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Class I - Preventive (exams, cleanings, x-rays, etc.)
100% †
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Class II - Basic (fillings, repairs, etc.)
80% †
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Class III - Major (bridge, root canals, oral surgery, etc)
70% †
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Class III - Major (dentures)
60% †
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Class IV - Specialty Care (when performed at a specialist)
50%
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Deductible
None
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Primary Care Maximum
$2,500
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Specialty Care Maximum
$800
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Orthodontic Maximum (Lifetime)
$1800 benefit up to age 19, $1200 benefit ages 19+
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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.
