Dental Benefit Summary
Chappaqua Central School District
Employee Benefit Fund
Predetermination Review – The Preferred Group will gladly assist you and your dentist by determining what benefits are payable for services and procedures of $300 and more. Have your dentist send your treatment plan to The Preferred Group. Note that it is a predetermination review and we will let your dentist know what benefits would be payable. (This includes orthodontic treatment if your plan includes it.)
Special Limitation: Teeth lost or missing before a covered person becomes insured by this plan. A covered person may have one or more congenitally missing teeth or have lost one or more teeth before he became insured by this plan. We won’t pay for a prosthetic device which replaces such teeth unless the device also replaces one or more natural teeth lost or extracted after the covered person became insured by this plan.
General Limitations and Exclusions: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: cosmetic or experimental treatments, any treatments to the extent benefits are payable by any other payor or for which no charge is made. First year fund members are limited to a maximum $500 in combined dental and vision services combined.
Services In-Network Out-of-Network
Preventive Services* 100% MAC*
Emergency Palliative Treatment
Oral Examination 3 per policy year
X-rays bitewings full mouth series every 3 years
Bitewings – no more than 8 films per policy year
Teeth Cleaning – 3 per policy year
Fluoride Treatments for Children
(2 per policy year to age 19)
Topical Sealants for unrestored molar teeth covered
Basic Services 80% MAC*
Fillings: Amalgam, Silicate & Acrylic
Crowns: Stainless Steel
Repairs of dentures, bridgework, crowns, etc.
Endodontic Services/Root Canal Therapy
Oral Services – Uncomplicated extractions
General Anesthesia – surgical procedures only
Injectable Antibiotics – for treatment of a dental
Major Services 80% MAC*
Bridges Installation-fixed and removable
Dentures-Full and Partial
Crowns: Acrylic, Metal, Porcelain
Orthodontic Services 80% MAC*
*MAC: Maximum Allowable Charge is equivalent to the amount paid to in-network providers.
$3,000 Individual Lifetime Maximum and $5,000 Combined Family Lifetime Maximum.
(As of July 1, 2017, the amount paid for pediatric orthodontia is NOT included in your plan year maximum.)
New member per person maximum is $500 during the first year of eligibility.
The plan year runs from July 1 to June 30.
Employee/Dependents enrolling outside of the plan eligibility period may be subject to the first year $500 per person maximum.
Children are covered up to age 19, or up until age 26 if an eligible full time student
All out of network services are based on Maximum Allowable Charge (MAC) which is equivalent to the amount paid to in-network providers.
As of July 2020 individuals have an annual deductible of $50 and families have an annual deductible of $150 for all except preventive services.
Please submit Dental Claim Form to ANTHEM (address listed on form).
For details/questions, contact:
Chappaqua Congress of Teachers Benefit Fund
℅ The Preferred Group
P.O. Box 15136
Albany, NY 12212-5136
(518) 591-4965 phone / (518) 641-0325 fax
(866) 989-8997 / Web: www.mytpgplan.com
General E-mail questions: firstname.lastname@example.org
ADA Dentist Nomination Process
• If the dentist does not participate in any Aetna product currently, the Dentist should:
1. Access Aetna's Website, click here → Aetna Dental Access.
2. Click on “Contact Us” on the left hand side of the page.
3. This link will walk the provider through a brief series of questions
It is as simple as 1-2-3!
If the dentist currently participates in any Aetna dental product, they should call 1-800-451-7715 and request to opt-in to the Aetna Dental Access network.