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CALIFORNIA AETNA DENTAL PLAN OPTIONS

The Aetna INDIVIDUAL DENTAL PPO MAX PLAN an insurance plan underwritten by Aetna Life Insurance Company, may be a good choice if you're looking for a plan that offers an attractive balance of plan features and affordable premiums.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna company that offers, underwrites, or administers insurance coverage is Aetna Life Insurance Company.

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
Oral Exams	100% not subject to deductible	50% not subject to deductible
Periodic oral exam	100% not subject to deductible	50% not subject to deductible
Comprehensive oral exam	100% not subject to deductible	50% not subject to deductible
Problem-focused oral exam	100% not subject to deductible	50% not subject to deductible
X-rays
Bitewing — single film	100% not subject to deductible	50% not subject to deductible
Complete series	100% not subject to deductible	50% not subject to deductible
PREVENTIVE SERVICES
Adult cleaning	100% not subject to deductible	50% not subject to deductible
Child cleaning	100% not subject to deductible	50% not subject to deductible
Sealants — per tooth	Discount	Not covered
Fluoride application — with cleaning	100% not subject to deductible	50% not subject to deductible
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	Discount	Not covered
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	Discount	Not covered
Removal of impacted tooth — partially bony	Discount	Not covered
Endodontic Services	Discount	Not covered
Bicuspid root canal therapy	Discount	Not covered
Molar root canal therapy	Discount	Not covered
Periodontic Services	Discount	Not covered
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. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. All products not available in all counties. Please refer to the state map located on page 2 of the Aetna Advantage Brochure. A summary of exclusions is listed on page 19. For a full list of benefit coverage and exclusions refer to the plan documents.

Individual Health Insurance | Family Health Insurance | Dental Insurance | Senior Insurance Plans
Aetna California Advantage Plan MC 1500 | Aetna California Advantage Plan MC 2500
Aetna California Advantage Plan MC 3500 | Aetna California Advantage Plan MC 500
Aetna California Advantage Plan MC 5000 | Aetna California High Deductible MC 1 HSA Compatible
Aetna California High Deductible MC 2 HSA Compatible | Aetna California Individual Dental PPO Max Plan
Aetna California MC Value 1500 | Aetna California MC Value 2500
Aetna California MC Value 5000 | Aetna California Preventative Hospital Care 1250
Aetna California Preventative Hospital Care 3000 HSA Compatible