Dental PPO Plan

The Dental PPO plan offers coverage for preventive, basic & major restoration, as well as orthodontia.

Plan Features Dental PPO
  In-Network (% of Negotiated Fee) Out-of-Network (% of Negotiated Fee)
Calendar Year Deductibles $50 $50
Annual Maximum Benefit $1,750 $1,750
Orthodontia Lifetime Maximum (Per Person) $1,750 $1,750
Coverage Type
Type A - Preventive* (cleanings, exams, fluoride, x-rays) 100% 100%
Type B - Basic Restoration (fillings, extractions, general anesthesia) 80% 80%
Type C - Major Restoration (crowns, dentures, bridges) 50% 50%
Type D - Orthodontia 50% 50%

* Plan covers two cleanings, exams and fluoride treatments (dependent children up to age 16).

Child(ren)'s eligibility for dental coverage is from birth up to age 26.

Dental HMO Plan

The DHMO Plan offers a wide range of dental benefits through a network of participating dentists. With this plan, you are responsible for co-payments associated with each covered procedure.

Plan Features Dental HMO
  Co-payment
Office Visit $5 per visit
Preventive Services 
 Exams $5
 X-rays $0
Sealants $6 per tooth
Yearly cleanings (up to 4) $5 - first two*
Basic & Major Services 
Crowns $255
Root canal $95-$225
Osseous Surgery $200
Extractions $15 - $110**
General anesthesia & nitrous oxide (when medically necessary) $0
Orthodontics 
Adults $2,400***
Children $2,600***

*After first two cleanings, additional cleanings $45 adults/$35 children

**Higher cost for impacted tooth

***Additional charges for initial exam ($250), removable appliance therapy and fixed appliance therapy.