Air Products and Chemicals, Inc.

Dental Plan Coverage Period: 01/01/2018-12/31/2018

Summary of Benefits and Coverage: What this Plan Covers1 & What it Costs Coverage for: All | Plan Type: DMO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy document
at www.aetna.com or by calling 1-877-238-6200. For the Plan document call the Employee Help Center at the number below.

Important Questions Answers Why this Matters:

What is the overall deductible?
Are there other
deductibles for specific services?
$0 See the chart starting on page 2 for your costs for services this
Plan covers.
No. You dont have to meet deductibles for specific services, but see the
chart starting on page 2 for other costs for services this Plan covers.

Is there an outofpocket limit on No. This Plan has no out-of-pocket Theres no limit on how much you could pay during a coverage
my expenses? limit. period for your share of the cost of covered services.
What is not included in the outof Balance-billed charges and dental Not applicable because theres no out-of-pocket limit on your
pocket limit? care this plan does not cover. expenses.
Is there an overall annual limit on No.2 The chart starting on page 2 describes any limits on what the Plan
what the Plan pays? will pay for specific covered services, such as office visits.
Yes. For a list of participating If you use an in-network dentist, this Plan will pay some or all of the
providers, see www.aetna.com or costs of covered services. Be aware, your in-network dentist may use
call 1-877-238-6200. 3 an out-of-network provider for some services. Plans use the term in-
Does this Plan use a network of
providers? network, preferred, or participating for providers in their network.
See the chart starting on page 2 for how this Plan pays different kinds
of providers.
Yes. This Plan will pay some or all of the costs to see a specialist for
Do I need a referral to see a
covered services but only if you have the Plans permission before
specialist?
you see the specialist.
Yes. Some of the services this Plan doesnt cover are listed on page 4. See
Are there services this Plan doesnt
your policy or Plan document for additional information about
cover?
excluded services.
1
Comprehensive dental benefits where participants choose a dentist from a list of local dentists who participate in the DMO. You go to that dentist, or to a
specialist referred by that dentist for all your care. The DMO is not available in all areas of the United States. Contact Aetna for network information.
2 There is no annual or lifetime maximum benefit limits when services are performed/referred by your DMO participating dentist.
3 Limited coverage, subject to maximum eligible amounts, may be available for services provided by non-participating dental providers. Check your
member handbook or contact Aetna member services for further details.
For eligibility: Air Products Employee Help Center - 1-800-272-5442 or employhc@airproducts.com. For dental benefits: Aetna 1-877-238-6200 or
www.aetna.com. For more dental information go to: https://intranet.sp.apci.com/sites/hrus/benefits/Pages/Dental.aspx. Obtain the Uniform Glossary
at www.cciio.cms.gov or 1-800-633-4227 1 of 44
 Air Products and Chemicals, Inc. Dental Plan Coverage Period: 01/01/2018-12/31/2018
Summary of Benefits and Coverage: What this Plan Covers1 & What it Costs Coverage for: All | Plan Type: DMO

Copayments are fixed dollar amounts (for example, $15) you pay for covered dental care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For
example, if the Plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200.
This may change if you havent met your deductible.
The amount the Plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay
and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This Plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance
amounts.
Common Your cost if you use an In-network
Services You May Need Limitations & Exceptions4
Dental Event Provider
Routine exam and prophylaxis limited to 4
Routine Oral Exams visits per calendar year; prophylaxis
limited to 6 treatments per calendar year.
Bitewings -limited to 2 sets per year; 1 full
Diagnostic Full-Mouth &
mouth set every 3 rolling years; vertical
Preventative Bitewing X-Rays Covered at 100% of eligible expenses.
bitewings 1 set every 3 rolling years.
Services Limited to children under the age of 18.
Topical Applications of Fluoride
One treatment per calendar year.
Limited to one application every 3 years
Sealants
for permanent molars only.
Space maintainers Covered at 60% of eligible expenses. ---------------none---------------
Stainless steel crowns Covered at 100% of the eligible expenses. ---------------none---------------
Composite fillings are a covered benefit on
Restorative teeth numbers 4-13 and 20-29. Alternative
Services Composite Fillings Covered at 100% of eligible expenses. coverage applies to permanent molars
(teeth numbers 1-3, 14-19 and 30-32).

For eligibility: Air Products Employee Help Center - 1-800-272-5442 or employhc@airproducts.com. For dental benefits: Aetna 1-877-238-6200 or
www.aetna.com. For more dental information go to: https://intranet.sp.apci.com/sites/hrus/benefits/Pages/Dental.aspx. Obtain the Uniform Glossary
at www.cciio.cms.gov or 1-800-633-4227 2 of 44
 Air Products and Chemicals, Inc. Dental Plan Coverage Period: 01/01/2018-12/31/2018
Summary of Benefits and Coverage: What this Plan Covers1 & What it Costs Coverage for: All | Plan Type: DMO

Amalgam (silver) fillings ---------------none---------------

Pulp Capping and Apicoectomy ---------------none---------------

Endodontic Pulpotomy Covered at 100% of eligible expenses. ---------------none---------------

Services Routine Root Canal Therapy with
X-rays and Cultures
Molar and/or Complex Root Canal
Correction of Occlusion
Periodontic Scaling and Root Planing
Services Subgingival Curettage
Gingivectomy
Osseous Surgery
Incision and Drainage of Abscess
Uncomplicated Extractions
Oral Surgery Surgical Removal of Erupted
and Extractions
Teeth
Removal of Soft Tissue Impaction
Full or Partial Bony Impaction
Inlays/Onlays
Crowns (Freestanding)
Prosthodontics Crown and Bridge Repair
and Repairs
Full, Partial Dentures and Repairs
Crowns (Abutments/Bridgework)
Pontics (False Teeth)
Orthodontic
Braces
4
All dental services are subject to clinical guidelines determined by the claims administrator.
Covered at 100% of eligible expenses.
Covered at 60% of the eligible expenses.
Covered at 100% of the eligible expenses.
Covered at 100% of the eligible expenses.
Covered at 100% of the eligible expenses.
Covered at 100% of the eligible expenses.
Covered at 60% of the eligible expenses.
Covered at 100% of the eligible expenses.
Covered at 100% of the eligible expenses.
Covered at 100% of the eligible expenses.
Covered at 100% of the eligible expenses.
Covered at 60% of the eligible expenses.
Covered at 60% of the eligible expenses.
Covered at 50% of the eligible expenses.
Limited to Anterior and Bicuspids only.
---------------none---------------
---------------none---------------
Limited to 4 separate quadrants per rolling
year.
---------------none---------------
---------------none---------------
---------------none---------------
---------------none---------------
---------------none---------------
---------------none---------------
---------------none---------------
Replacement limited to once every 5 years
of any previously installed prosthetic
and/or crown.
Limited to dependent children who start
treatment before the age of 20.

For eligibility: Air Products Employee Help Center - 1-800-272-5442 or employhc@airproducts.com. For dental benefits: Aetna 1-877-238-6200 or
www.aetna.com. For more dental information go to: https://intranet.sp.apci.com/sites/hrus/benefits/Pages/Dental.aspx. Obtain the Uniform Glossary
at www.cciio.cms.gov or 1-800-633-4227 3 of 44
 Air Products and Chemicals, Inc. Dental Plan Coverage Period: 01/01/2018-12/31/2018
Summary of Benefits and Coverage: What this Plan Covers1 & What it Costs Coverage for: All | Plan Type: DMO

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or Plan document for other excluded services.)

Acupuncture General anesthesia and intravenous sedation Charges for replacement or repair of
Cosmetic surgery unless done with another covered service orthodontic appliance or loss/theft of denture
Facings on molar crowns and pontics Treatment of jaw joint disorder or bridgework

Other Covered Services (Check your policy or Plan document for other covered services and your costs for these services.)

Your Rights to Continue Coverage:

If you lose coverage under the Plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep
dental coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the
premium you pay while covered under the Plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the claims administrator at the number below. You may also contact your state
insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the
U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims the Plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact the claims administrator at the number below. Additionally, a consumer
assistance program can help you file your appeal. Contact Pennsylvania Department of Insurance at 877-881-6388 or www.insurance.pa.gov.

Language Access Services:

Espaol: Para obtener asistencia en Espaol, llame al 1-800-272-5442. Aetna or other claims administrators at the phone numbers below.
: 1-800-272-5442. Aetna or other claims administrators at the phone numbers below.

For eligibility: Air Products Employee Help Center - 1-800-272-5442 or employhc@airproducts.com. For dental benefits: Aetna 1-877-238-6200 or
www.aetna.com. For more dental information go to: https://intranet.sp.apci.com/sites/hrus/benefits/Pages/Dental.aspx. Obtain the Uniform Glossary
at www.cciio.cms.gov or 1-800-633-4227 4 of 44