Page 20 - Franklin Madison 2021 Benefits Guide

Aetna Dental Plan Options

Plan Provision Aetna DHMO Aetna DPPO
In-Network Out-of-Network
Annual Deductible None $50/$100 $75/$150
(single/family
Preventive and Diagnostic
Services (exams, x-rays, routine 100% 100% 100%
cleanings, luoride treatment,
sealants, etc.)
Basic Restorative Services According to 80% of discounted rate 80% of R&C* after
(illings, extractions, etc.) schedule after deductible deductible
Major Restorative Services According to 50% of discounted rate 50% of R&C* after
(crowns, inlays, onlays, schedule after deductible deductible
bridgework, etc.)

Orthodontia (children and adults) According to 50% of discounted rate 50% of R&C* after
deductible
schedule
after deductible
Annual Maximum Beneit None $1,750 $1,250
Lifetime Orthodontia None $1,750 $1,250
Maximum Beneit

* Reasonable and customary charges.

Employee Cost of Dental

Options

Biweekly Paycheck Contributions

Full-Time Part-Time

Dental HMO
Employee $3.25 $6.50
Employee + $6.50 $13.00
Child(ren)
Employee + $7.50 $13.41
Spouse
Employee + Family $12.00 $23.07
Dental PPO
Employee $6.00 $12.00
Employee + $11.75 $23.50
Child(ren)
Employee + $13.00 $26.00
Spouse
Employee + Family $20.75 $41.50

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