| Benefit Features |
Core PPO Dental Benefits |
| |
In-network: |
Out-of-network: |
| Annual Deductibles |
|
|
| Individual |
$50 |
$50 |
| Family (2 members of family must each satisfy individual deductible) |
$100 |
$100 |
| Annual Benefit Maximum |
$2,000 |
$2,000 |
| Orthodontics Lifetime Maximum |
$2,000 |
$2,000 |
| Office Visit Copay |
$0 |
$0 |
| PREVENTIVE SERVICES and DIAGNOSTIC SERVICES |
| Dental cleaning Topical Application of Fluoride, Sealants and Space Maintainers |
100% Covered
frequency may apply to these services |
100% Covered
frequency may apply to these services |
| MINOR RESTORATIVE SERVICES |
| Fillings, Endodontics, Periodontics, Oral Surgery |
Covered up to 80%; after deductible |
Covered up to 80%; after deductible; Subject to reasonable and customary limits |
| MAJOR RESTORATIVE AND PROSTHODONTICS |
| Initial placement of Dentures or Bridges to one or more natural teeth which are lost while covered by the Plan. Inlays and Crowns (Porcelain or Stainless Steel) |
Covered up to 50%; after deductible; frequency may apply to these services |
Covered up to 50% after deductible; Subject to reasonable and customary limits; frequency may apply to these services |
| ORTHODONTICS |
| Exams, X-Rays, Models, Appliances (Adult and Child) |
Covered up to 50%; after deductible; frequency may apply to these services |
Covered up to 50% after deductible; Subject to reasonable and customary limits; frequency may apply to these services |