Proprietary 8-22 Aetna Out-of-Area PPO Dental Plan If you live outside of the network area that serves the Aetna DMO or Aetna PPO Dental Plans, dental coverage is offered under the Aetna Out-of-Area PPO Dental Plan. You may use any licensed dental provider. The Plan does not participate in any dental networks. 16 The chart below is a partial list of services covered by the Aetna Out-of-Area PPO Dental Plans. Aetna Out-of-Area PPO Dental Plans Service Low Option PPO Any Provider High Option PPO Any Provider Calendar Year Deductible $75 individual $225 family $50 individual $150 family Calendar Year Maximum $1,000 per person $2,000 per person Preventive Care (oral exams, cleanings, bitewing or full series of x-rays) 100% Deductible waived 100% Deductible waived Basic Treatment (fillings, simple extractions, non-surgical periodontics) 80% 80% Major Procedures (inlays, crowns, fixed bridgework, dentures, general anesthesia) 50% 50% Orthodontia Not covered Adults and Children: 50% up to $1,000 lifetime Orthodontia maximum Waiting Period for Major Procedures None None 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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