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P A G E 3
B E N E F I T S U M M A R Y
Good dental health is important to your overall well
being. At the same time, individuals need different levels
of dental treatment. The Aetna dental plan provides
affordable coverage based on the type of services
obtained –
Preventive, Basic or Major
– whether or not
you obtain services from an in-network or out-of-network
provider.
However, If you use dentists or dental specialists that are
part of Aetna’s network (In-Network Dental Provider) you
will have lower out-of-pocket expenses. Out-of-network
reimbursements are based on Aetna maximum allowable
charge, therefore you may be balanced billed for services
A complete provider directory can be accessed online at
www.aetna.com .For the DMO dental plan select DMO
providers and for the PPO plan select PPO providers.
Dental Benefit Description
Voluntary Dental
Plan Name
Aetna Voluntary Option 6A Ortho FOC PPO High Max
Network
Aetna DMO Plan
**Aetna PPO Plan
Election of Primary Dentist
Yes
No
Deductible - Calendar Year - (Waived
Preventive)
None
$50/$150
Calendar Year Maximum
None
$1,000
Office Visit Copay
$5
None
Diagnostic/Preventive Services
Periodic Exams, Prophylaxis, x-rays
100%
100% - In-Network
100% - Out-of-Network
Basic Restorative Services
Fillings, Root Canal Therapy (anterior teeth/
bicuspid teeth), Periodontics, Oral Surgery
100%
80% - In-Network
80% - Out-of-Network
Major/Specialty Services
Single crowns, inlays, onlays, Canal Therapy
(molar teeth)
60%
50% - In-Network
50% - Out-of-Network
Orthodontia Benefit - Children up to age 19
*$2,300 Copay
50% - In-Network
50% - Out-of-Network
Orthodontic Lifetime Maximum
*
$1,000
Dental Plan
**The PPO MAX plan has a Coverage Waiting Period. You must be an enrolled member of the PPO MAX plan for 12 months
before becoming eligible for coverage of any Major and Orthodontic Services. The waiting period does not apply to the DMO