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.