How the DMO Option Pays Benefits

If you enroll in the DMO Option, you agree to receive care solely from dentists participating in the managed care network. Limited out-of-network coverage may be available based on state mandates or in the case of certain, out-of-area emergencies, as noted below. If you receive any out-of-network care, you must file a claim to receive benefits. Check your Aetna DMO coverage certificate or contact customer service at the number on your ID card for details.


Benefit Provision	Coverage
Annual Deductible
Preventive	None
Restorative	None
Orthodontia	None
Preventive	100% coverage
Oral exams	Maximum two per calendar year
Fluoride	Maximum two per calendar year, and only covered for participants who are under age 19
Prophylaxis (cleaning)	Maximum two per calendar year
Full mouth X-ray	One full mouth X-ray limited to one set every three rolling years
Bitewing X-ray	Maximum two per calendar year
Sealants	Maximum two treatments per tooth (permanent molars only) per lifetime and only covered for participants who are under age 19
Basic restorative (fillings, extractions, root canal, periodontal, oral surgery, anesthesia)	90% coverage
Major restorative (dentures, inlays, onlays, crowns, bridges)	60% coverage
Orthodontia	50% coverage
Maximum Benefits
Combined annual for preventive and restorative	No maximum
Lifetime for orthodontia	One course of treatment per individual per lifetime
Out of Area Emergency Palliative Dental Care Out-of-Area Emergency Dental Care consists of necessary covered dental services given to covered persons by a Non-Participating (out-of-network) dental provider for the palliative (pain relieving; stabilizing) treatment of an emergency condition (if there is severe pain, swelling or bleeding). The emergency care is rendered outside of the 50 mile radius of the covered person's home address. Coverage for Out-of-Area Emergency Dental Care is subject to specific limitations described in the DMO Option. The JPMC DMO Option covers 100% of billed charges for out of area emergency care; benefits are limited to a $100 maximum and subject to R&C.	100% coverage for reasonable and customary charges, up to a maximum benefit of $100 per incident. If you receive any out-of-network care, you must file a claim to receive benefits.