Comparing the Dental Plans
The chart below provides an overview of covered dental services in the SAIC Dental PPO Plan and the DHMOs. For a complete list of DHMO benefits, a participant should refer to the plan's certificate of coverage.
Download the SAIC Dental Plans Table (32k)
| SAIC DENTAL PPO PLAN | AETNA DMO - Plan 58 | CIGNA DENTAL - Plan f1-r04 | DOMINION DENTAL PLAN - Plan 509sC | CIGNA INTERNATIONAL DENTAL | ||
|---|---|---|---|---|---|---|
| Group Number: | 698685-50 | 698685-51 | 10003465 | 4757 | 00666 | |
| Member Services Phone #: | 800-843-9126 | 877-238-6200 | 800-244-6224 | 888-518-5338 | 800-441-2668 or 302-797-3100 (collect) | |
| Plan Web Site Address: | Aetna (www.aetna.com) | Aetna (www.aetna.com) | CIGNA (www.cigna.com) | Dominion Dental (www.dominiondental.com) | CIGNA International Expatriates (www.cigna.com) | |
| Availability: | Nationwide | Nationwide except for Montana, North Dakota, South Dakota and Vermont. Service area based on dental plan's zip code eligibility criteria. | Nationwide except for Alaska, Hawaii, Maine, Montana, North Dakota, New Mexico, Nevada, South Dakota, and Wyoming. Service area based on dental plan's zip code eligibility criteria. | Available in Maryland, Virginia, W. Virginia, Pennsylvania, Delaware and Washington D.C. Service area based on dental plan's zip code eligibility criteria. | Available for participants on International Assignments of 6 months or more | |
| Choice of Dentist: | Any dentist. Using a PPO dentist results in higher benefit levels. | Select a dentist from a list of participating dentists in your area. | Select a dentist from a list of participating dentists in your area. | Select a dentist from a list of participating dentists in your area. | Any Dentist – Online directory available to search for Dentists in 450+ countries. | |
| COVERED SERVICES | NETWORK* | OUT-OF-NETWORK** | ||||
| Annual deductible | $50 per person | No deductible | No deductible | No deductible | $50 per person/$150 per family | |
| Annual maximum benefit | $1,500 per person | No maximum | No maximum | No maximum | $1,500 per person | |
| Preventive Services*** | Plan pays: | Plan pays 100% after: | ||||
| Periodic oral examination | 100% Not subject to deductible (2 per participant per calendar year) | 100% of R&C Not subject to deductible (2 per participant per calendar year) | $0 copay | $0 copay | $0 copay | $0 copay (2 per participant per calendar year) |
| Prophylaxis, scaling and periodontal cleanings | 100% (2 per participant per calendar year) | 100% of R&C (2 per participant per calendar year) | $0 copay (1 per participant every six months) | $0 copay (1 per participant every six months; routine cleaning with no active periodontal disease; age frequency) | $0 copay (1 per participant every six months) | $0 copay (2 per participant per calendar year) |
| X-rays — Complete series | 100% (1 per participant every 3 years) | 100% of R&C (1 per participant every 3 years) | $0 copay (1 per participant every 3 years) | $0 copay (1 per participant every 3 years) | $0 copay (1 per participant every 6 months) | $0 copay (1 per participant every 3 years) |
| X-rays — One set of bitewings | 100% (2 per participant per calendar year) | 100% of R&C (2 per participant per calendar year) | $0 copay (1 per year) | $0 copay (1 per participant every 3 years) | $0 copay (1 per participant every 6 months) | $0 copay (2 per participant per calendar year) |
| Topical application of sodium or stannous fluoride | 100% (ages 18 and younger; 1 per participant per calendar year) | 100% of R&C (ages 18 and younger; 1 per participant per calendar year) | $0 copay | $0 copay (To age 19) | $0 copay (1 per participant every 6 months) | $0 copay (To age 18, 1 per participant per calendar year) |
| Diagnostic Services | Plan pays: | Plan pays 100% after: | ||||
| Diagnostic X-rays | 90% | 80% of R&C | $0 copay | $0 copay | $0 copay | $0 copay |
| Single film | 90% | 80% of R&C | $0 copay | $0 copay | $0 copay | $0 copay |
| Fissure sealant, per tooth | 90% (ages 13 and younger; once every 3 calendar years) | 80% of R&C (ages 13 and younger; once every 3 calendar years) | $5 copay (under age 15) | $0 copay (ages 13 and younger) | $0 copay (under age 14) | $0 copay (ages 13 and younger, 1 per participant every 3 years) |
| Oral Surgery | ||||||
Simple extraction | 90% of negotiated fee | 80% of R&C | $0 copay (Extraction, erupted, exposed root) | $0 copay | $0 copay | Plan pays 80% |
Surgical extraction | 90% | 80% of R&C | $28 copay | $0 copay | $67 copay | Plan pays 80% |
Impactions | 90% | 80% of R&C | $46 soft tissue, $58 partially or $100 completely bony copay | $0 – $80 copay | $86 – $118 copay | Plan pays 80% |
General Anesthesia (only for surgical extractions) | 90% | 80% of R&C | General Anesthesia (deep sedation) or Conscious IV Sedation (first 30 min.): $165 copay, $70 copay for each additional 15 minutes | When medically necessary. $115 copay (first 30 minutes), $60 copay (each additional 15 minutes) | Not covered | Plan pays 80% |
| Fillings | ||||||
Amalgam restoration of Primary Teeth/Permanent Teeth | 90% | 80% of R&C | $0 copay | $0 copay | $0 copay | Plan pays 80% |
Composite restoration | 90% | 80% of R&C | $0-$50 copay depending on type. Contact Plan for specifics | $0-$75 copay | $0 copay | Plan pays 80% |
| Endodontics | ||||||
| Root canal therapy | 90% | 80% of R&C | Anterior: $70 copay. Bicuspid: $85 copay. Molar: $240 copay. | $0 – $245 copay (varies by tooth type) | $291 copay (molar) | Plan pays 80% |
| Pulpotomy | 90% | 80% of R&C | $14 copay | $0 copay | $0 copay | Plan pays 80% |
Apicoectomy and retro fill | 90% | 80% of R&C | Anterior: $85 copay. Bicuspid (1 root): $85 copay. Molar (1st root): $90 copay. Each additional root: $55 copay | $40 – $70 copay | $202 – $258 copay | Plan pays 80% |
| Periodontics | ||||||
Periodontal planing and root scaling | 90% | 80% of R&C | $55 copay | Not covered | $78 copay | Plan pays 80% |
Gingivectomy (per quadrant) | 90% | 80% of R&C | $100 copay (Limit 1 per quadrant every 3 years) | $125 copay | $151 copay | Plan pays 80% |
| Restorative Services | Plan pays: | Plan pays 100% after: | ||||
| Crowns & Bridges | ||||||
Crowns — per unit | 60% | 50% of R&C | $180-$220 copay depending on type. Contact Plan for specifics | $255 – $335 copay | $157 – $280 copay | Plan pays 50% |
Bridges — per unit | 60% | 50% of R&C | $210 copay per unit | $255 – $335 copay | $269 copay | Plan pays 50% |
Stainless steel crowns | 60% | 50% of R&C | $50 copay | $0 copay | $67 copay | Plan pays 50% |
| Recementation | ||||||
| Inlay | 60% | 50% of R&C | $10 copay | $0 copay | $22 copay | Plan pays 50% |
| Crown | 60% | 50% of R&C | $10 copay | $0 copay | $22 copay | Plan pays 50% |
| Bridge | 60% | 50% of R&C | $15 copay | $0 copay | $36 copay | Plan pays 50% |
| Prosthetics (Dentures) | ||||||
Complete upper or lower denture | 60% fee | 50% of R&C | $275 copay | $300 copay | $403 copay | Plan pays 50% (1 per participant every 5 years |
Partial upper or lower denture | 60% fee | 50% of R&C | $275 copay | $300 copay | $414 copay | Plan pays 50% |
| Denture and Partial Adjustment | 60% | 50% of R&C | $10 copay | $15 copay | $18 copay | Plan pays 50% |
| Denture Reline | 60% fee | 50% of R&C | $45 copay (chairside)$85 copay (laboratory) | $0 copay (chairside) | $84 - $134 copay | Plan pays 50% |
| Denture Duplication | 60% fee | 50% of R&C | Not covered | Not covered | Not covered | Not covered |
| Denture and Partial Repairs | 90% | 50% of R&C | $25 - $86 copay | $40 copay | $44 - $50 copay | Plan pays 80% |
| Adding Teeth or Clasps to Partial Denture – per unit | 90% | 50% of R&C | $35 - $40 copay | $40 copay | $50 - $62 copay | Plan pays 80% |
| Orthodontia | Plan pays: | Plan pays 100% after: | ||||
| Full banded case | 50% up to a separate $1,500 lifetime maximum per participant | 50% up to a separate $1,500 lifetime maximum per participant | $1,545 copay, plus $30 orthodontic screening exam, $150 diagnostic records, $275 retention fee. Other fees may apply per Aetna's Dental Care Schedule. **** | $1,600 (child) – $2,200 (adult) copay, plus $300 retention fee. $40 pre-orthodontic treatment visit. $150 orthodontic treatment plan & records. $275 (child) - $300 (adult) banding. Other fees may apply per CIGNA's patient charge schedule. **** | $2,800 – $3,100 copay; $350 for records and models; $350 for 1 year of retention | Not covered |
| Partial banded case | 50% up to a separate $1,500 lifetime maximum per participant | 50% up to a separate $1,500 lifetime maximum per participant | Not covered | Varies | Plan pays 75% of U&P fee | Not covered |
| Annual maximum benefit | $1,500 per person | No maximum | No maximum | No maximum | N/A | |
* Covered services received from a network provider will be paid based on the negotiated rate.
** Covered services received from an out-of-network provider will be paid based on the reasonable and customary (R&C) limit.
*** Preventive services are not subject to the annual deductible.
**** Participants are advised to refer to the Evidence of Coverage, contact the individual dental plan carrier and obtain a predetermination of benefits for services in excess of $150.
Dental Plan Exclusions:
Contact the individual dental plan carrier for specific exclusions pertaining to dental work already in progress.
Note for Aetna DMO Plan: All charges for crown and bridge are per unit. There will be an additional patient charge for the actual cost of gold/high noble metal for some procedures. Prosthetics/Dentures: Benefit includes relines, adjustments, rebases within 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.