Page 12 - B12797-ITDR-Enrollment-Guide-2020

2020 Dental plans (for Medicare and non-Medicare eligible retirees)
Aetna Dental® Preferred Provider Organization (PPO) Plan - stand-alone dental plan
Under the PPO dental plan, you may choose at the time of service either a PPO participating dentist or any nonparticipating dentist. If you select a participating dentist, savings are possible because the participating dentists have agreed to provide care for covered services at negotiated rates. Nonparticipating benefits are subject to usual and prevailing charge limits, as determined by Aetna.
Monthly premium
Retiree
Retiree + spouse Retiree + child(ren) Retiree + family
Annual deductible*
Individual Family
Preventive services
Partial list of services includes oral examinations, cleanings, X-rays bitewing and full series.
Basic services
Partial list of services includes root canal therapy for anterior/bicuspid teeth, scaling and root planing, gingivectomy, amalgam (silver) fillings, composite fillings (anterior teeth only), stainless steel crowns and more.
Major services
Partial list of services includes inlays, onlays, crowns, crown lengthening, full and partial dentures, pontics, general anesthesia/sedation, denture repairs, crown build-ups and more.
Annual benefit maximum Office visit copay
Orthodontic services** Orthodontic deductible Orthodontic lifetime maximum
$42.14 $84.28 $94.81 $136.95
Retiree pays
$50 $150
What the plan pays
80% 60%
50%
$1,000 n/a 50% None $1,000
*The deductible applies to preventive, basic and major services.
**Orthodontia is covered only for children (appliance must be placed prior to age 20) 12