Plan Design

This section will help participants understand how the SAIC Dental PPO Plan pays benefits.

Network Benefits

If a participant goes to a network dentist, he or she saves money because dentists in the network have agreed to charge discounted fees. For most services, the participant must first meet the $50 annual deductible. Then, whenever the participant receives dental services, the SAIC Dental PPO Plan pays a percentage of the cost. The participant pays the remaining amount (the coinsurance).

There are no claim forms to file because the Aetna (www.aetna.com) network dentist submits claims for the participant.

Out-of-Network Benefits

When a participant uses a dentist who does not participate in the Aetna PPO network, that dentist is considered to be out of network.

For most services, each participant must first meet the $50 annual deductible. Then, whenever the participant receives dental services, the SAIC Dental PPO Plan pays a percentage of the cost of services, up to the reasonable and customary limit. The participant pays the remaining percentage (the coinsurance) plus any amount above the reasonable and customary limit.

Participants who go to out-of-network providers may be responsible for filing their own claims for reimbursement from the SAIC Dental PPO Plan. Check with your provider for information on their payment and claim filing policies.

Reasonable and Customary Limit

The reasonable and customary limit is the maximum amount the SAIC Dental PPO Plan will pay for a covered service, based on what dentists in the participant's geographic area charge for similar services. The determination of what the reasonable and customary limit is for a specific dental procedure is within the sole discretion of Aetna and is not subject to challenge or review.