Additional Plan Information For Aetna Dental Direct Preferred PPO

Annual Maximum

This is the total amount per person your plan will pay toward the cost of dental care each year.

• $1,250, per enrollee on the plan

Deductible For Covered Services

• $50 per individual per calendar year
• $150 annual deductible for families

Waiting Periods

• After 6 months of continuous coverage under the PPO Plan: Resin filling (1 surface), periodontal maintenance cleanings, extraction (uncomplicated).
• After 12 months of continuous cover under the PPO Plan: Oral surgery, crowns, root canal therapy, and dentures.

Choose any dentist

See dentists both in and out of our network. With our dental insurance plans for individuals, you can get services from either a participating or nonparticipating dentist. Participating dentists have agreed to provide services at a negotiated rate for covered services. You also have the flexibility to visit a licensed dentist who does not participate in our network. However, if you do this, you won’t benefit from negotiated rates.

Dental insurance plans are underwritten by Aetna Life Insurance Company.

This is only a summary of the plan's exclusions and limitations. See the insurance policy for details.

Charges for services or supplies

• Provided by an out-of-network provider in excess of the recognized charge.
• Provided for your personal comfort or convenience, or the convenience of any other person, including a dental provider.
• Rendered before the effective date or after the termination of coverage, unless coverage is continued  under the Special coverage options after your plan coverage ends section of your policy.
• Cancelled or missed appointment charges or charges to complete claim forms.
• For which you have no legal obligation to pay.
• In excess of the benefit, dollar, day, visit, or supply limits stated in your schedule of benefits.
• That would not be made if you did not have coverage.
• That are cosmetic in nature. Teeth whitening and facings on molar crowns and pontics will always be considered cosmetic.
• That are experimental or investigational.
• That are not medically necessary.
• For prescribed drugs, pre-treatments or analgesia.
• That are provided by a family member.
• For work-related conditions.
• For work that began before you were covered under the plan

• Acupuncture, acupressure and acupuncture therapy
• Crown, inlays and onlays, and veneers unless for one of the following:
  - It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material
  - The tooth is an abutment to a covered partial denture or fixed bridge.
• Dental implants, false teeth, prosthetic restoration of dental implants, plates, dentures, braces, mouth guards, and other devices to protect, replace or reposition teeth and removal of implants
• Dental services and supplies made with high noble metals (gold or titanium) except as covered in the Eligible Dental Services section of your insurance policy
• Dentures, crowns, inlays, onlays, bridges, or other appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or correcting attrition, abrasion, or erosion
• First installation of a denture or fixed bridge, and any inlay and crown that serves as an abutment to replace congenitally missing teeth or to replace teeth all of which were lost while the person was not covered
• General anesthesia and intravenous sedation, unless specifically covered and only when done in connection with another eligible dental service
• Instruction for diet, plaque control and oral hygiene
• Orthodontic treatment except as covered in the Eligible Dental Services section of your insurance policy
• Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of appliances that have been damaged due to abuse, misuse or neglect and for an extra set of dentures
• Replacement of teeth beyond the normal complement of 32
• Services and supplies provided where there is no evidence of pathology, dysfunction or disease, other than covered preventive services
• Surgical removal of impacted wisdom teeth when only for orthodontic reasons
• Temporomandibular joint dysfunction/disorder.

Aetna Dental Direct PPO Plans are Subject to the Following Rules:

Replacement Rule

The replacement of; addition to; or modification of: existing dentures; crowns; casts or processed restorations; removable denture; fixed bridgework; or other prosthetic services is covered only if specific criteria are met.

Tooth Missing But Not Replaced Rule

Coverage for the first installation of removable dentures; fixed bridgework and other prosthetic services is subject to the requirements that such removable dentures, fixed bridgework and other prosthetic services are:

• needed to replace one or more natural teeth that were removed while this policy was in force for the covered person; and
• are not abutments to a partial denture; removable bridge; or fixed bridge installed during the prior 8 years.

Alternate Treatment Rule

If more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service. If treatment is being given by a participating dental provider and the covered person asks for a more costly covered service than that for which coverage is approved, the specific copayment for such service will consist of:

• the copayment for the approved less costly service; plus
• the difference in cost between the approved less costly service and the more costly covered service.