|
Annual Deductible
(waived for preventive)
|
$25 person /
$75 family
|
None
|
$50 person /
$150 family
|
No deductible applies. Coinsurance may apply.
|
|
Annual Benefit Maximum
|
$1,500 per person
|
Unlimited
|
$1,000 per person
|
Unlimited
|
|
Lifetime Orthodontia Maximum
|
$1,500 per person
(child only)
|
$1,500 per person
(child only)
|
$1,000 per person
(child only)
|
Unlimited
|
|
Preventive
- Exams (limit 2 per year)*
- Cleaning (limit 2 per year)
- Fluoride (limit 1 per year) to age 18
- Sealants on permanent molar (limit 1 every 3 years to age 16)
- DMO has no age limitation
- Bitewing X-rays (limit 2 per year)
- X-rays full mouth (one set every 2 years)**
|
100%
|
|
Endodontics
- Pulp Capping
- Root Canal Anterior and Bicuspid
- Molar Root Canal Anterior & Bicuspid
|
80%
80%
80%
|
85%
85%
85%
|
50%
50%
50%
|
100%
100%
60%****
|
|
Restorations
- Filings
- Stainless Steel Crowns
- Acrylic Temp. Crowns
|
80%
80%
80%
|
85%
85%
85%
|
50%
50%
50%
|
100%
100%
60%****
|
|
Oral Surgery***
- Extractions
- Incision/drainage
- Removal impacted teeth
|
80%
80%
80%
|
85%
85%
85%
|
50%
50%
50%
|
100%
100%
60%****
|
|
Restoration and Prosthodontics
- Inlays and Onlays
- Crowns (freestanding)
- Bridge and crown repairs
- Dentures
- Denture Repairs
- Bridges
- False teeth
- Occlusal guard (for bruxism only), limited to 1 every 3 years
|
80%
|
60%
|
50%
|
60%****
|
|
Anesthesia is covered when medically necessary and in conjunction with covered services
|
80%
|
85%
|
50%
|
60%****
|
|
Space Maintainers
|
80%
|
85%
|
50%
|
60%****
|
|
Orthodontia
|
50%
(child only)
|
50%****
|