Page 21 - OpenX 2022 Book of Benefits

DENTAL PLANS

Regular dental exams and cleanings can keep your teeth in tip-top shape, as well as detect
problems before they become painful and expensive. Healthy teeth and gums are also an important
part of maintaining your overall health. That’s why our plans cover at least two cleanings per year,
and a third is covered if medically necessary. OpenX offers two dental plans through Aetna: a Dental
Preferred Provider Organization (DPPO) Low plan and a DPPO high plan.

The DPPO gives you the freedom to visit any in-network or out-of-network dentist you choose.
Generally, the plan pays higher benefits when you visit an in-network dentist, which means you
pay less out of pocket. The difference between the two plans that OpenX offers is the annual plan
maximum, i.e., how much Aetna will cover in costs per covered individual in a calendar year.

AETNA DPPO LOW PLAN AETNA DPPO HIGH PLAN

Annual Plan Maximum Plan Pays $1,000 Plan Pays $2,000

ANNUAL DEDUCTIBLE AND MAXIMUM

Individual IN/OUT $50 / $100 $25 / $50
Family IN/OUT $150 / $300 $75 / $150

COINSURANCE

Preventative 0% 0%
Basic 10% / 20% 10% / 20%

Major 40% / 50% 40% / 50%

ORTHODONTICS***

Orthodontic 50% 50%

Deductible None None

Lifetime Maximum $1,000 $2,000

Using in-network dental providers
While you have the option of choosing any provider, you’ll save money when you use in-network dentists.
Out-of-network dental providers charge more because they have not agreed to a negotiated rate.
*All percentages shown are the member’s responsibility.
**UCR is the percentage paid for dental services in a geographic area based on what providers in the area usually charge for the
same or similar services, and is used to determine the allowed amount.
***Orthodontia is available to adults, as well as dependents under age 26.

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