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