DENTAL INSURANCE
Fast Track Urgent Care offers dental coverage through Aetna. The Dental PPO Plan allows you to use in-network or out-of-network benefits. If out-of-network dentists are used, you will be responsible for pay the difference between Aetna’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plan.
DPPO PLAN
In-Network
Calendar Year Deductible
Individual
$
Family
$
Annual Maximum (pre covered member)
Per covered member
$
Preventive Services
Exams, Cleanings, & Fluoride
Covered in full
Basic Services
Fillings, Simple Extractions, & Periodontal Maintenance
__% after deductible
Major Services
Crowns, Bridges, Perio, Endo, Surgical Extractions, Root Canal, & Dentures
__% after deductible
Orthodontia
Child only
Member% $x,xxx lifetime maximum per person
Out-of Network 1
Calendar Year Deductible
$ / $
Schedule of Services: Preventive Basic Major
__% after deductible __% after deductible __% after deductible
Member% $x,xxx lifetime maximum per person
Orthodontia
Annual Maximum (pre covered member)
$
90 th Usual & Customary Charges
Basis of Payment
Bi-Weekly Cost for Coverage
$
Employee Only
$
Employee + Spouse
$
Employee + Child(ren)
$
Employee + Family
4 1 Subject to balance billing. Please refer to your plan document for specific details.
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