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Hi, I’m David, and this is Aetna’s dental preferred provider organization, or PPO. This PPO gives you great coverage. Preventive care, like checkups, cleanings, and x-rays, is almost always 100 percent covered, and there’s coverage for basic care, like fillings, and major care, like root canals and crowns. If you need to see a specialist, you can see any licensed dentist you’d like without a referral. The PPO gives you the flexibility to see any dentist you’d like at any time. But, this is where the term “preferred” comes in. The PPO has a network of dentists who have agreed to negotiated rates for Aetna’s members, including over 215,000 available dental practice locations. See a network dentist, and your final cost will typically be lower, letting you stretch your annual maximum even further. 

That’s Aetna’s Dental PPO. 
 

* In Texas, the Preferred Provider Organization (PPO) plan is known as the Participating Dental Network (PDN).

** These facts are as of December 2013 based on Aetna provider data.

Exclusions and Limitations 

Some services not covered are:

1. Services or supplies that are covered in whole or in part:

a) under any other part of this Dental Care Plan; or

b) under any other plan of group benefits provided by or through your employer.

2. Services and supplies to diagnose or treat a disease or injury that is not:

a) a non-occupational disease; or

b) a non-occupational injury.

3. Services not listed in the Dental Care Schedule that applies, unless otherwise specified in the Booklet-Certificate.

4. Those for replacement of a lost, missing or stolen appliance, and those for replacement of appliances that have been damaged due to abuse, misuse or neglect.

5. Those for plastic, reconstructive or cosmetic surgery, or other dental services or supplies, that are primarily intended to improve, alter or enhance appearance. This applies whether or not the services and supplies are for psychological or emotional reasons. Facings on molar crowns and pontics will always be considered cosmetic.

6. Those for or in connection with services, procedures, drugs or other supplies that are determined by Aetna to be experimental or still under clinical investigation by health professionals.

7. Those for dentures, crowns, inlays, onlays, bridgework, or other appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or to correct attrition, abrasion or erosion.

8. Those for any of the following services:

a) An appliance or modification of one if an impression for it was made before the person became a covered person;

b) A crown, bridge, or cast or processed restoration if a tooth was prepared for it before the person became a covered person;

c) Root canal therapy if the pulp chamber for it was opened before the person became a covered person.

9. Services that Aetna defines as not necessary for the diagnosis, care or treatment of the condition involved. This applies even if they are prescribed, recommended or approved by the attending physician or dentist.

10. Those for services intended for treatment of any jaw joint disorder, unless otherwise specified in the Booklet-Certificate.

11. Those for space maintainers, except when needed to preserve space resulting from the premature loss of deciduous teeth.

12. Those for orthodontic treatment, unless otherwise specified in the Booklet-Certificate.

13. Those for general anesthesia and intravenous sedation, unless specifically covered. For plans that cover these services, they will not be eligible for benefits unless done in conjunction with another necessary covered service.

14. Those for treatment by other than a dentist, except that scaling or cleaning of teeth and topical application of fluoride may be done by a licensed dental hygienist. In this case, the treatment must be given under the supervision and guidance of a dentist.

15. Those in connection with a service given to a dependent age 5 or older if that dependent becomes a covered dependent other than:

a) during the first 31 days the dependent is eligible for this coverage, or

b) as prescribed for any period of open enrollment agreed to by the employer and Aetna. This does not apply to charges incurred:

i. after the end of the 12-month period starting on the date the dependent became a covered dependent; or

ii. as a result of accidental injuries sustained while the dependent was a covered dependent; or

iii. for a primary care service in the Dental Care Schedule that applies as shown under the headings Visits and Exams, and X-rays and Pathology.

16. Services given by a nonparticipating dental provider to the extent that the charges exceed the amount payable for the services shown in the Dental Care Schedule that applies.

17. Those for a crown, cast or processed restoration unless:

a) It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material; or

b) The tooth is an abutment to a covered partial denture or fixed bridge.

18. Those for pontics, crowns, cast or processed restorations made with high-noble metals, unless otherwise specified in the Booklet-Certificate.

19. Those for surgical removal of impacted wisdom teeth only for orthodontic reasons, unless otherwise specified in the Booklet-Certificate.

20. Services needed solely in connection with non-covered services.

21. Services done where there is no evidence of pathology, dysfunction or disease other than covered preventive services.

Dental PPO/PDN insurance plans are underwritten and/or administered by Aetna Life Insurance Company (Aetna).

If you require language assistance from an Aetna representative, please call the Member Services number located on your ID card, and you will be connected with the language line if needed; or you may dial direct at 1-888-982-3862. (140 languages are available. You must ask for an interpreter.) TDD 1-800-628-3323 (hearing impaired only).

Si requiere la asistencia de un representante de Aetna que hable su idioma, por favor llame al número de Servicios al Miembro que aparece en su tarjeta de identifi cación y se le comunicará con la línea de idiomas si es necesario; de lo contrario, puede llamar directamente al 1-888-982-3862. (140 idiomas disponibles. Debe pedir un intérprete.)  TDD-1-800-628-3323 (sólo para las personas con impedimentos auditivos).

This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits vary by location. Dental insurance plans contain exclusions and limitations. Dental providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to dental services. Not all dental services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and/or group size and are subject to change. For self-funded accounts, benefits coverage is offered by your employer, with administrative services only provided by Aetna Life Insurance Company. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.

Policy forms issued in OK include:  GR-9/GR-9N. GR-23 and/or GR-29/GR-29N.

© 2014 Aetna Inc.

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