Page 12 - 2015 Four Seasons Sante Fe/Vail Enrollment Guide
P. 12
Dental Insurance
Dental insurance is with Aetna. Under the plan you can receive care from
a dentist who participates in the plan’s network or any other dentist you
choose. You do not have to choose a primary dentist.
If you need specialist care, you do not have to get prior approval from the
plan. If you receive services in-network, your dentist will submit claims for
you. When you go out-of-network, you will be responsible for iling claims
and pre-certifying certain types of procedures.
You can obtain more detailed summary plan descriptions (SPDs) through
the My Four Seasons Beneits website.
Key Features Cost to you under the Aetna PPO *
In-Network Out-of-Network
Deductible
Individual $50 $100
Family $100 $200
Calendar Year Maximum (per $1,500 $1,500
person)$1,500
Preventive Services
Teeth Cleaning Deductible 10% plus all costs
above R&C
Examination of Teeth waived after deductible
X-rays (deductible
Sealants for Permanent Bicuspids and waived in Texas)
Molars (for dependent children 14 and
up only)
Basic Services
Fillings 20% after 30% of R&C after
Endodontics (root treatment) deductible deductible
Periodontics (gum treatment)
Oral Surgery
Major Services
Crowns and Bridges 50% after 60% of R&C after
Dentures deductible deductible
Orthodontia (Only dependent children 50% after 50% of R&C after
are eligible up to $1,500 lifetime deductible deductible
maximum beneit; maximum does
not apply against calendar-year
maximum)
Colour Elements
* Due to network availability, not all hotels participate in Aetna’s Active PPO Dental Plan.
Contact the My Four Seasons Beneits Center to see what plans are available at your
hotel.
Logo & Logo Variations
My Four Seasons BENEFITS My Four Seasons 12
BENEFITS
Icon Image Elements Font Elements
Tandelle
Century Gothic
Dental insurance is with Aetna. Under the plan you can receive care from
a dentist who participates in the plan’s network or any other dentist you
choose. You do not have to choose a primary dentist.
If you need specialist care, you do not have to get prior approval from the
plan. If you receive services in-network, your dentist will submit claims for
you. When you go out-of-network, you will be responsible for iling claims
and pre-certifying certain types of procedures.
You can obtain more detailed summary plan descriptions (SPDs) through
the My Four Seasons Beneits website.
Key Features Cost to you under the Aetna PPO *
In-Network Out-of-Network
Deductible
Individual $50 $100
Family $100 $200
Calendar Year Maximum (per $1,500 $1,500
person)$1,500
Preventive Services
Teeth Cleaning Deductible 10% plus all costs
above R&C
Examination of Teeth waived after deductible
X-rays (deductible
Sealants for Permanent Bicuspids and waived in Texas)
Molars (for dependent children 14 and
up only)
Basic Services
Fillings 20% after 30% of R&C after
Endodontics (root treatment) deductible deductible
Periodontics (gum treatment)
Oral Surgery
Major Services
Crowns and Bridges 50% after 60% of R&C after
Dentures deductible deductible
Orthodontia (Only dependent children 50% after 50% of R&C after
are eligible up to $1,500 lifetime deductible deductible
maximum beneit; maximum does
not apply against calendar-year
maximum)
Colour Elements
* Due to network availability, not all hotels participate in Aetna’s Active PPO Dental Plan.
Contact the My Four Seasons Beneits Center to see what plans are available at your
hotel.
Logo & Logo Variations
My Four Seasons BENEFITS My Four Seasons 12
BENEFITS
Icon Image Elements Font Elements
Tandelle
Century Gothic
