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Preventive (cleanings, x-rays, exams)
100%
-
Basic (fillings)
85% †
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Major (root canals, crowns, dentures)
80-85% †
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Specialty Care
50%
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Orthodontic Lifetime Maximum (Comprehensive Case Only)
$1,800 for dependents up to age 19, $1,200 for adult member & spouse
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Primary Care Maximum
$2,500
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Specialty Care Maximum
$800
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Total Annual Maximum
$3,300
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2026 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.
