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Aetna DMO
The DMO Dental Plan option works similarly to a medical HMO. Just as the HMO medical option requires you to select a PCP, the DMO dental option requires you to select a network participating Dentist as your Primary Care Dentist (PCD). In order for you to receive the benefits, all your services must be performed by your PCD. Under this option, you will pay a fixed copay per procedure, with diagnostic, preventive, and restorative service covered at 100%. In most circumstances, your out-of-pocket expenses are generally less expensive than the PPO option.
The charts below highlight the key benefits of the Aetna DMO plan. For a complete listing of service copays, please refer to Appendix B of the Dental Plan Summary Plan Description. The Dental Plan Summary Plan Description can be found on About You > Forms and Documents or on Your Benefits Resources™.
| Annual Deductible |
None
|
|
Annual Maximum Benefit
|
None |
| Preventative / Diagnostic Care — Cleanings,
routine x-rays, routine exams, and fluoride treatments |
Covered at 100% |
| Basic Restorative Care — Fillings,
general anesthesia, sealants, endodontics, periodontics, prosthetic
repairs, and space maintainers |
Covered
at 100% |
|
Major Restorative Care — Crown / bridges, onlays,
bridgework, inlays, and dentures
|
Please refer to the listing of scheduled
copays in Appendix B of the Dental Plan Summary Plan Description. |
|
Orthodontics
|
Please refer to the listing of scheduled copays in Appendix
B of the Dental Plan Summary Plan Description.
|
Frequencies
| Exams |
Two routine exams per calendar year. Exams do not need to
be six months apart.
|
|
Cleanings
|
Two routine cleanings per calendar
year. Cleanings do not need to be six months apart. |
| Bitewing X-Rays |
Two bitewing x-rays per calendar
year. Bitewing x-rays do not need to be six months apart. |
| Fluoride Treatments |
Dependent children up to age 18 are
covered for one application per calendar year. |
|
Complete X-Ray Series
|
One complete set of x-rays once every
three years. |
|
Periodontic Scaling and Root Planing or Subgingival Curettage
|
Four separate quadrants per calendar year.
|
| Sealants |
Dependent children up to age 15 are
covered for one sealants treatment for permanent molars every
three years. |
|
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