• Make a Payment via Online Portal

  • Payment Authorization Form

  • Monthly Payment (Single Coverage)

    $29.00

  • Office Visit

    $10.00

  • Class I - Preventive

    100% †

  • Class II - Basic

    80% †

  • Class III - Major

    65% †

  • Class IV - Orthodontic

    35% †

  • Annual Maximum per Covered Person:

  • Primary Care Maximum

    $1500

  • Specialty Care Maximum

    $500*

  • Provider Locator

  • 2020 Schedule of Benefits

  • Monthly Payment (Single Coverage)

    $34.00

  • Office Visit

    $10.00

  • Class I - Preventative

    100% †

  • Class II - Basic

    80% †

  • Class III - Major

    65% †

  • Class IV - Orthodontic

    35% †

  • Annual Maximum per Covered Person:

  • Primary Care Maximum

    $2000

  • Specialty Care Maximum

    $500*

  • Provider Locator

  • 2020 Schedule of Benefits

  • Monthly Payment (Single Coverage)

    $16.93

  • Office Visit

    $10.00

  • Class I - Preventive

    100% †

  • Class II - Basic

    60% †

  • Class III - Major

    50% †

  • Class IV - Orthodontic

    35% †

  • Annual Maximum per Covered Person:

  • Primary Care Maximum

    $1200

  • Specialty Care Maximum

    $0

  • Provider Locator

  • 2020 Schedule of Benefits

  • Monthly Payment (Single Coverage)

    $24.42

  • Office Visit

    $10.00

  • Class I - Preventative

    100%†

  • Class II - Basic

    60%†

  • Class III - Major

    50% †

  • Class IV - Orthodontic

    35% †

  • Annual Maximum per Covered Person:

  • Primary Care Maximum

    $1500

  • Specialty Care Maximum

    $300*

  • Provider Locator

  • 2020 Schedule of Benefits

† PERCENTAGES are APPROXIMATE, see co-payments as listed on the Schedule of Benefits and Fixed Co-Pays.