Dental Plan Highlights: What You Pay

Plan Features Dental PPO Dental HMO Dental EPO
  In-Network Out-of-Network In-Network Only In & Out-of-Network
Calendar Year Deductibles
Individual $50 $0 $50
Family $150 $0 $150
Maximum
Calendar Year $1,000 per person $0

$1,250 Dental Services; $1,500 Orthodontic Services

12-month waiting period for Orthodontic Services

Waiting Period 12-month waiting period for Major Services No waiting period for Major Services No waiting period for Major Services
Visits and Exams
Office Visit You pay 0%   You pay any charges in excess of allowed amount* $5 Copays vary by service according to patient charge schedule*
Oral Exam $0
X-rays $0
Basic Services
Fillings You pay 20% You pay 20% and any charges in excess of allowed amount* Copays vary by service according to patient charge schedule* Copays vary by service according to patient charge schedule*
General Services
Space Maintainers
Major Services
Crowns You pay 50% You pay 50% and any charges in excess of allowed amount* Copays vary by service according to patient charge schedule* Copays vary by service according to patient charge schedule*
Dentures/Bridges
Orthodontic Services
Orthodontia Not covered Not covered Copays vary by service according to patient charge schedule*
Adult and children orthodontia
No waiting period
Copays vary by service according to patient charge schedule*
Children only (up to age 19)

* The benefit percentage applies to the schedule of maximum allowable charges. Maximum allowable charges are limitations on billed charges in the geographic area in which the expenses are incurred.