-
Class I - Preventive (exams, cleanings, most x-rays)
100%†
-
Class II - Basic (fillings, repairs, etc.)
75%†
-
Class III - Major (bridge, dentures, root canals, oral surgery, etc)
65%†
-
Class IV - Specialty Care (oral surgery, endodontics,periodontics,pedodontics)
50%†
-
Deductible
None
-
Primary Care Maxiumum
$2,500
-
Specialty Care Maxiumum
$800
-
2024 Orthodontic Maximum (Lifetime)
$3,000 up to age 19, $1,800 adults 19+ (Comprehensive Case Only)
-
2025 Orthodontic Maximum (Lifetime)
$1800 up to age 19, $1200 adults 19+ Comprehensive Case Only
-
2025 Schedule of Benefits and Fixed Copays
-
Provider Directory
-
Class I - Preventive (exams, cleanings, most x-rays)
100% †
-
Class II - Basic (fillings, repairs, etc.)
75%†
-
Class III - Major (bridge, dentures, root canals, oral surgery, etc)
65%†
-
Class IV - Specialty Care (oral surgery, endodontics,periodontics,pedodontics)
50%†
-
Specialty Care
50%
-
Deductible
None
-
Primary Care Maxiumum
$1,500
-
Specialty Care Maximum
$800
-
Orthodontic Maximum (Lifetime)
$1,800 up to age 19, $1,200 adults 19+ (Comprehensive Case Only)
-
2025 Schedule of Benefits and Fixed Copays
-
Provider Directory
† PERCENTAGES are APPROXIMATE, see co-payments as listed on the Schedule of Benefits and Fixed Co-Pays.