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Dental Benefit Summary
Chappaqua Central School District
Employee Benefit Fund


Dental Summary

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* 80%    

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* 80%    

Laboratory Test

Fillings: Amalgam, Silicate & Acrylic

Crowns: Stainless Steel

Repairs of dentures, bridgework, crowns, etc.

Endodontic Services/Root Canal Therapy

Periodontal Services

Oral Services – Uncomplicated extractions

General Anesthesia – surgical procedures only

Injectable Antibiotics – for treatment of a dental

condition only.


Major Services                                                                                   80%                                                       MAC* 80%    

Bridges Installation-fixed and removable

Dentures-Full and Partial

Crowns: Acrylic, Metal, Porcelain






Orthodontic Services                                                                      80%                                                       MAC* 80%    

*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 25 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: 

General E-mail questions:

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. 

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