Page 9 - LADACIN 2022-23 Benefit Guide
P. 9
Your Dental
Plan
It’s important to have regular dental exams and
cleanings so problems are detected before they
become painful—and expensive. Keeping your teeth
and gums clean and healthy will help prevent most
tooth decay and periodontal disease and is an
important part of maintaining your medical health.
You have a choice of two dental plans. Each plan has a
different network of dentists, so be sure to check to
determine which plan (if any) your dentist participates
in. This chart shows what you pay for each service:
Provision Aetna DMO Aetna PPO
Annual deductible
$0/$0 $25/$75
Individual/Family
Annual benefit maximum per individual None $1,250
Diagnostic and Preventive, to include
cleanings, fluoride treatments, sealants No Charge for most services 0% no deductible
and x-rays
Basic Services to include fillings,
periodontics, scaling and root planning, See Copay Schedule 10% after deductible
oral surgery
Major Services to include crowns,
See Copay Schedule 50% after deductible
bridges, full and partial dentures
Orthodontia (Adults & Child up to age 26)
Includes exam, records, retention and $2,000 Copay Not Covered
appliance
th
Out of Network Reimbursement Level Not Applicable 90 Percentile
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