-
Preventive
100%†
-
Basic
50%†
-
Major
50%†
-
Orthodontic Maximum (Lifetime)
$1,800 Up to age 19, $1,500 Adults 19+ Comprehensive Case Only
-
Primary Care Maximum
Unlimited
-
Specialty Care
50%†
-
2025 Schedule of Benefits
-
Provider Directory
-
Preventive
100% †
-
Basic
100% †
-
Major
100% †
-
Orthodontics (up to age 19)
$0 copayment
-
Orthodontics (adults 19+)
$1250 copayment
-
Primary Care Maximum
Unlimited
-
Specialty Care
85%†
-
2025 Schedule of Benefits
-
Provider Directory
† PERCENTAGES are APPROXIMATE, see co-payments as listed on the Schedule of Benefits and Fixed Co-Pays.
