AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

• For root canal therapy;
• For routine tooth removal (not needing cutting of bone).
In addition, Covered Expenses do not include charges:
• To remove, repair, replace, restore or reposition teeth lost or damaged in the course of biting or chewing;
• To repair, replace, or restore filling, crowns, dentures or bridgework;
• For non-surgical periodontal treatment;
• For dental cleaning, in-mouth scaling, planning or scraping;
• For myofunctional therapy; this is:
o Muscle training therapy; or
o Training to correct or control harmful habits.
EMERGENCY ROOM TREATMENT
EMERGENCY CARE
If treatment:
• Is received in the emergency room of a Hospital while a person is not a full-time Inpatient; and
• The treatment is Emergency Care;
Covered Expenses for charges made by the Hospital for such treatment will be paid at the Payment
Percentage.
NON-EMERGENCY CARE
Benefits will be payable at the payment percentage if treatment:
• Is received in the emergency room of a Hospital while a person is not a full-time Inpatient; and
• The treatment is not Emergency Care;
TREATMENT BY AN URGENT CARE PROVIDER
You should not seek medical care or treatment from an Urgent Care Provider if your Illness, Injury, or
condition is an emergency condition. Please go directly to the emergency room of a Hospital or call 911 (or
the local equivalent) for ambulance and medical assistance.
URGENT CARE
This Plan pays for the charges made by an Urgent Care Provider to evaluate and treat an Urgent Condition.
When travel to an Urgent Care Provider for treatment of an Urgent Condition is not feasible, such treatment
may be paid at the Preferred level of benefits. If a claim for treatment of an Urgent Condition is paid at the
Non-Preferred level and you believe that it should have been paid at the Preferred level, please contact
Members Services at the toll-free number on your I.D. card.
NON-URGENT CARE
For benefit coverage reference Benefits Summary for Covered Expenses for charges made by an Urgent
Care Provider to treat a non-Urgent Condition.
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