aetna_ifp_brochure_c.. - Health Insurance

AETNA ADVANTAGE PLAN OPTIONSINDIVIDUAL DENTAL PPO MAX PLANMEMBER BENEFITS PREFERRED NONPREFERREDAnnual Deductible per Member (Does not apply $25; $25;to Diagnostic and Preventive Services) $75 family maximum $75 family maximumAnnual Maximum Benefit Unlimited UnlimitedDIAGNOSTIC SERVICESOral examsPeriodic oral exam 100% deductible waived 50% deductible waivedComprehensive oral exam 100% deductible waived 50% deductible waivedProblem-focused oral exam 100% deductible waived 50% deductible waivedX-raysBitewing — single film 100% deductible waived 50% deductible waivedComplete series 100% deductible waived 50% deductible waivedPREVENTATIVE SERVICESAdult cleaning 100% deductible waived 50% deductible waivedChild cleaning 100% deductible waived 50% deductible waivedSealants — per tooth Discount Not coveredFluoride application — with cleaning 100% deductible waived 50% deductible waivedSpace maintainers Discount Not coveredBASIC SERVICESAmalgam fillings — 2 surfaces 100% after deductible 50% after deductibleResin fillings — 2 surfaces Discount Not coveredOral Surgery Discount Not coveredExtraction — exposed root or erupted tooth Discount Not coveredExtraction of impacted tooth — soft tissue Discount Not coveredMAJOR SERVICESComplete upper denture Discount Not coveredPartial upper denture (resin based) Discount Not coveredCrown — Porcelain with noble metal Discount Not coveredPontic — Porcelain with noble metal Discount Not coveredInlay — Metallic (3 or more surfaces) Discount Not coveredOral SurgeryRemoval of impacted tooth — partially bony Discount Not coveredEndodontic ServicesBicuspid root canal therapy Discount Not coveredMolar root canal therapy Discount Not coveredPeriodontic ServicesScaling & root planing — per quadrant Discount Not coveredOsseous surgery — per quadrant Discount Not coveredORTHODONTIC SERVICES Discount Not covered10Access to negotiated discounts: members are eligible to receive non covered services, including cosmetic services such as tooth whitening, at the PPO negotiated rate whenvisiting a participating PPO dentist at any time.Nonpreferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area.Above list of covered services is representative. A summary of exclusions is listed on page 13. For a full list of benefit coverage and exclusions refer to the plan documents.All products not available in all counties. Please refer to the state map located on page 2 of the Aetna Advantage Brochure.