Dental Coverage
Quick Links: » Resources » Employee Monthly Rates » Plan Year Maximum » Plan Year Deductible » Preventive & Diagnostic Services » Basic Services » Major Services » Orthodonic Dental Services
Resources
» Provider Search: Click Here » Video: Watch » Out of Network Claim Form: Click Here Top of Page »
Employee Monthly Rates
$36.98 Employee Only $79.58 Employee & Spouse $54.24 Employee & Child $65.46 Employee & Children $83.46 Employee, Spouse & Child $99.62 Employee, Spouse & Children » For Retiree, COBRA or Disability COBRA Rates, please contact the Health Plan's Administration Office Top of Page »
Plan Year Maximum
$1,500 » Plan Paid - Does Not Include Amounts Paid by Member » After Plan Paid Maximum is Reached, Member is Responsible for 100% of Incurred Charges Top of Page »
Plan Year Deductible
$50 » Member Paid Top of Page »
Preventive & Diagnostic Services
100% Plan Paid Twice Per Plan Year » Not Subject to Deductible » Examples Services Include: Cleaning, Polishing, Bite-Wing X-Ray’s and Prophylaxis Top of Page »
Basic Services
80% Plan Paid » 80% Plan Paid of Allowable In-Network Charges » After Plan Year Deductible Is Met » Up To Plan Year Maximum » After Plan Year Maximum is Met, Member is Responsible for 100% of Incurred Charges » Examples Services Include: Simple Extractions, Simple Fillings & Some Bridge Work Top of Page »
Major Services
50% Plan Paid » 50% Plan Paid of Allowable In-Network Charges » After Plan Year Deductible Is Met » Up To Plan Year Maximum » After Plan Year Maximum is Met, Member is Responsible for 100% of Incurred Charges » Examples Services Include: Complex Extractions, Complex Fillings, Major Bridge Work Top of Page »
Orthodontic Dental Services
No Coverage » This Dental Plan Does Not Include Coverage for Orthodontic Services » See Optional Orthodontic Dental Coverage plan Detail Here: Click Here Top of Page »