-
Class I - Preventive (exams, cleanings, x-rays, etc.)
100% †
-
Class II - Basic (fillings, repairs, etc.)
85% †
-
Class III - Major (bridge, dentures, root canals, oral surgery, etc)
80% †
-
Class IV - Specialty Care (oral surgery, endodontics, periodontics, pedodontics)
50%
-
Deductible
None
-
Primary Care Maximum
$2,500.00
-
Specialty Care Maximum
$800.00
-
Orthodontic Maximum (Lifetime)
$1,800 discount up to age 19
-
Orthodontic Maximum (Lifetime)
$1,200 discount ages 19+ comprehensive cases only
-
2024 Schedule of Benefits and Fixed Copays
-
2025 Schedule of Benefits and Fixed Copays
-
Provider Directory
-
Class I - Preventive (exams, cleanings, x-rays, etc.)
100% †
-
Class II - Basic (fillings, repairs, etc.)
100% †
-
Class III - Simple & surgical extractions, root canals
100% †
-
Class III - Major (bridges, dentures, limited crowns)
80% †
-
Class IV - Specialty Care (when performed at a specialist)
70%
-
Deductible
None
-
Primary Care Maximum
$3,500
-
Orthodontic Maximum (Lifetime)
$3,000 Benefit up to age 19, $3,000 Benefit ages 19+, Comprehensive cases only
-
2024 Benefit Summary
-
2025 Schedule of Benefits and Fixed Copays
-
Emerald Provider Directory
† PERCENTAGES are APPROXIMATE, see co-payments as listed on the Schedule of Benefits and Fixed Co-Pays.