Proprietary 8-23 14 Service Aetna DMO Prepaid Dental Plan MetLife Safeguard Dental Plan (Only available in California) Calendar Year Deductible N/A N/A Calendar Year Maximum N/A N/A Preventive Care (oral exams, cleanings, x-rays) 100% after $5 office visit copay 100% after $5 office visit copay Basic Treatment* n Fillings n Root Canals n Extractions n Periodontics $10 – $35 $70 – $340 $11 – $100 $27 – $300 $10 – $80 $105 – $275 $0 – $130 $38 – $300 Major Procedures* n Inlays/crowns n Dentures $180 – $220 $275 – $350 $165 – $185 $210 – $225 Orthodontia (children & adults) 100% after $2,000 copay** 100% after $1,695 copay** Waiting Period for Major Procedures N/A N/A * The dentist determines the amount you pay for services . You must have a referral from your PCD in order to receive coverage for any services a specialist dentist provides. ** This includes copays for screening exams, diagnostic records, treatment, and retention. Members do not need a referral from their PCD for orthodontic services. The terms of your benefit plans are governed by legal documents. Please refer to your Aetna or MetLife Safeguard SPD for more details and plan limitations. Here is a partial list of services covered by the Aetna DMO Prepaid Dental Plan and the MetLife SafeGuard Dental Plan. Aetna DMO Prepaid Dental Plan and MetLife SafeGuard Dental Plan Under both the Aetna DMO Prepaid Dental Plan and the MetLife SafeGuard Dental Plan, you can select a different dental provider for each family member you enroll. Dental benefits are payable only if you seek care from a participating network dentist. If you are electing the Aetna DMO Prepaid Dental Plan or MetLife Safeguard Dental Plan, enter the Primary Care Dentist (PCD) code and name on the “Primary Care Physician Information” page when completing your online enrollment. You will need to enter this information for yourself and each dependent. The dentist that you choose will provide routine care — checkups, cleanings, etc. — and refer you to a specialist, if necessary. If you would like to change the dentist that you have selected, you may call the dental plan’s toll-free number and give them the new dentist’s code number. This toll-free number is listed on your dental I.D. card. Most diagnostic and preventive services are covered at 100% after you pay the office visit copayment. For other services, you pay a copayment directly to the participating dentist. The amount depends on the procedure performed. The SPD tells you the specific copayment for each service. Both plans cover diagnostic and preventive care, including full-mouth x-rays, office visits, and cleanings. Also covered are basic services such as fillings, crowns, periodontal (gum) treatments, root canals, dentures, and oral surgery. Both the Aetna DMO Prepaid Dental Plan and MetLife SafeGuard Plan provide limited orthodontia coverage for children and adults. You do not have to file a claim for dental expenses; all you have to do is pay the dentist the copayment for the dental service at the time you receive treatment.
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