Dental Benefit Summary


Chappaqua Central School District

Employee Benefit Fund



Example:  Out of network vs MAC plan


Services                                                                                   In-Network                                    Out-of-Network (R&C)


Preventive Services*                                                                      100%                                                       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%                                                          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%                                                          80%

Bridges Installation-fixed and removable

Dentures-Full and Partial

Crowns: Acrylic Metal, Porcelain






Orthodontic Services                                                                      80%                                                        80%


$3,000 Lifetime Maximum for child(ren) under age 19 (amount paid for orthodontics is NOT included in your plan year maximum)


There is a $3,000 annual maximum for Preventive, Basic and Major services combined, subject to the maximum rollover.

A maximum of $5,000 per family per plan year.

New member per person maximum is $500 during the first year of eligibility.

Employee/Dependents enrolling outside of the plan eligibility period may be subject to Late Entrant penalties with a $500 maximum per person for the first year.

Children are covered up to age 19 or 25 if a full time student.

Employee/Dependents enrolling outside of the plan eligibility period may be subject to Late Entrant penalties with a $500 per person maximum for the first year.

All out of network services are based on usual, reasonable, and customary rates for given area.


P.O. Box 15136
Albany, NY 12212-5136
(866) 989-8995 • FAX: (518) 641-0325 / (866) 539-1394

Web: • General E-mail questions:

TPG has contracted with dental providers to provide discounts off services and procedures to TPG’ dental plan members. To locate a provider, please reference the Provider Directory at We have also contracted with Aetna Dental Administrator Network.


Predetermination Review – TPG 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 TPG. 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.


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. 

Anyone interested in viewing audit reports, please contact any CCTBF member.