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|
|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|
|Office Visit||$5 per visit|
|Sealants||$6 per tooth|
|Yearly cleanings (up to 4)||$5 - first two*|
|Basic & Major Services|
|Extractions||$15 - $110**|
|General anesthesia & nitrous oxide (when medically necessary)||$0|
*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.