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Arizona Health Insurance > Aetna > Individual Dental PPO MAX Benefits

Aetna

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Individual Dental PPO MAX plan
Member Benefits Preferred Nonpreferred
Annual Deductible per Member
(Does not apply to Diagnostic and Preventive Services) 		$25; $75 family maximum $25; $75 family maximum
Annual Maximum Benefit Unlimited Unlimited
Diagnostic Services
Periodic oral exam 100% deductible waived 50% deductible waived
Comprehensive oral exam 100% deductible waived 50% deductible waived
Problem-focused oral exam 100% deductible waived 50% deductible waived
X-rays
Bitewing — single film 100% deductible waived 50% deductible waived
Complete series 100% deductible waived 50% deductible waived
Preventive Services
Adult cleaning 100% deductible waived 50% deductible waived
Child cleaning 100% deductible waived 50% deductible waived
Sealants — per tooth Discount Not Covered
Fluoride application — with cleaning 100% deductible waived 50% deductible waived
Space maintainers Discount Not Covered
Basic Services
Amalgam filling — 2 surfaces 100% after deductible 50% after deductible
Resin filling — 2 surfaces anterior Discount Not Covered
Oral Surgery Discount Not Covered
Extraction – exposed root or erupted tooth Discount Not Covered
Extraction of impacted tooth —soft tissue Discount Not Covered
Major Services
Complete upper denture Discount Not Covered
Partial upper denture (resin base) Discount Not Covered
Crown — Porcelain with noble metal Discount Not Covered
Pontic — Porcelain with noble metal Discount Not Covered
Inlay — Metallic (3 or more surfaces) Discount Not Covered
Oral Surgery
Removal of impacted tooth — partially bony Discount Not Covered
Endodontic Services
Bicuspid root canal therapy Discount Not Covered
Molar root canal therapy Discount Not Covered
Periodontic Services
Scaling & root planing — per quadrant Discount Not Covered
Osseous surgery — per quadrant Discount Not Covered
Orthodontic Services Discount Not Covered
Access to negotiated discounts: members are eligible to receive non covered services, including cosmetic services such as tooth whitening, at the PPO negotiated rate when visiting a participating PPO dentist at any time. Nonpreferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. All products not available in all counties. Please refer to the state map located on page 2 of the Aetna Advantage Brochure. For a full list of benefit coverage and exclusions refer to the plan documents. The Aetna Advantage Plans for Individuals, Families and Self- Emplyed are offered, underwritten or administered by Aetna Life Insurance Company. In some states, Sole Proprietors may be eligible for Small Group Healthcare Plans. For a full list of benefit coverage and exclusions refer to the plan documents.
* Maximum applies to combined in and out-of-network benefits.
** Copay is billed separately and not due at time of service. Copay does not count towards coinsurance or out-of-pocket maximum.
*** Aetna Discount Available
+ Payment for out-of-network facility care is determined based upon Aetna’s Allowable Fee Schedule. Payment for other out-of-network facility care is determined based upon the negotiated charge that would apply if such services or supplies were received from a Preferred Provider.

 
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