As individual as you are

We’ve got you and your family covered with the choice of two great dental insurance plans.

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Are you looking for dental insurance for you and your family? Check out our dental plans for individuals. If you need coverage for preventive care, basic and major dental services, we offer two options.

See dentists both in and out of our network

With our dental insurance plans for individuals, you can get services from either a participating or nonparticipating dentist. Participating dentists have agreed to provide services at a negotiated rate for covered services.

You also have the flexibility to visit a licensed dentist who does not participate in our network. However, if you do this, you won’t benefit from negotiated rates.

To find a participating dentist, visit our online provider directory at aetna.com. Or you can call us at 1-877-238-6200.

Here is a sample of covered services

Aetna Dental® Direct Preferred PPO

In Network You Pay

Out of Network You Pay

Aetna Dental® Direct Core PPO

In Network You Pay Out of Network

You Pay

Preventive services – Waiting period*: None

Preventive oral examinations No Cost 20% No Cost 20%

Cleanings No Cost 20% No Cost 20%

Full mouth series images No Cost 20% No Cost 20%

Sealants (permanent molars only) No Cost 20% No Cost 20%

Basic services – Waiting period*: 6 months

Resin filling (1 surface) 20% 40% 50% 50%

Periodontal maintenance cleanings 20% 40% 50% 50%

Extraction (uncomplicated) 20% 40% 50% 50%

Major services – Waiting period*: 12 months

Oral Surgery 50% 60% 50% 70%

Crowns 50% 60% 50% 70%

Root canal therapy 50% 60% 50% 70%

Dentures 50% 60% 50% 70%

Orthodontics not covered not covered

Deductible (calendar year)** $50 (Individual); $150 (Family) $50 (Individual); $150 (Family)

Annual maximum benefit** $1,250 $1,000 $1,000 $750

*In Pennsylvania, the “waiting period” is called an “elimination period.”** Deductible and Annual Maximum cross-apply between In-Network and Out-of-Network. Deductible applies to Basic &

Major services only.Dental insurance plans are underwritten by Aetna Life Insurance Company.

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Here are some examples of covered dental services

• Preventive care — cleanings, X-rays and more

• Basic care — fillings, simple extractions,basic restorative work and more

• Major services — bridges, crowns, dentures,root canals and more

Some covered services have limitations based on your age or how often they’re used. Coverage for Basic services is subject to a waiting period* and will take effect after 6 months of continuous coverage under the PPO Plan. Coverage for Major services is subject to a waiting period* and will take effect after 12 months ofcontinuous coverage under the PPO Plan. See the insurance policy for details on covered services and benefits levels.

Thinking about your yearly coverage limit? Dentists in our network have agreed to provide covered services at negotiated rates. So smile — see a network dentist.

Save on what matters most to you

You can get discounts on products and services that fit your life and help you manage your budget. Save on everything from gym memberships, acupuncture and weight-loss programs to eyeglasses.

These discounts are not insurance.

Feel good about your dental care decisions — our online services can help

You’ll get the tools you need to manage your dental care and get the dental health information you need 24 hours a day, 7 days a week.

Manage your dental benefits online — it’s a snap Find a dentist. Track a claim. View or print your ID card and more. It’s easy with your member website.

You can sign up on aetna.com by clicking on the log-in button on the homepage. You can register from there and then:

• Find a network dentist through our online directory.Search for a dentist by name, specialty, ZIP codeand miles. You can do it by city and state or countyand state, too. You’ll even find maps and directionsto your dentist’s office.

• Get estimated average costs for cleanings, fillings,X-rays, crowns, dentures and more. It’s a great toolto help you manage your dental expenses.

• See who’s covered by your plan.

• Check claims and statements.

• View or print ID cards.

No computer — no problem

Contact us by phone After you enroll, you can call our customer service representatives toll-free for answers to your questions. just call 1-877-238-6200 for benefits and claim questions and 1-855-837-6453 for eligibility and billing questions.

Need emergency dental care? You’re covered 24 hours a day, 7 days a week.

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Other Important Information

This benefits summary describes the more frequently performed dental procedures. Under the Aetna Dental Direct Preferred Provider Organization (PPO) plan, you may choose at the time of service either a PPO participating dentist or any nonparticipating dentist. With the PPO plan, savings are possible because the participating dentists have agreed to provide care for covered services at negotiated rates. Non-participating benefits are subject to recognized charge limits.

Emergency Dental Care

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.

When emergency services are provided by a participating PDN dentist, your co-payment/coinsurance amount will be based on a negotiated fee schedule. When emergency services are provided by a non-participating dentist, you will be responsible for the difference between the plan payment and the dentist’s usual charge. Refer to your plan documents for details. Subject to state requirements. Emergency dental care may be reviewed by our dental consultants to verify appropriateness of treatment.

Exclusions

This is only a summary of the plan’s exclusions and limitations. See the insurance policy for details.

Charges for services or supplies • Provided by an out-of-network provider in excess

of the recognized charge.

• Provided for your personal comfort or convenience,or the convenience of any other person, including adental provider.

• Rendered before the effective date or after thetermination of coverage, unless coverage is continuedunder the Special coverage options after your plancoverage ends section of your policy.

• Cancelled or missed appointment charges or chargesto complete claim forms.

• For which you have no legal obligation to pay.

• In excess of the benefit, dollar, day, visit, or supplylimits stated in your schedule of benefits.

• That would not be made if you did not have coverage.

• That are cosmetic in nature. Teeth whiteningand facings on molar crowns and pontics willalways be considered cosmetic.

• That are experimental or investigational.

• That are not medically necessary.

• For prescribed drugs, pre-treatments or analgesia.

• That are provided by a family member.

• For work-related conditions.

• For work that began before you werecovered under the plan

The following dental services and supplies • Acupuncture, acupressure and acupuncture therapy

• Crown, inlays and onlays, and veneers unless for oneof the following:

- It is treatment for decay or traumatic injury andteeth cannot be restored with a filling material

- The tooth is an abutment to a covered partialdenture or fixed bridge.

• Dental implants, false teeth, prosthetic restorationof dental implants, plates, dentures, braces, mouthguards, and other devices to protect, replace orreposition teeth and removal of implants

• Dental services and supplies made with high noblemetals (gold or titanium) except as covered in the EligibleDental Services section of your insurance policy

• Dentures, crowns, inlays, onlays, bridges, or otherappliances or services used for the purpose of splinting,to alter vertical dimension, to restore occlusion, orcorrecting attrition, abrasion, or erosion

• First installation of a denture or fixed bridge, and anyinlay and crown that serves as an abutment to replacecongenitally missing teeth or to replace teeth all ofwhich were lost while the person was not covered

• General anesthesia and intravenous sedation, unlessspecifically covered and only when done in connectionwith another eligible dental service

• Instruction for diet, plaque control and oral hygiene

• Orthodontic treatment except as covered in the EligibleDental Services section of your insurance policy

• Replacement of a device or appliance that is lost,missing or stolen, and for the replacement ofappliances that have been damaged due to abuse,misuse or neglect and for an extra set of dentures

• Replacement of teeth beyond the normal complementof 32

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Exclusions (continued)

• Services and supplies provided where there is noevidence of pathology, dysfunction or disease, otherthan covered preventive services

• Surgical removal of impacted wisdom teeth when onlyfor orthodontic reasons

• Temporomandibular joint dysfunction/disorder.

Aetna Dental Direct PPO Plans are Subject to the Following Rules:

Replacement Rule The replacement of; addition to; or modification of: existing dentures; crowns; casts or processed restorations; removable denture; fixed bridgework; or other prosthetic services is covered only if specific criteria are met.

Tooth Missing But Not Replaced Rule 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:

• needed to replace one or more natural teeth that wereremoved while this policy was in force for the coveredperson; and

• are not abutments to a partial denture; removablebridge; or fixed bridge installed during the prior 8 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.

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:

• the copayment for the approved less costlyservice; plus

• the difference in cost between the approved lesscostly service and the more costly covered service.

Finding Participating Providers

Consult Aetna Dental’s online provider directory, at aetna.com, 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. 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 available at aetna.com.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).

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For more information, visit aetna.com.

In case of a conflict between your insurance policy and this information, the insurance policy 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 providers. Aetna Dental does not provide health care services and, therefore, cannot guarantee any results or outcomes. This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Plan features and availability may vary by location and are subject to change. Discount offers provide access to discounted services and are not part of the insurance policy. The member is responsible for the full cost of the discounted services. While this material is believed to be accurate as of this production date, it is subject to change. For more information about Aetna plans, refer to aetna.com.

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TTY:711

English To access language services at no cost to you, call the number on your ID card.

Albanian Për shërbime përkthimi falas për ju, telefononi në numrin që gjendet në kartën tuaj të identitetit.

Amharic የ ቋን ቋ አ ገ ልግሎቶችን ያ ለክፍያ ለማግኘት፣ በመታወቂያዎት ላይ ያ ለውን ቁጥር ይደውሉ፡ ፡

Arabic .للحصول على الخدمات اللغوية دون أي تكلفة، الرجاء االتصال على الرقم الموجود على بطاقة اشتراكك

Armenian

Ձեր նախընտրած լեզվով ավվճար խորհրդատվություն ստանալու համար

զանգահարեք ձեր բժշկական ապահովագրության քարտի վրա նշված

հէրախոսահամարով

Bantu-Kirundi Kugira uronke serivisi z'indimi ata kiguzi, hamagara inomero iri ku karangamuntu kawe

Bengali আপনাকে বিনামূকযে ভাষা পবিকষিা পপকে হকয আপনাি পবিচয়পকে পেওয়া নম্বকি পেবযক ান েরুন।

Burmese သင့္အေနျဖင့္ အခေၾကးေငြ မေပးရပဲ ဘာသာစကား၀န္ေဆာင္မႈမ်ား ရရိွႏိုင္ရန္၊ သင့္ ID ကတ္ေပၚတြင္ရိွေသာ ဖုန္းနံပတ္အား ေခၚဆိုပါ။

Catalan Per accedir a serveis lingüístics sense cap cost per a vostè, telefoni al número indicat a la seva targeta d’identificació.

Cebuano Aron maakses ang mga serbisyo sa lengguwahe nga wala kay bayran, tawagi ang numero nga anaa sa imong kard sa ID.

Chamorro Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu kard aidentifikasion.

Cherokee ᏩᎩᏍᏗ ᎦᏬᏂᎯᏍᏗ ᎢᏅᎾᏓᏛᏁᏗ Ꮭ ᎪᎱᏍᏗ ᏗᏣᎬᏩᎳᏁᏗ ᏱᎩ, ᏫᎨᎯᏏᎳᏛᏏ ᎾᏍᎩ ᏗᏎᏍᏗ

ᏥᏕᎪᏪᎵ ᎤᎾᎢ ID ᏆᏂᏲᏍᏗ ᏣᏤᎵᎢ.

Chinese Traditional 如欲使用免費語言服務，請撥打您健康保險卡上所列的電話號碼

Choctaw Anumpa tosholi i toksvli ya peh pilla ho ish i payahinla kvt chi holisso kallo iskitini holhtena takanli ma i payah

Chuukese Ren omw kopwe angei aninisin eman chon awewei (ese kamé), kopwe kééri ewe nampa mei mak won noum ena katen ID

Cushitic-Oromo Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa fuula waraaqaa eenyummaa (ID) kee irraa jiruun bilbili.

Dutch Voor gratis taaldiensten, bel het nummer op uw ziekteverzekeringskaart.

French Pour accéder gratuitement aux services linguistiques, veuillez composer le numéro indiqué sur votre carte d'assurance santé.

French Creole

(Haitian)

Pou ou jwenn sèvis gratis nan lang ou, rele nimewo telefòn ki sou kat idantifikasyon asirans sante ou.

German Um auf den für Sie kostenlosen Sprachservice auf Deutsch zuzugreifen, rufen Sie die Nummer auf Ihrer ID-Karte an.

Greek Για πρόσβαση στις υπηρεσίες γλώσσας χωρίς χρέωση, καλέστε τον αριθμό στην κάρτα ασφάλισής σας.

Gujarati તમારે કોઇ પણ જાતના ખર્ચ વિના ભાષા સેિાઓ મેળિિા માટે, તમારા આઇડી કાડચ પરરહલે નબંર પર કૉલ કરિો.

Hawaiian No ka walaʻau ʻana me ka lawelawe ʻōlelo e kahea aku i ka helu kelepona ma kāu kāleka ID. Kāki ʻole ʻia kēia kōkua nei.

Hindi बिना किसी िीमत िे भाषा सेवाओ ंिा उपयोग िरने िे लिए, अपन ेआईडी िाडड पर दिए नंिरपर िॉि िरें।

Hmong Yuav kom tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj daim npav ID.

Igbo Inweta enyemaka asụsụ na akwughi ụgwọ obụla, kpọọ nọmba nọ na kaadi njirimara gị

Ilocano Tapno maakses dagiti serbisio ti pagsasao nga awanan ti bayadna, awagan ti numero nga adda ayan ti ID kardmo.

Indonesian Untuk mengakses layanan bahasa tanpa dikenakan biaya, silakan hubungi nomor telepon di kartu asuransi Anda.

Italian Per accedere ai servizi linguistici senza alcun costo per lei, chiami il numero sulla tessera identificativa.

Japanese 無料の言語サービスは、IDカードにある番号にお電話ください。

Karen vXw>urRM>usdmw>rRpXRtw>zH;w>rRwz.

vXwtd.'D;tyShRvXeub.[h.tDRt*D>vXttd.vXecd.*DR A (ID) tvdRM.wuh>I

Korean 무료 다국어 서비스를 이용하려면 보험 ID 카드에 수록된 번호로 전화해

주십시오.

Kru-Bassa I nyuu kosna mahola ni language services ngui nsaa wogui wo, sebel i nsinga i ye ntilga i kat yong matibla

Kurdish ( IDخزمەتگوزاری زمان بەبێ تێچوون بۆ تۆ، پەيوەندی بکە بە ژمارەی سەر ئای دی)بۆ دەسپێڕاگەيشتن بە

کارتی خۆت.

Lao ເພ ື່ ອເຂ ົ້ າເຖິງບໍ ລິ ການພາສາທ ື່ ບໍື່ ເສຍຄື່ າ, ໃຫົ້ ໂທຫາເບ ໂທຢ ື່ ໃນບັດປະຈໍ າຕ ວຂອງທື່ ານ.

Marathi आपल्यािा िोणत्याही शुल्िालशवाय भाषा सेवांपयतं पोहोचण्यासाठी, आपल्या ID िाडाडवरीिक्रमांिावर फोन िरा.

Marshallese Ņan bōk jipan̄ kōn kajin ilo an ejjeļọk wōņean n̄an kwe, kwōn kallok nōṃba eo ilo kaat in ID eo aṃ.

Micronesian-

Ponapean

Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw doaropwe en ID.

Mon-Khmer,

Cambodian ដ ើម្បីទទួលបានដេវាកម្មភាសាដ លឥតគិតថ្លៃេម្រាប់ដោកអ្នក េូម្ដៅទូរេព្ទដៅកានដ់លខដ លានដៅដលើបណ្ណ េាា លខ់ល នួរបេ់ដោកអ្នក។

Navajo

T’11 ni nizaad k’ehj7 bee n7k1 a’doowo[ doo b33h 7l7n7g00 naaltsoos

bee atah n7l98go nanitin7g77 bee n44ho’d0lzin7g77 b44sh bee hane’7 bik1’7g77 1aj8’ h0lne’.

Nepali भाषासम्िन्धी सेवाहरूमाथि ननिःशुल्ि पहुुँच राख्न आफ्नो िाडडमा रहेिो नम्िरमा ििगनुडहोस।्

Nilotic-Dinka Të kɔɔr yïn ran de wɛɛ̈r̈ de thokic ke cïn wëu kɔr keek tënɔŋ yïn. Ke yïn cɔl ran ye kɔc kuɔny në namba de abac tɔ̈ në ID kard duɔ̈n de tïït de nyin de panakim kɔ̈u.

Norwegian For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt.

Pennsylvanian-

Dutch Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.

Persian Farsi .برای دسترسی بە خدمات زبان بە طور رايگان، با شماره قید شده روی کارت شناسايی خود تماس بگیريد

Polish Aby uzyskać dostęp do bezpłatnych usług językowych, należy zadzwonić pod numer podany na karcie identyfikacyjnej.

Portuguese Para aceder aos serviços linguísticos gratuitamente, ligue para o número indicado no seu cartão de identificação.

Punjabi ਤੁਹਾਡ ੇਲਈ ਬਿਨਾਂ ਬਿਸ ੇਿੀਮਤ ਵਾਲੀਆ ਂਪੰਜਾਿੀ ਸੇਵਾਵਾਂ ਦੀ ਵਰਤੋਂ ਿਰਨ ਲਈ, ਆਪਣੇ ਆਈਡੀ ਿਾਰਡ‘ਤ ੇਬਦਿੱ ਤ ੇਨੰਿਰ 'ਤ ੇਫ਼ੋਨ ਿਰ।ੋ

Romanian Pentru a accesa gratuit serviciile de limbă, apelați numărul de pe cardul de membru.

Russian Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону, приведенному на вашей идентификационной карте.

Samoan Mō le mauaina o 'au'aunaga tau gagana e aunoa ma se totogi, vala'au le numera i luga o lau pepa ID.

Serbo-Croatian Za besplatne prevodilačke usluge pozovite broj naveden na Vašoj identifikacionoj kartici.

Spanish Para acceder a los servicios lingüísticos sin costo alguno, llame al número que figura en su tarjeta de identificación.

Sudanic Fulfulde Heeɓa a naasta nder ekkitol jaangirde woldeji walla yoɓugo, ewnu lamba je ɗon windi ha do ɗerowol maaɗa.

Swahili Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya kitambulisho.

Syriac-Assyrian ܵܓܵܢܐܼܝܬ، ܪܵܬܐ ܒܸܠܵܫܵܢܐ ܼܡܲ ܼܝܲ ܐ ܕܼܗܲ ܬ ܹ̈

ܠ ܸܚܠܼܡܲ ܵܕܵܡܝܼܘܵܬܐ ܐܸܢ ܣܢܼܝܵܩܐ ̄ܝܬܘܼܢ ܼܥܲ ܠ ܸܦܬܵܩܐ ܼܗܲ ܩܪܼܝܡܘܲܢ ܸܡܢܵܝܵܢܐ ܼܥܲܘܼܟܘܲܢ. ܕܼܝܵ

Tagalog Upang ma-access ang mga serbisyo sa wika nang walang bayad, tawagan ang numero sa iyong ID card.

Telugu భాష సేవలను మీకు ఖర్చు లేకుుండా అుందుకునుందుకు, మీ ఐడి కార్చు పై ఉన్న న్ుంబర్చకు కాల్

చేయుండి.

Thai หากท่านตอ้งการเขา้ถงึการบรกิารทางดา้นภาษาโดยไมม่คีา่ใชจ้่าย โปรดโทรหมายเลขทีแ่สดงอยูบ่นบตัรประจ าตวัของท่าน

Tongan Kapau ‘oku ke fiema’u ta’etōtōngi ‘a e ngaahi sēvesi kotoa pē he ngaahi lea kotoa, telefoni ki he fika ‘oku hā atu ‘i ho’o ID kaati.

Turkish Dil hizmetlerine ücretsiz olarak erişmek için kimlik kartınızdaki numarayı arayın.

Ukrainian Щоб безкоштовнj отримати мовні послуги, задзвоніть за номером, вказаним на вашій ідентифікайній картці.

Urdu کارڈ پر درج نمبر پر کال IDلسانی خدمات تک ُمفت رسائی کے لیے، اپنے بیمہ کے

کریں۔

Vietnamese Để sử dụng các dịch vụ ngôn ngữ miễn phí, vui lòng gọi số điện thoại ghi trên thẻ ID của quý vị.

Yiddish אייער צו באקומען שפראך סערוויסעס פריי פון אפצאל, רופט דעם נומער אויףID .קארטל

Yoruba Láti ráyèsí àwọn iṣẹ́ èdè fún ọ lọ́fẹ̀ẹ́, pe nọ́mbà tó wà lórí káàdì ìdánimọ̀ rẹ.

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As individual as you are Are you looking for dental insurance for you and your family? Check out our dental plans for individuals See dentists both in and out of our networkHere are some examples of covered dental services Save on what matters most to you These discounts are not insurance Feel good about your dental care decisions — our online services can help No computer — no problem Need emergency dental care? Other Important Information Emergency Dental Care Exclusions Aetna Dental Direct PPO Plans are Subject to the Following Rules Finding Participating Providers Back Cover