13 / 28
13
Dental Plan Features
Aetna Dental - Dual Option
DMO Option
Low Option
High Option
In-Network (only)
In-Network
Out-of-Network
In-Network
Out-of-
Network
Calendar Year
Deductible*
Individual
N/A
$50
$50
Family
N/A
$150
$150
Calendar Year
Maximum
N/A
$1,000
$1,500
Diagnostic &
Preventive
Exams & Cleanings
100%
100%
100%
100%
100%
Fluoride
100%
100%
100%
100%
100%
X-rays
100%
100%
100%
100%
100%
Sealants
100%
100%
100%
100%
100%
Basic Services
Amalgam Fillings
100%
100%
100%
80%
80%
Composite Fillings
100%
100%
100%
80%
80%
Root Canal (Molars)
60%
100%
100%
80%
80%
Root Canal
(Anterior/ Bicuspid)
100%
100%
100%
80%
80%
Periodontics
(Scaling)
100%
100%
100%
80%
80%
Denture Repair
60%
100%
100%
80%
80%
Stainless Steel
Crowns
100%
100%
100%
80%
80%
Simple Extractions
100%
100%
100%
80%
80%
Dentures
60%
100%
100%
80%
80%
Major Services
Onlays, Inlays,
Crowns
60%
Not Covered
Not Covered
50%
50%
Implants
Not Covered
Not Covered
Not Covered
50%
50%
Orthodontia
$1,500 Copay
Not Covered
Not Covered
Not Covered
Not Covered
*Deductible is waived for Preventive Services.
This information is a summary of benefits only and should not be considered a
contract or a complete statement of
benefits. All benefits are subject to the terms and provisions as explained in the Plan Document, including exclusions
from and limitations on covered expenses. In the event the benefits outlined in this summary differ from those in the Plan
Document, the Plan Document language will prevail.
How to find an in network dentist:
You can access Aetna’s website to search for
providers in the network by going to Doc Find at:
www.aetna.comor logging into Aetna Navigator at
www.aetna.com/navigator .