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09.03.303.1 N (8/14)

Easy-to-use coverage that fits your budgetAetna Dental® DMO® Plan

* In Illinois, the Dental DMO plan provides limited out-of-network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by their PCD. In Illinois, the Dental DMO plan is not an HMO.

** Your PCD keeps a list of eligible patients that is updated monthly. Your name will appear on this list when it is updated the month after your selection. Some dentists will only treat patients whose names appear on this printed monthly roster. Once you are a member, you can call Member Services if your doctor needs to verify your eligibility.

What to do How the DMO* benefits and insurance plan works

Pick a PCD from the Aetna network.** To find one, use our online directory at www.aetna.com.

• Your DMO plan begins with your PCD. • See your PCD for regular exams and to get referrals if you need specialty care.• Covered family members can pick their own PCDs, too.• You can change your PCD once a month. Switch by the 15th day of the current

month. The change will be effective the first day of the next month. Call Member Services for help.**

Visit your PCD. You need to visit a PCD in the Aetna DMO network. Otherwise, you could end up paying more.

• Give your personal information at your visit.• Pay your share of the cost. This may be a copay, which is a set dollar amount.

Or it may be coinsurance, which is a percent of the dentist’s charge.• Check your benefits summary so you know what you will pay.• That’s it. No deductible, no claims forms and no yearly dollar limits.

A primary care dentist (PCD) helps guide your care

The Aetna Mobile app puts our most popular online features at your fingertips. It’s available for iPhone® and Android™ mobile devices.

Visit www.aetna.com/mobile.

Find what you need — wherever, whenever

* State laws vary with regard to out-of-network benefits. Some states allow limited benefits when you go out of network for covered services. In California, your PCD may refer you to out-of-network dentists in that state. Check your plan documents for details.

** Not all plans include orthodontic care. See your plan documents for coverage details. In California, referrals to specialty care are required.

The Aetna Dental DMO benefits and insurance plan is offered, underwritten and/or administered by Aetna Dental Inc., Aetna Dental of California Inc., Aetna Health Inc. and/or Aetna Life Insurance Company, and in Texas, by Aetna Dental Inc. (Aetna). Each insurer has sole responsibility for its own products.Apple, the Apple logo and iPhone are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. Android and Google Play are trademarks of Google Inc. 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 benefits and dental insurance plans contain exclusions and limitations. 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. 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. Dental information programs provide general dental information and are not a substitute for diagnosis or treatment by a dentist or other dental care professional. 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 Oklahoma include: GR-9/GR-9N, GR-23 and/or GR-29/GR-29N.

www.aetna.com

©2014 Aetna Inc. 09.03.303.1 N (8/14)

Referrals for specialty dentists

Need a specialist? Your PCD will refer you to a dentist in the Aetna network.*

• Provide your personal information at your visit.

• Pay your share of the cost to the dentist. Your benefits summary shows you how much.

• There’s usually no paperwork involved.

And no referrals for orthodontists

Is someone in the family getting braces? When you visit an orthodontist** who participates in the Aetna network, you won’t need a referral. Now that’s easy to use.

You’ll usually save when you visit network dentists. That’s because they’ve agreed to offer some services at special rates.

Extra online help

Get your informationWhen you’re an Aetna member, you get tools and resources to help you manage your health and your benefits. All of your plan information and cost-saving tools are in one place — your secure member website. Sign up today at www.aetna.com.

And get tips for a brighter, healthier smile Check out our dental articles and interactive tools. You’ll find topics ranging from fillings and flossing to dentures … and more. Plus, get expert opinions from the Columbia University College of Dental Medicine, as well as the latest dental news.

Visit www.simplestepsdental.com.

Something new this year: no more ID cards

Instead, when you visit the dentist’s office, just give your personal information. But if you want a card, no problem. Once you’re a member, get one by logging in to your member website at www.aetna.com, using our mobile app or calling Member Services.

Looking for simple, budget-friendly dental coverage? Enroll in the Aetna Dental DMO plan today.

ed.2014"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.

Current Dental Terminology © 2014 American Dental Association. All rights reserved.

CODEPATIENT

PAYS CODEPATIENT

PAYS$0

D0120-D0180 No Charge D0277 No ChargeD0210 No Charge D0330 No ChargeD0220-D0230 No Charge D0391 No ChargeD0240 No Charge D0460 No ChargeD0250-D0260 No Charge D0470 No ChargeD0270-D0274 No Charge D0472-D0474 No Charge

D1110 $12 D1510 $100D1120 $10 D1515 $100D1208 No Charge D1520 $100D1206 No Charge D1525 $100D1330 No Charge D1550 $15D1351 $10 D1555 $15D1352 $10 D2990 $10

D2140 $22 D2391 $22D2150 $32 D2392 $32D2160 $43 D2393 $43D2161 $53 D2394 $53D2330

$40D2921

$7D2331 $55 D2940 $15D2332 $60 D2941 $7 D2335

$70D2951

$15D2390 $80

D2510$275

D6073$325

D2520$275

D6074$325

D2530$275

D6075$325

D2542

$275

D6076

$325D2543

$275

D6077

$325D2544

$275D6078

$350D2610

$275D6079

$475D2620 $275 D6094 $325D2630 $275 D6205 $325D2642 $275 D6210 $325D2643 $275 D6211 $325D2644 $275 D6212 $325

Resin-Based Composite Crown, Anterior

Interim therapeutic restoration - primary dentition

Inlay, Porcelain/Ceramic - 3 or More Surf

Onlay, Porcelain/Ceramic - 4 or More Surf

Onlay, Porcelain/Ceramic - 2 Surf

Implant/Abutment Supported Fixed Denture for Completely Edentulous ArchImplant/Abutment Supported Fixed Denture for Partially Edentulous ArchAbutment Supported Crown - (Titanium)

Space Maintainer - Removable Bilateral

Amalgam - 3 Surf Primary or Permanent

Inlay, Porcelain/Ceramic - 2 Surf

CROWNS/BRIDGESInlay - Metallic 1 Surf Abutment Supported Retainer for Cast Metal

FPD (Predominantly Base Metal)

Onlay - Metallic 2 Surf

Onlay, Metallic - 4 or More Surf

Inlay, Porcelain/Ceramic - 1 Surf

Implant Supported Retainer for Ceramic FPD

Implant Supported Retainer for Porcelain Fused to Metal FPD (Titanium, Titanium Alloy or High Noble Metal)

Onlay - Metallic 3 Surf

Onlay, Porcelain/Ceramic - 3 Surf

Implant Supported Retainer for Cast Metal FPD (Titanium, Titanium Alloy or High Noble Metal)

Pontic - Indirect Resin Based Composite

Pontic - Cast Predominantly Base MetalPontic - Cast Noble Metal

Resin-Based Composite 3 Surf, PosteriorResin-Based Composite 4+ Surf, PosteriorReattachment of tooth fragment, incisal edge or duspProtective Restoration

Pin Retention - In Addition to Restoration

Inlay - Metallic 3 Surf

Resin-Based Composite 2 Surf, AnteriorResin-Based Composite 3 Surf, AnteriorResin-Based Composite 4+ Surf; Anterior (or involving Incisal angle)

Charges for resin based posterior composites are equal to the amalgam fee when performed on molars or stress bearing surfaces of pre-molars. There may be additional charges for the actual cost for the resin based composite.

Panoramic ImageFull mouth series Images

Abutment Supported Retainer for Cast Metal FPD (Noble Metal)

Inlay - Metallic 2 Surf

Space Maintainer - Fixed UnilateralSpace Maintainer - Fixed Bilateral

Resin-Based Composite 1 Surf, Anterior

Oral Hygiene Instruction

Amalgam - 4+ Surf Primary or Permanent

Diagnostic and Preventive services may be subject to age and frequency limitations. See your booklet for details.

DIAGNOSTIC

Pulp Vitality Test

Application of Topical Fluoride Varnish

Bitewings

Oral Evaluations

Fluoride - Child

Prophy - AdultProphy - Child

PREVENTIVE

Vertical Bitewings - 7 to 8 Films

ARCHDIOCESE OF PHILADELPHIA

Dental Benefits SummaryEffective Date: 07-01-2015

Plan 51

Office Visit CopayPROCEDURE PROCEDURE

Resin Infiltration of Lesion

Diagnostic CastsAccession of Tissue

PeriapicalsIntraoral, Occlusal ImageExtraoral Images

Interpretation of Diagnostic Image

Space Maintainer - Removable Unilateral

Sealant - Per tooth

Resin-Based Composite 1 Surf, PosteriorResin-Based Composite 2 Surf, Posterior

Recement Space Maintainer

Amalgam - 1 Surf Primary or PermanentAmalgam - 2 Surf Primary or Permanent

Removal of Space Maintainer

RESTORATIVE PRIMARY OR PERMANENT TEETH

Preventive Resin Restoration

Pontic - Cast High Noble Metal





Plan 51

D2650 $275 D6214 $325D2651 $275 D6240 $325D2652

$275D6241

$325D2662 $275 D6242 $325D2663 $275 D6245 $325D2664 $275 D6250 $325D2710 $325 D6251 $325D2712 $240 D6252 $325D2720

$325D6545

$275D2721

$325D6548

$275D2722 $325 D6600 $275D2740 $325 D6601 $275D2750 $325 D6602 $295D2751

$325D6603

$295D2752 $325 D6604 $275D2780

$300D6605

$275D2781

$300D6606

$295D2782 $300 D6607 $295D2783 $300 D6608 $275D2790 $325 D6609 $275D2791 $325 D6610 $295D2792 $325 D6611 $295D2794 $325 D6612 $275D2910

$18D6613

$275D2915 $9 D6614 $295D2920 $18 D6615 $295

D2929 $91D6624

$295D2930

$65D6634

$295D2931

$80D6710

$325D2934 $65 D6720 $325D2950

$55D6721

$325D2952

$95D6722

$325D6053

$350D6740

$325D6054

$375D6750

$325D6058

$325D6751

$325D6059

$325D6752

$325D6060

$325D6780

$325D6061

$325D6781

$325

Crown - Porcelain Fused to High Noble Metal

Implant/Abutment Supported Removable Denture for Completely Edentulous Arch

Pontic - Porcelain Fused to High Noble MetalInlay, Composite/Resin - 3 Surf

Crown - Porcelain/Ceramic Substrate

Inlay, Composite/Resin - 1 Surf Inlay, Composite/Resin - 2 Surf

Onlay, Composite/Resin - 3 Surf Onlay, Composite/Resin - 2 Surf

Pontic - Titanium

Pontic - Porcelain Fused to Noble Metal

Inlay - Cast High Noble Metal, 3+ Surf

Pontic - Porcelain Fused to Predominantly Base Metal

Crown - 3/4 Resin-Based Composite, IndirectCrown - Resin With High Noble Metal

Onlay, Composite/Resin - 4 or More Surf Crown - Resin-Based Composite, Indirect Pontic - Resin With Predominantly Base Metal

Pontic - Resin With Noble MetalRetainer - Cast Metal for Resin-Bonded Fixed Prosthesis

Crown - Resin With Predominantly Base Metal

Crown - Resin With Noble Metal

Crown - Full Cast Predominantly Base Metal

Crown - 3/4 Cast Noble MetalCrown - 3/4 Porcelain/Ceramic

Crown - 3/4 Cast High Noble Metal

Crown - 3/4 Cast Predominantly Based Metal

Crown - Porcelain Fused to Predominantly Base MetalCrown - Porcelain Fused to Noble Metal

Crown - Full Cast High Noble Metal

Recement Cast or Prefab Post and CoreRecement Crown

Recement Inlay, Onlay or Partial Coverage Restoration

Crown - Full Cast Noble MetalCrown - Titanium

Prefab, Stainless Steel Crown - Primary Tooth

Prefab Porcelain/Ceramic Crown - Primary Tooth

Prefab, Stainless Steel Crown - Permanent Tooth

Abutment Supported Porcelain Fused to Metal Crown (Noble Metal)

Post & Core in Addition to Crown

Core Buildup, Including Any Pins

Implant/Abutment Supported Removable Denture for Partially Edentulous ArchAbutment Supported Porcelain/Ceramic Crown

Abutment Supported Porcelain Fused to Metal Crown (High Noble Metal)Abutment Supported Porcelain Fused to Metal Crown (Predominantly Base Metal)

Prefabricated Esthetic Coated Stainless Steel

Crown - Resin With High Noble MetalCrown - Resin With Predominantly Base Metal

Crown - Resin With Noble Metal

Crown - Porcelain/Ceramic

Inlay - Porcelain/Ceramic, 2 SurfInlay - Porcelain/Ceramic, 3+ SurfInlay - Cast High Noble Metal, 2 Surf

Onlay - Cast High Noble Metal, 2 Surf

Inlay - Cast Predominantly Base Metal, 3+ Surf

Inlay - Cast Noble Metal, 3+ SurfOnlay - Porcelain/Ceramic, 2 SurfOnlay - Porcelain/Ceramic, 3+ Surf

Inlay - Cast Noble Metal, 2 Surf

Pontic - Porcelain/CeramicPontic - Resin With High Noble Metal

Onlay - Titanium

Onlay - Cast High Noble Metal, 3+ SurfOnlay - Cast Predominantly Base Metal, 2 SurfOnlay - Cast Predominantly Base Metal, 3+ Surf

Inlay - Titanium

Inlay - Cast Predominantly Base Metal, 2 Surf

Onlay - Cast Noble Metal, 2 Surf

Retainer - Porcelain/Ceramic for Resin-Bonded Fixed Prosthesis

Crown - 3/4 Cast Predominantly Base Metal

Onlay - Cast Noble Metal, 3+ Surf

Crown - Porcelain Fused to High Noble Metal

Crown - Porcelain Fused to Predominantly Base Metal

Crown - Indirect Resin Based Composite

Crown - Porcelain Fused to Noble Metal

Crown - 3/4 Cast High Noble Metal





Plan 51

D6062$325

D6782$325

D6063$325

D6783$325

D6064$325

D6790$325

D6065

$325

D6791

$325D6066

$325D6792

$325D6067

$325D6794

$325D6068

$325D6930

$20D6069

$325D6070

$325D6071

$325D6072

$325$125

D3110 $8 D3333 $130D3120 $8 D3346

$250D3220 $50 D3347

$295D3221 $10 D3348

$395D3222 $45 D3410 (1) $156D3230 $50 D3421 (1)

$156D3240 $50 D3425 (1)

$190D3310 $150 D3426 (1)

$130D3320 $195 D3427 (1)

$117D3330 $295 D3430 (1)

$75D3331 $150 D3450 (1)

$100D3332 $98

D4210 (1) $160 D4273 (1) $155

D4211 (1) $43 D4275 (1) $310

Incomplete Endodontic Therapy; Inoperable, Unrestorable or Fractured Tooth

Periradicular surgery without apicoectomy

Apicoectomy/Periradicular Surgery- Each Additional Root

Gingivectomy or Gingivoplasty - 1-3 Teeth - Per Quadrant

Soft Tissue Allograft

Treatment of Root Canal Obstruction, Nonsurgical Access

Retrograde Filling - Per Root

Root Canal Therapy - Bicuspid (excluding final restoration)

Retreatment of Previous Root Canal Therapy - Molar

Pulpal Debridement, Primary and Permanent Teeth

Charges for crowns and bridgework are per unit. There will be additional charges for the actual cost for gold/high noble metal.Full mouth rehabilitation is defined as 6 or more units of covered crowns and/or pontics under one treatment plan.

Internal Root Repair of Perforation Defects

Abutment Supported Cast Metal Crown (High Noble Metal)Abutment Supported Cast Metal Crown (Predominantly Base Metal)

Abutment Supported Retainer for Porcelain/Ceramic FPD

Abutment Supported Retainer for Porcelain Fused to Metal FPD (Predominantly Base Metal)

Abutment Supported Retainer for Porcelain Fused to Metal FPD (High Noble Metal)

Abutment Supported Cast Metal Crown (Noble Metal)Implant Supported Porcelain/Ceramic Crown

Implant Supported Porcelain Fused to Metal Crown (Titanium, Titanium Alloy or High Noble Implant Supported Metal Crown (Titanium, Titanium Alloy or High Noble Metal)

Abutment Supported Retainer for Porcelain Fused to Metal FPD (Noble Metal)

Pulpal Therapy (Resorbable Filling) - Posterior, Primary Tooth

Apicoectomy/Periradicular Surgery - Bicuspid (First Root)

Pulp Cap - Indirect (excluding final restoration)

Therapeutic Pulpotomy (excluding final restoration)

Retreatment of Previous Root Canal Therapy - Bicuspid

Partial Pulpotomy

Abutment Supported Retainer for Cast Metal FPD (High Noble Metal)

Pulp Cap - Direct (excluding final restoration)

Crown - Full Cast Noble Metal

Crown - 3/4 Cast Noble Metal

Crown - 3/4 Porcelain/Ceramic

Crown - Full Cast Predominantly Base Metal

Recement Fixed Partial Denture

Crown - Titanium

Crown - Full Cast High Noble Metal

Apicoectomy/Periradicular Surgery - Molar (First Root)

(1) Certain services may be covered under the Medical Plan. Contact Member Services for more details.

Additional Charge per Unit for Full Mouth Rehabilitation.

ENDODONTICS

Retreatment of Previous Root Canal Therapy - Anterior

Pulpal Therapy (Resorbable Filling) - Anterior, Primary Tooth

Apicoectomy/Periradicular Surgery - Anterior

Root Canal Therapy - Molar (excluding final restoration)

Root Canal Therapy - Anterior (excluding final restoration)

Root Amputation - Per Root

PERIODONTICSGingivectomy or Gingivoplasty - 4 or More Teeth - Per Quadrant

Subepithelial Connective Tissue Graft, Per Tooth





Plan 51

D4212 (1) $17 D4276 (1) $256

D4240 (1) $200 D4277 (1) $110

D4241 (1) $120 D4278 (1) $55

D4245 (1) $200 D4341 $65

D4249 $204 D4342 $39

D4260 (1) $340 D4355 $60

D4261 (1) $204 D4910 $60

D4268 (1) $136 D4920 $10

D4270 (1) $260

D5110 $350 D5225$450

D5120 $350 D5226$450

D5130 $400 D5281$375

D5140 $400 D5410 $15D5211 $375 D5411

$15D5212 $375 D5421

$15D5213 $475 D5422

$15D5214 $475

D5510 $35 D5730 $65D5520 $25 D5731

$65D5610 $45 D5740 $65D5620 $45 D5741 $65D5630 $45 D5750 $110D5640 $45 D5751 $110D5650 $45 D5760 $110D5660 $50 D5761 $110D5670 $95 D5820

$110D5671 $95 D5821

$110D5710 $95 D5850 $35Tissue Conditioning, Maxillary

Periodontal Scaling and Root Planing - 4 or More Teeth - Per Quadrant

Gingival Flap Procedure, Including Root Planing - 1-3 Teeth - Per QuadrantApically Positioned Flap

Connective Tissue/Pedicle Graft, Per Tooth

Periodontal Maintenance

(2) Includes relines, adjustments, rebases within the 1st six months. Adjustments to dentures that are done within six months of placement of the denture, are limited to no more than four adjustments.

Maxillary Partial Denture - Flexible Base (including any clasps, rests and teeth)

Surgical Revision Procedure, Per Tooth

Rebase Complete Maxillary Denture

Interim Partial Denture (Maxillary) (3)Add Clasp to Existing Partial DentureAdd Tooth to Existing Partial Denture

Interim Partial Denture (Mandibular) (3)

Adjust Partial Denture - Maxillary

Repair Cast FrameworkReline Maxillary Partial Denture (Chairside)

Adjust Complete Denture - Mandibular

Replace All Teeth and Acrylic on Cast Metal Framework (Maxillary)

Repair or Replace Broken Clasp

Repair Broken Complete Denture Base

Osseous Surgery (Including Flap Entry and Closure) - 4 or More Teeth - Per Quadrant

Periodontal Scaling and Root Planing - 1-3 Teeth - Per Quadrant

PROSTHODONTICS-REMOVABLE (2)Complete Denture - Maxillary

Mandibular Partial Denture - Flexible Base (including any clasps, rests and teeth)

Complete Denture - Mandibular

Clinical Crown Lengthening, Hard Tissue

Debridement

Reline Complete Maxillary Denture (Lab)

Immediate Denture - Mandibular

Reline Complete Maxillary Denture (Chairside)

Reline Mandibular Partial Denture (Chairside)

Replace Missing or Broken Teeth - Complete Denture (each tooth)

Maxillary Partial Denture - Resin Base (including any conventional clasps, rests and teeth)

Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)

REPAIRS TO PROSTHETICS

Gingival Flap Procedure, Including Root Planing - 4 or More Teeth - Per Quadrant

Reline Complete Mandibular Denture (Lab)Replace Broken Teeth - Per Tooth

Repair Resin Denture Base

Mandibular Partial Denture - Resin Base (including any conventional clasps, rests and teeth)

Osseous Surgery (Including Flap Entry and Closure) - 1-3 Teeth - Per Quadrant

Removable Unilateral Partial Denture - One Piece Cast Metal (including clasps and teeth)

Reline Complete Mandibular Denture (Chairside)


Replace All Teeth and Acrylic on Cast Metal Framework (Mandibular)

Free soft tissue graft - each additional tooth

Immediate Denture - Maxillary

Adjust Partial Denture - Mandibular

Adjust Complete Denture - Maxillary

Reline Maxillary Partial Denture (Lab)Reline Mandibular Partial Denture (Lab)

Unscheduled Dressing Change (By Someone Other Than Treating Dentist)

Pedicle Soft Tissue Graft Procedure

Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)

Gingivectomy to allow access, per tooth

Free soft tissue graft - first tooth





Plan 51

D5711 $95 D5851 $35D5720 $95D5721 $95

D7111 $12 D7285 (1)$100

D7140 $30 D7286 (1)$100

D7210 (1) $60 D7287 (1) $50D7220 (1) $80 D7310 (1)

$55D7230 (1) $100 D7311 (1)

$28D7240 (1) $150 D7320 (1)

$75D7241 (1) $150 D7321 (1)

$38D7250 (1) $55 D7510 (1)

$50D7251 $75 D7511 (1)

$55D7280 (1)

$77D7960 (1)

$128D7282 (1)

$90 D7963 (1) $134D7283

$18

D9110 $10 D9310 No Charge

D9220 $165 D9940$90

D9221 $70 D9942$23

D9241 $165 D9951$25

D9242 $70 D9952$90

$30$150

$1,845

Not Covered$275

Removal of Impacted Tooth - Partially Bony

Orthodontic Screening Exam

Frenulectomy (Frenectomy, Frenotomy) Separate Procedure

Surgical Access of Unerupted Tooth

Consultation - Diagnostic Service Provided by Dentist or Physician Other Than Requesting Dentist or Physician

Incision and Drainage of Abcess - Intraoral Soft Tissue - Complicated

Alveoloplasty Not in Conjunction With Extractions - 1-3 Teeth or Tooth Spaces - Per Quadrant

Removal of Impacted Tooth - Completely Bony

Frenuloplasty

OTHER (ADJUNCTIVE) SERVICES

Removal of Impacted Tooth - Soft Tissue

ORTHODONTICS

Diagnostic RecordsComprehensive Orthodontic Treatment

Incision and Drainage of Abcess - Intraoral Soft Tissue

Adolescent (appliance must be placed prior to age 20)Adult

Orthodontic RetentionPLAN EXCLUSIONS AND LIMITATIONS*

1. Services or supplies that are covered in whole or in part:Some Services Not Covered Under the Plan Are:

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

Repair and/or Reline of Occlusal Guard

Occlusal Adjustment - limited

Surgical Removal of Erupted Tooth Cytological Sample Collection

Rebase Mandibular Partial Denture

Intravenous conscious sedation/analgesia – each additional 15 minutes

Deep sedation/general anesthesia – first 30 minutes

Occlusal Guard, by Report

Deep sedation/general anesthesia – each additional 15 minutes

Occlusal Adjustment - complete

Intravenous conscious sedation/analgesia – first 30 minutes

Alveoloplasty in Conjunction With Extractions - 1 to 3 Teeth or Tooth Spaces - Per Quadrant

Alveoloplasty in Conjunction With Extractions - 4 or More Teeth or Tooth Spaces - Per Quadrant

Rebase Maxillary Partial Denture

Extraction, Erupted Tooth or Exposed Root (Elevation and/or Forceps Removal)

Biopsy of Oral Tissue - Soft

Removal of Impacted Tooth - Completely Bony, With Unusual Surgical Complications

Alveoloplasty Not in Conjunction With Extractions - 4 or More Teeth or Tooth Spaces - Per Quadrant

(3) Eligible on Anterior Teeth only.

Tissue Conditioning, Mandibular

Palliative (Emergency) Treatment of Dental Pain - minor procedure

Placement of Device to Facilitate Eruption of Impacted Tooth


Extraction, Coronal Remnants - Deciduous Tooth Biopsy of Oral Tissue - Hard (Bone, Tooth)

Coronectomy - intentional partial tooth removal (Eff. 1/1/11)

Mobilization of Erupted or Malpositioned Tooth to Aid Eruption

Surgical Removal of Residual Tooth Roots

ORAL SURGERY

Rebase Complete Mandibular Denture





Plan 51

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.

Other Important Information

2. Services and supplies to diagnose or treat a disease or injury that is not:(a) a non-occupational disease; or

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

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

(b) a non-occupational injury.

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. Does not apply to CA contracts.

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.

8. Those for any of the following services (Does not apply to TX contracts):(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.

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

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

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

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.

Specialty Referrals

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

Any exclusion above will not apply to the extent that coverage of the charge is required under any law that applies to the coverage.

(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.

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

Due to state law, limited (varying by state) DMO® benefits for non-emergency services rendered by non-participating providers are available for plan contracts written in: CT, IL, KY and OH and for members residing in MA and OK (regardless of contract situs state).

This Benefit summary of the Aetna Dental Maintenance Organization (DMO®) provides information on benefits provided when services are rendered by a participating dentist. In order for a covered person to be eligible for benefits, dental services must be provided by a primary care dentist selected from the network of participating DMO dentists. Out of network benefits may apply. Please refer to your Schedule of Benefits.

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

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.

21. Services done where there is no evidence of pathology, dysfunction or disease other than covered preventive services. Does not apply to CA contracts.

*This is a partial list of exclusions and limitations, others may apply. Please check your plan booklet for details.





Plan 51

2. DMO members may visit an orthodontist without first obtaining a referral from their primary care dentist. In an effort to easethe administrative burden on both participating Aetna dentists and members, Dental has opened direct access forDMO members to orthodontic services.

If you need emergency dental care for the palliative treatment (pain relieving, stabilizing) of a dental emergency, you are covered 24 hours a day, 7 days a week. You should contact your Primary Care Dentist to receive treatment. If you are unable to contact your PCD, contact Member Services for assistance in locating a dentist. Refer to your plan documents for details. Subject to state requirements. Out-of-area emergency dental care may be reviewed by our dental consultants to verify appropriateness of treatment.

Your Dental Care Plan Coverage Is Subject to the Following Rules:

Tooth Missing But Not Replaced Rule (Does not apply to TX and CA contracts.)Coverage for the first installation of removable dentures; fixed bridgework and other prosthetic services is subject to the requirements that such removable dentures; fixed bridgework and other prosthetic services are (i) needed to replace one or more natural teeth that were removed while this policy was in force for the covered person; and (ii) are not abutments to a partial denture; removable bridge; or fixed bridge installed during the prior 5 years.

Alternate Treatment Rule: If more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that all of the following terms are met: (a) the service must be listed on the Dental Care Schedule; (b) the service selected must be deemed by the dental profession to be an appropriate method of treatment; and (c) the service selected must meet broadly accepted national standards of dental practice.If treatment is being given by a participating dental provider and the covered person asks for a more costly covered service than that for which coverage is approved, the specific copayment for such service will consist of: (a) the copayment for the approved less costly service; plus (b) the difference in cost between the approved less costly service and the more costly covered service.

Finding Participating Providers

Replacement RuleThe replacement of; addition to; or modification of:existing dentures;crowns;casts or processed restorations;removable denture; fixed bridgework; orother prosthetic servicesis covered only if one of the following terms is met:

The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or bridgework was installed. This coverage must have been in force for the covered person when the extraction took place.

The existing denture, crown; cast or processed restoration, removable denture, bridgework, or other prosthetic service cannot be made serviceable, and was installed at least 5 years before its replacement.

The existing denture is an immediate temporary one to replace one or more natural teeth extracted while the person is covered, and cannot be made permanent, and replacement by a permanent denture is required. The replacement must take place within 12 months from the date of initial installation of the immediate temporary denture.

The extraction of a third molar does not qualify. Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth.

Emergency Dental Care

1. Under the DMO dental plan, services performed by specialists are eligible for coverage only when prescribed by the primary care dentist and authorized by Aetna Dental. If Aetna's payment to the specialty dentist is based on a negotiated fee, then the member's copayment for the service will be based on the same negotiated fee. If Aetna's payment is on another basis, then the copayment will be based on the dentist's usual feefor the service, reviewed by Aetna for reasonableness.





Plan 51

Dental plans are provided or administered by Aetna Life Insurance Company, Aetna Dental Inc., Aetna Dental of California Inc. and/or Aetna Health Inc.In Arizona, DMO Dental Plans are provided or administered by Aetna Health Inc.

This material is for informational purposes only and is neither an offer of coverage nor dental advice. It contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide dental services and, therefore, cannot guarantee any results or outcomes. The availability of a plan or program may vary by geographic service area. Certain dental plans are available only for groups of a certain size in accordance with underwriting guidelines. Some benefits are subject to limitations or exclusions. Consult the plan documents (Schedule of Benefits, Certificate/Evidence of Coverage, Booklet, Booklet-Certificate, Group Agreement, Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to your plan.

Consult Aetna Dental’s online provider directory, DocFind®, for the most current provider listings. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna Dental or its affiliates. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Not every provider listed in the directory will be accepting new patients. Although Aetna Dental has identified providers who were not accepting patients in our DMO plan as known to Aetna Dental at the time the provider directory was created, the status of a provider’s practice may have changed. For the most current information, please contact the selected provider or Aetna Member Services at the toll-free number on your online ID card, or use our Internet-based provider directory (DocFind) available at www.aetna.com.

Specific products may not be available on both a self-funded and insured basis. The information in this document is subject to change without notice. In case of a conflict between your plan documents and this information, the plan documents will govern. In the event of a problem with coverage, members should contact Member Services at the toll-free number on their online ID cards for information on how to utilize the grievance procedure when appropriate. All member care and related decisions are the sole responsibility of participating providers. Aetna Dental does not provide health care services and, therefore, cannot guarantee any results or outcomes.

Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutions

Enjoy the extras — at no extra cost

00.02.335.1 G (8/14)

Aetna Dental® Programs and Discounts

www.aetna.com

Aetna Dental plans come with some really nice features — at no added cost

When you enroll in any of our dental benefits and insurance plans, you get:

• Extra dental benefits if you have specific health conditions

• Online tools for keeping smiles healthier — and managing dental benefits

• Access to savings on daily dental-care products, vision and hearing care, fitness, weight loss and more

1 Oral Health and Your Body: The Mouth-Body Connection. Available at: www.simplestepsdental.com/SS/ihtSS/r.WSIHW000/st.31848/t.32629/pr.3.html. Accessed February 15, 2014.

2 An examination of periodontal treatment and per member per month medical costs in an insured population. BMC Health Services Research. August 16, 2006; 6: 103. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1574303. Accessed February 17, 2014.

3 Guideline on Xylitol Use in Caries Prevention. American Academy of Pediatric Dentistry, Council on Clinical Affairs. 2011; 35 (No. 6). Available at: www.aapd.org/media/policies_guidelines/g_xylitoluse.pdf. Accessed March 18, 2014.

The Aetna Dental DMO benefits and insurance plan is offered, underwritten and/or administered by Aetna Dental Inc., Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna), and in Texas, by Aetna Dental Inc. In Florida, by Aetna Life Insurance Company. Each insurer has sole responsibility for its own products.

Extra dental benefits

Researchers are finding that a healthy mouth may be important to your overall health. That’s especially true if you have a condition like heart disease or diabetes.1 So we have a special program to help. It includes extra dental benefits for members who have a health condition that qualifies under the program. If that’s you, we’ll ask you to participate.

Tips for a brighter, healthier smile

Check out our dental articles and interactive tools. You’ll find topics ranging from fillings and flossing to dentures … and more. Plus, get expert opinions from the Columbia University College of Dental Medicine. And the latest dental news, too. Visit www.simplestepsdental.com.

Dentist extras for healthier outcomes

Columbia faculty helps us put together online dental courses for dentists in the Aetna network. The courses help the dentists keep up with the latest dental care standards. Topics range from helping patients quit smoking to treating gum disease. The focus is on healthier outcomes for members.

Discounts on products for daily dental care

Our research with Columbia shows how oral care helps lower medical costs for our members with specific health conditions.2 That’s why we offer special costs on some dental products for daily use. They’re available through the secure member website at www.aetna.com.

Save on Epic Dental cavity-fighting productsSave on products that contain xylitol. It’s a natural sweetener shown to stop tooth decay.3 There are discounts on gum, toothpaste, mouthwash and more. Fight cavities and keep smiling.

Save on Waterpik® productsWho doesn’t love a clean, healthy mouth? With Aetna Dental, you also save on Waterpik oral health care products.

Make the most of dental add-ons

* Participation is for new gym members only. If you belong to a gym now or belonged recently, call GlobalFit to see if a discount applies.

** The ChooseHealthy program is made available through American Specialty Health Administrators, Inc. (ASH Administrators), a subsidiary of American Specialty Health Incorporated (ASH). ChooseHealthy is a federally registered trademark of ASH and used with permission herein.

*** Certain brands impose a no-discount policy.

Aetna members also can get deals on products and services for healthy living. To use these discounts, sign up for your member website at www.aetna.com.

At home products

Save on Omron blood pressure monitors and more.

Books

Save on books, DVDs and more through the American Cancer Society Bookstore and the Mayo Clinic Bookstore. You can also get discounts on yoga DVDs and books from Pranamaya.

Fitness

Look and feel better for less. Save on gym memberships* and name-brand home fitness and nutrition products that support a healthy lifestyle, with services provided by GlobalFit®.

Hearing

Pay less for hearing aids, hearing aid batteries mailed to your home, exams and more. Choose from leading manufacturers. You also get free follow-up service for one year.

Natural products and services

Get a discount off the normal fee for acupuncture, chiropractic, massage therapy and nutrition services through the ChooseHealthy® program.** And get a discount on a variety of health and wellness products.

Through Vital Health Network, there are savings on online consultations and alternative remedies provided by naturopathic or integrated medicine doctors for a variety of conditions. No claims forms needed.

Vision

Taking care of your eyes cost you less with Aetna’s vision discounts. You can choose from popular designer frames*** and get discounts on vision items that don’t need a prescription.

Just visit national chains like Pearle Vision®, LensCrafters®, JCPenney Optical, Target Optical® and participating Sears Optical® locations. Or go to any of the thousands of eye doctors in private practices. To find a vision provider near you, search our online directory at www.aetna.com.

Weight management

Save on some of today’s most popular weight-loss programs and meal plans from CalorieKing®, Jenny Craig® and Nutrisystem®. Enjoy one-on-one help, personalized menus, online tools, chat rooms and more.

What to know about the discounts

Discounts are a great way to save money. But they’re not insurance. Instead, with a discount, you get access to a vendor who has agreed to give Aetna Dental plan members discounted prices on products and services. You pay the full discounted price directly to the vendor.

Because discounts aren’t insurance, you don’t have to worry about claims or referrals. And there are no limits on how often you can use them. Discount offers are not guaranteed and may be stopped at any time. Discounts are in addition to any plan benefits. These discounts may change without notice.

Enjoy discounts for healthy living

The Aetna Mobile app puts our most popular online features at your fingertips. It’s available for iPhone® and Android™ mobile devices.

Visit www.aetna.com/mobile.

Get extra help online

Find a network dentistDentists in the Aetna network offer special rates for covered services. So your share of the cost is usually lower. To check for network dentists, use our online directory. Visit www.aetna.com.

Make the most of your dental planWhen you’re an Aetna member, you get tools and resources to help manage your dental health and your benefits. All of your plan information and cost-saving tools are in one place — your secure member website. It lets you:

• See details about your plan

• Review your claims

• Compare costs for dentists and specialists … and more

Sign up today at www.aetna.com.

Find what you need — on the go

Call us for answers

Member Services representatives are standing by to answer your questions. Just call 1-877-238-6200.

Support from our dental teamWhen you call, you get help from claims and customer service representatives who specialize in dental matters. They’ve been with us an average of 11 years. And they’ve exceeded customer service goals every month for more than 132 months.4

… and from our oral surgery specialistsThis group answers your questions about oral surgery. Plus, they help with claims that may be covered under your medical plan.

Speak another language?Customer service reps are ready. They have access to interpreters who can talk to you in over 200 languages.

Something new this year: Say good-bye to ID cards You no longer need a member ID card to get dental care. So visiting the dentist is easier than ever. But if you want a card, no problem. Once you’re a member, you can get one by logging in to the member website at www.aetna.com, using our mobile app or calling Member Services.

4Aetna Dental Customer Service Objectives. Reported from January 2003 to present.

We’re here when you need us

Apple, the Apple logo and iPhone are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. Android and Google Play are trademarks of Google Inc. Other trademarks and logos displayed are the property of their respective owners.This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Aetna may receive a percentage of the fee you pay to a discount vendor. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Health and dental information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Aetna does not provide care or guarantee access to health and dental care services. Aetna does not endorse any vendor, product or service associated with discount offers. 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 Oklahoma include: GR-9/GR-9N, GR-23, GR-29/GR-29N and/or GR-96402- 02 04-09.

www.aetna.com

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Enroll in any Aetna Dental benefits and insurance plan. And enjoy all the extras.

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