Page 10 - Polyventive 2022 Benefits Guide
P. 10
Dental
Aetna Dental Plan
Polyventive will ofer dental insurance through Aetna. This dental program provides eligible Employees easy
access to a national network of dental providers consisting of general and specialty dentists who meet well-
established credentialing standards. Beneits are based on negotiated fees, and participating dentists agree
to accept negotiated fees.
Core Plan Buy-Up Plan
In-Network Out-of-Network In-Network Out-of-Network
$50 Individual $50 Individual
Deductible (Waived for Preventive Services)
$150 Family $150 Family
Diagnostic and Preventive 100% 100%
Basic Services 80% 80%
Major Services Not Covered 50%
Annual Maximum $1,000/person $2,000/person
Orthodontic Services: N/A 50% up to age 19
Lifetime Maximum $1,500/dependent
Please refer to the summary plan description for dental beneit frequency limitations or services not covered.
Bi-Weekly Employee
Contributions
Core Plan Buy-Up Plan
Employee $2.16 $5.86
Employee + Spouse $11.07 $22.28
Employee + Child(ren) $15.96 $27.42
Family $29.24 $47.85
To view a listing of providers, covered services, status
of a claim, deductible balance, and oral health and
wellness information, go to www.aetna.com.
10
Aetna Dental Plan
Polyventive will ofer dental insurance through Aetna. This dental program provides eligible Employees easy
access to a national network of dental providers consisting of general and specialty dentists who meet well-
established credentialing standards. Beneits are based on negotiated fees, and participating dentists agree
to accept negotiated fees.
Core Plan Buy-Up Plan
In-Network Out-of-Network In-Network Out-of-Network
$50 Individual $50 Individual
Deductible (Waived for Preventive Services)
$150 Family $150 Family
Diagnostic and Preventive 100% 100%
Basic Services 80% 80%
Major Services Not Covered 50%
Annual Maximum $1,000/person $2,000/person
Orthodontic Services: N/A 50% up to age 19
Lifetime Maximum $1,500/dependent
Please refer to the summary plan description for dental beneit frequency limitations or services not covered.
Bi-Weekly Employee
Contributions
Core Plan Buy-Up Plan
Employee $2.16 $5.86
Employee + Spouse $11.07 $22.28
Employee + Child(ren) $15.96 $27.42
Family $29.24 $47.85
To view a listing of providers, covered services, status
of a claim, deductible balance, and oral health and
wellness information, go to www.aetna.com.
10
