Orthodontic Dental Coverage

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» Resources
» Employee Monthly Rates
» Plan Year Maximum
» Plan Year Deductible
» Preventive & Diagnostic Services
» Basic Services
» Major Services
» Orthodontic Dental Services

Resources

» Provider Search: Click Here
» Video: Watch
» Coverage Highlights: Click Here
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Employee Monthly Rates

  53.28  Employee Only
109.79  Employee & Spouse
121.99  Employee & Child
121.99  Employee & Children
191.86  Employee, Spouse & Child
191.86  Employee, Spouse & Children
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Plan Year Maximum

$2,000
» Plan Paid - Does Not Include Amounts Paid by Member
» After Plan Paid Maximum is Reached, Member is Responsible for 100% of Incurred Charges
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Plan Year Deductible

$50
» Member Paid
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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
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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
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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
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Orthodontic Dental Services

$1,500 Lifetime Maximum
» Not Subject to Deductible
» Coverage Available to Adults & Children
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