| In-Network | |
|---|---|
| Annual Deductible | $50 per person, $150 maximum per family |
| Annual Maximum Benefit | $2,500 per person |
Preventive Care (two exams each calendar year; includes routine exams, X-rays and three cleanings) | 100%, no deductible |
Annual Fluoride Treatment (under age 19 only) | 100%, no deductible |
Basic Restorative Services (includes fillings, extractions, root canals and denture repairs) | 80% after deductible |
Major Restorative Services (includes inlays, crowns, bridges and dentures) | 50% after deductible |
Orthodontics (adults and children) | 50%, no deductible - Lifetime maximum up to $2,500 per covered person |