Aetna Dental Expense Plan and DPO – Benefit Comparison*
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In deciding whether to enroll and which dental plan to choose, you should consider the differences in out-of-pocket costs, the covered services between the Dental Expense Plan and a Dental Plan Organization, and the degree of flexibility that you may want in selecting a dentist. Check out Fact Sheet #37 or your Dental Member Handbook for more information.
| Deductible
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$50 per person per calendar year.
None for diagnostic/preventative and orthodonic services.
Maximum of 3 individual deductibles ($150) per family.
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None
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| Coinsurance
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Plan pays:
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Plan pays 100% (less copay). 100% Diagnostic and Preventative.
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| Copay
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None
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Varies depending on service
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| Benefits Maximum
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$3,000 per member annually (excluding orthodontics).
$1,000 (lifetime) per child for orthodontics.
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Unlimited
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| Provider Limitations
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Any licensed dentist
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Must use DPO participating dentist
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| Examinations
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Oral evaluations limited to twice per calendar year. Plan pays 100%
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Oral evaluations limited to twice per calendar year. Plan pays 100%
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| X-rays
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Covered subject to limitations. Plan pays 100%
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Covered subject to limitations. Plan pays 100%
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| Cleanings
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Two cleanings per calendar year
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Two cleanings per calendar year
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| (Oral prophlylaxis)
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Plan pays 100%
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Plan pays 100%
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| Fluoride applications
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Covered only for children under age 19.
Twice per calendar year. Plan pays 100%1
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Covered only for children under age 19.
Plan pays 100%
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| Tooth sealants
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Covered for children under age 19 (with restrictions)
Plan pays 100%1
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Covered only for children under age 19
No copay (limitations apply)
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| Routine fillings
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Plan pays 80%1
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Covered. Copay may apply2
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| Simple extraction
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Plan pays 80%1
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Covered after copay of $20
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| Crowns
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Plan pays 65%1
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Covered after copay of $150-2252
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| Root Canal (Endodontics)
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Plan pays 80%1
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Endodontic Therapy covered after copay of: $100-$1752
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| Dentures
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Repair of existing dentures covered at 80%1. New or replacement dentures covered at 50%.
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Covered after copay (with limitations)2
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| Oral surgery for removal of impacted tooth
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Plan pays 80%
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Covered after copay of $65
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| Periodontics
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Plan pays 50% (with limitations)
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Covered after copay of:
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$30 for gingivectomy (one to three teeth).
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$55 for root planing (per quadrant).
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$100 - $175 for osseous surgery
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| Orthodontic
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After you have been employed for 10 months, eligible services covered at a 50% coinsurance level, up to a $1,000 lifetime maximum per child.
Covered only for those who start treatment before age 19.
(See page 18 of the SHBP Employee Dental Plans Member Handbook for specifics.)
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Maximum treatment is 24 months. Copay as follows:
Patient under age 18 - after copayment of $1,000 or 50% of bill whichever is less. Patient age 18 or over - after copayment of $1,750 or 50% of bill whichever is less.
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1You are responsible for the amount the dentist charges above the reasonable and customary allowances.
2See pages 21-30 of the SHBP Employee Dental Plans Member Handbook.
*See your Dental Member Handbook for more information
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