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 |