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Aetna US Healthcare PPO Dental Program

This Benefit summary of the Aetna U.S. Healthcare Preferred Provider Organization (PPO) coverage is provided by Aetna Life Insurance Company for some of the more frequently performed dental procedures. Under this plan, you may choose at the time of service either a PPO participating dentist or any non-participating dentist. With the PPO Plan, savings are possible because the PPO participating dentists have agreed to provide care at a negotiated fee schedule. The coverage levels for some common dental services are shown. Non-Participating benefits are subject to reasonable and customary charge limits.

Annual Deductible	Participating	Non-Participating
Individual	$50.00	$100.00
Family	$150.00	$300.00
Preventative Service Covered Percent	100 %	80 %
Basic Service Covered Percent	80 %	70 %
Major Service Covered Percent	50 %	40 %
Annual Benefit Maximum	$1,500.00	$1,000.00

	Participating	Non-Participating
Preventive
Oral Examination (a)	100%	80%
Cleanings, including scaling and polishing (a) Adult & Child	100%	80%
Fluoride (a)	100%	80%
Sealants (permanent molars only) (a)	100%	80%
Bitewing X-rays (a)	100%	80%
Full mouth series (a)	100%	80%
Space Maintainers	100%	80%
Basics
Root canal therapy, with X-rays & cultures Anterior & Bicuspid	80%	70%
Amalgam (silver) fillings	80%	70%
Composite Fillings (anterior teeth only)	80%	70%
Stainless Steel Crowns	80%	70%
Scaling & Root Planing (a)	80%	70%
Gingivectomy	80%	70%
Incision & Draining of Abscess	80%	70%
Uncomplicated Extractions	80%	70%
Surgical Removal of Erupted Tooth	80%	70%
Surgical Removal of Impacted Tooth (soft tissue)	80%	70%
Major
Root Canal therapy, molar teeth, with x-rays and cultures	50%	40%
Osseous Surgery (a)	50%	40%
Surgical Removal of Impacted Tooth (partial bony/full bony)	50%	40%
General Anesthesia/intravenous sedation	50%	40%
Crowns	50%	40%
Full & Partial Dentures	50%	40%
Denture Repairs	50%	40%
(a) Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certificate or evidence of coverage.

Participating

Non-Participating

Major- Continued
Inlays	50%	40%
Onlays	50%	40%
Pontics	50%	40%
Space Maintainers Orthodontics
Coinsurance	50%	50%
Orthodontic Deductible	$50	$50
Lifetime Maximum	$1000	$1000

PPO Monthly Rates:

Employee Only: $29.39*

Employee and One: $64.75*

Employee and Family $104.15*

* Premiums are collected a month in advance

Emergency Dental Care

Under the PPO dental plan, you may choose at the time of service either a Preferred Provider Organization (PPO) participating dentist or any non-participating dentist. Under the PPO dental plan, the benefits payable, when services are provided by a PPO participating dentist, are based on a negotiated fee schedule. When services are provided by a non-participating provider, the benefits payable are limited to the reasonable and customary charges, as determined by Aetna U.S. Healthcare.

* Covered emergency services may vary, based on state law.

* Please refer to dental insurance contract for policy provision and exclusions.

* Annual Policy renewal date is July 1st.

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Basics

Major

Major- Continued

PPO Monthly Rates:

Emergency Dental Care