Annual Deductible*

Individual $75

Family $225

Preventive Services 100%

Basic Services 80%

Major Services 50%

Annual Benefit Maximum $1,000

Office Visit Copay N/A

Oral examinations (a)

100%

Cleanings (a) Adult/Child

100%

Fluoride (a)

100%

Sealants (permanent molars only) (a)

100%

Bitewing Images (a)

100%

Full mouth series Images (a)

100%

Basic

Root canal therapy

Anterior teeth / Bicuspid teeth

80%

Incision and drainage of abscess*

80%

Uncomplicated extractions

80%

Surgical removal of erupted tooth*

80%

Surgical removal of impacted tooth (soft tissue)*

80%

Denture repairs

80%

Major

Inlays

50%

Onlays

50%

Crowns

50%

Full & partial dentures

50%

Full Mouth Debridement (D4355)/ 1 per lifetime

50%

With PPOII Network

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

Farmers Agent Group Benefits -Out-of-Area benefit plan

*The deductible applies to: Basic,Major & Orthodontic services only

Farmers Agent Group Benefits -Out-of-Area benefit plan

2. Services and supplies to diagnose or treat a disease or injury that is not:

(a) a non-occupational disease; or

This Aetna Dental® Preferred Provider Organization (PPO) benefits summary is provided by Aetna Life Insurance Company for

some of the more frequently performed dental procedures. Under the Dental Preferred Provider Organization (PPO) plan, you

(b) a crown, bridge, or cast or processed restoration if a tooth was prepared for it before the person became a covered

(c) root canal therapy if the pulp chamber for it was opened before the person became a covered person.

(b) a non-occupational injury.

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

(a) an appliance or modification of one if an impression for it was made before the person became a covered person;

6. Those for or in connection with services, procedures, drugs or other supplies that are determined by Aetna to be experimental

7. Those for dentures, crowns, inlays, onlays, bridgework, or other appliances or services used for the purpose of splinting, to alter

1. Services or supplies that are covered in whole or in part:

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

Partial List of Exclusions and Limitations* - Coverage is not provided for the following:

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

13. Those for general anesthesia and intravenous sedation, unless specifically covered. For plans that cover these services, they

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

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

Farmers Agent Group Benefits -Out-of-Area benefit plan

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

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

Replacement Rule

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

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.

The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or

Farmers Agent Group Benefits -Out-of-Area benefit plan

Farmers Agent Group Benefits -Out-of-Area benefit plan