plus 20% off prescription sunglasses balance over allowance Up to $65 2018 Recovery Centers of America Benefit Guide | 9

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