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BENEFITS SUMMARY

MILA Dental Plan

Benefits Summary

Shown below is the MILA Dental Plan Benefits Summary for eligible active Members, and for those Pensioners age 58 and over who are eligible for benefits in the Premier, Basic, Core or Medicare Wrap-Around Plans and Medicare Advantage Plans and who have not waived participation in the MILA Dental Plan as explained in Section IV, Participation. This chart allows you to see at-a-glance the key Plan Features. The deductible and coinsurance amounts are what you will pay when you seek treatment from a Participating Network Dentist. MILA pays the balance of covered charges up to the maximum benefit payable under the Plan. If you seek treatment from a dentist who does not participate in the Aetna Dental Network that is contracted for the MILA Dental Plan, you will be responsible for any additional charges made by that dentist beyond the negotiated rates that MILA has contracted to pay Participating Network Dentists.

BENEFIT PLAN FOR MEMBERS PARTICIPATING IN:
Who Participates
Active Members Premier, Basic and Core Plans
Retired Members Premier, Basic and MediCare Wrap-Around Plans
Retired Members Medicare Advantage Plan if qualified for Part B premium reimbursement
FEATURES MEMBER BENEFITS & COST
Calendar Year Deductible Expenses
Applies to the following expenses Applies only to Basic and Major Expenses
Individual Deductible $25 per calendar year, waived for preventive
Family Deductible Limit No more than $75 per calendar year
Coinsurance Dental Expense Payable by Participant
Preventive Dental Treatment 0% coinsurance (Plan pays 100%)
Basic Dental Treatment 15% coinsurance after deductible (Plan pays 85%)
Major Dental Treatment 15% coinsurance after deductible (Plan pays 85%)
Orthodontic Dental Treatment 15% coinsurance after deductible (Plan pays 85%)
Maximum Benefit Payable by Plan
Payable for preventive, basic and major dental treatment incurred by each person during each calendar year $2,500 per person
Payable for orthodontic dental treatment incurred by a child during that child’s lifetime $1,500 per person
Benefits payable Out-of-Network will be paid based on a charge which would have been eligible if it had been rendered by a Network dentist operating in the Network. Any additional charge presented by that Out-of-Network dentist will be the Member’s responsibility.

Important

The following is important information which every MILA Member covered under the MILA Dental Plan should keep in mind when accessing dental service. This information will help you obtain the highest level of benefits from the MILA Dental Plan while ensuring that you obtain the care you require.