Dental Insurance PPO
• $50 per individual per calendar year
• $100 per family per calendar year
• $1,500 Calendar year maximum benefit allowance per person for Types I, II, and III
• $1,000 Lifetime maximum benefit allowance per child for Type IV
Benefit Percentages (of reasonable and customary fees of covered expenses)
• Type I: 100% Coverage of preventative maintenance visits to include cleanings, exams, and x-rays
• *Type II: 80% Coverage of basic dental procedures to include fillings, routine extractions, root canals, periodontal cleanings, and gum surgeries
• *Type III: 50% Coverage of major restorative procedures to include crowns, inlays, bridges, and dentures
• *Type IV: 50% Coverage of orthodontic services for covered children only; employees and their spouses are not eligible for this benefit
• You may use any dentist.
• Aetna will pay based on reasonable and customary charges.
* Individual or family deductible must be met before coverage percentages apply.
* See Aetna website for Aetna providers