Dental

Note:

• In-network costs listed
• Rates are lowest with in-network providers
• In- and out-of-network deductibles and out-of-pocket maximum amounts accrue separately

• A Basic PPO (preferred provider organization)
• Covers in- and out-of-network care
• No coverage for major services
• No coverage for orthodontia

• A Basic PPO (preferred provider organization)
• Covers in- and out-of-network care
• Covers major services
• Covers orthodontia for children up to age 19

• A Basic PPO (preferred provider organization)
• Covers major services
• Orthodontia coverage for children and adults

Includes:

Oral exams and cleanings, Problem-focused oral exams, Fluoride applications, Bitewing X-rays, Full mouth/panelipse X-rays, Sealants, Space maintainers

100% covered
No deductible

100% covered
No deductible

100% covered
No deductible

BASIC SERVICES

Includes:

Fillings, Endodontic services, Full mouth debridement, Periodontal Cleanings, Periodontic services, Simple extractions, Complex Oral surgery

You pay 20% (coinsurance) after deductible

You pay 20% (coinsurance) after deductible

You pay 20% (coinsurance) after deductible

Includes:

Stainless steel crowns, Denture relines – rebases and adjustments, Crowns, Prosthodontics – removable and fixed, Implants, Occlusal guard (bruxism)

Not covered

You pay 40% (coinsurance) after deductible

You pay 20% (coinsurance) after deductible

ORTHODONTIC SERVICES¹

Not covered

• You pay 50% (coinsurance)
• No deductible
• Children up to age 19 only

• You pay 50% (coinsurance)
• No deductible
• Coverage for children and adults

ANNUAL DEDUCTIBLE

(Employee only | Family)

ANNUAL maximum coverage

Per person

ORTHODONTIA LIFETIME LIMIT

Excluded from annual out-of-pocket maximum