|
Dental Plan - Aetna
July 1,
2008 -
June 30, 2009 |
|
Information provided is in summary
format. Any difference between the summary provided and
actual contract will be settled in favor of the contract.
|
|
|
DMO |
Passive PPO |
|
Deductible-
applies to basic and major services only |
None
|
Individual -
$50
Family - $150 |
|
Office Visit Copay Per Visit |
$5 |
None |
|
Preventive |
100%
|
100% |
|
Basic |
100% |
80% |
|
Major |
60% |
50% |
|
Annual
Maximum |
None
|
$1000 |
|
Orthodontia |
Not covered |
|
Out of Area Emergency Care |
Reimbursement up to $100 if provider is
more than 50 miles away from Member's home |
