Dental
Let Us Cover Your Smile
Plan Highlights
Benefits | In Network | Out of Network |
---|---|---|
Diagnostic & Preventative (No waiting period) | 100% | 100% |
Exams & cleanings - Space maintainers | ||
Bitewing x-rays - Sealants | ||
Full Mouth x-ray - fluoride treatments | ||
Emergency | ||
Basic Services (No waiting period) | ||
Amalgam fillings - Basic extractions | 80% | 80% |
Oral Surgery - Denture repairs | ||
Endonotics - Bridge repair | ||
Nonsurgical period - Surgical extractions | ||
Anesthesia | ||
Major Services (12 month waiting period) | ||
Surgical period - In/Onlays, Crowns | 50% | 50% |
Dentures / Bridges | ||
Orthodontic Services (12 month waiting period) | ||
Dependant children under age 19 | 50% | 50% |
Deductible | ||
Per person/per family (calendar year) | $50/$150 | $50/$100 |
Applies to Basic and Major Services only | ||
Maximum | ||
Annual Maximum per person (calendar year) | $3,000 | $3,000 |
Lifetime Ortho Maximums per person | $3,000 | $3,000 |
Claim Payments | ||
Claim basis | PPO Fee Schedule | 90% of UCR |
*See company brochure for more details. Plan not available in all states.