Page 11 - Benefits Guide

Dental Coverage
Like your medical plan options, your dental coverage options also include preventive care benefits.
You have a choice of two dental options provided through Aetna. The plan provides the same benefits coverage for both in-network and out-of-network providers. However, it is usually to your advantage to use an in-network dentist because they will generally charge you lower fees. Using in-network providers also protects you from being balance-billed for services (charged more than the reasonable and customary amounts for services rendered).
You can choose the option that’s right for you. For example, if you don’t need orthodontic care (braces) or major restorative care, the Base Plan may be all you need. You can contact Aetna Dental at 1-800-938-0508 or www.aetna.com.
Health Care
Paying for Coverage
You’ll pay the cost of dental coverage with before-tax dollars. How much you pay is based on
the dependents you cover. You can enroll any combination of you, your spouse, and your children in the option you choose.
Provider: Aetna
Dental Base Plan
Dental Buy-Up Plan
In-Network
Out-of-Network
In-Network
Out-of-Network
Deductible
(individual/family)
$100/$300
$100/$300*
$50/$150
$50/$150*
Annual Maximum Benefit the Plan Pays
(excludes orthodontic care)
$1,500
$1,500*
$2,000
$2,000*
Preventive and Diagnostic Care
Covered 100%, no deductible
Covered 100%, no deductible*
Covered 100%, no deductible
Covered 100%, no deductible*
Basic Restorative Care
(such as root canal treatment, gum disease treatment, and oral surgery)
You pay 20% after deductible
You pay 20% after deductible*
You pay 20% after deductible
You pay 20% after deductible*
Major Restorative Care
You pay 50% after deductible
You pay 50% after deductible*
You pay 30% after deductible
You pay 30% after deductible*
Orthodontic Care
Not covered
Not covered
Covered for adults and children You pay 50%, no deductible Lifetime maximum orthodontic benefit plan pays: $2,000 per person
Covered for adults and children You pay 50%, no deductible* Lifetime maximum orthodontic benefit plan pays: $2,000 per person*
*Out-of-Network Benefits: The coinsurance amount is based on charges that are considered “reasonable and customary.” You will be responsible for any amount billed over the reasonable and customary amount allowed when going out of network.
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