Proprietary 8-23 15 Aetna PPO Dental Plans The Aetna PPO Dental Plans are dual-option plans. This means that you can receive your dental care from any dentist you choose. However, you can reduce your out-of-pocket dental expenses if you use a provider in the Aetna PPO dental network. There are two PPO options, the High Option (which offers higher benefits) and the Low Option. Both plans pay a higher level of benefits for in-network dental services. In addition, Aetna network dentists are paid for services based on reduced negotiated fees. When you use a dentist outside the Aetna dental network, you may receive a balance bill, as the plan only covers benefits up to the recognized charge limits in your area. You will also have to file a claim. The plans cover preventive, basic, and major services. In addition, the High Option offers orthodontia coverage. After you pay a calendar year deductible, each option pays a calendar year maximum for covered services. The chart below is a partial list of services covered by the Aetna PPO Dental Plans. Aetna PPO Dental Plans Services Low Option PPO Dental* High Option PPO Dental* In-Network Out-of-Network In-Network Out-of-Network Calendar Year Deductible $75 individual $225 family $50 individual $150 family $75 individual $225 family Calendar Year Maximum $1,000 per person $2,000 per person $1,000 per person Preventive Care (oral exams, cleanings, bitewing or full series of x-rays) 100% Deductible waived 90% Deductible waived 100% Deductible waived 90% Deductible waived Basic Treatment (fillings, simple extractions, non-surgical periodontics) 80% 60% 80% 60% Major Procedures (inlays, crowns, fixed bridgework, dentures, general anesthesia) 50% 50% 50% 50% Orthodontia Not covered Not covered Adult and Children: 50% up to $1,000 Orthodontia Lifetime Maximum Waiting Period for Major Procedures None None None None * The state of Texas does not allow for an active dental PPO plan. The Texas Dental PPO plans have same in-network and out-of-network benefits. The benefit coverage level can vary based on the nature of the services. The terms of your benefit plans are governed by legal documents. Please refer to your Aetna SPD for more details and plan limitations.
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