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Preventive
100% †
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Basic
85% †
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Major
80-85% †
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Orthodontic Maximum (Lifetime)
$1,800 Benefit up to age 19, $1,200 Benefit ages 19+, Comprehensive cases only
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Primary Care Maximum
$2,500.00
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Specialty Care Maximum
$800.00
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Total Annual Maximum
$3,300.00
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2025 Schedule of Benefits and Fixed Copays
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Provider Directory
† PERCENTAGES are APPROXIMATE, see co-payments as listed on the Schedule of Benefits and Fixed Co-Pays.
