-
Monthly Payment (Single Coverage)
$16.93
-
Office Visit
$10.00
-
Class I - Preventive
100% †
-
Class II - Basic
70% †
-
Class III - Major
60% †
-
Class IV - Orthodontic
35% †
-
Annual Maximum per Covered Person:
-
Primary Care Maximum
$1200
-
Specialty Care Maximum
$0
-
Provider Locator
-
2024 Schedule of Benefits
-
Monthly Payment (Single Coverage)
$24.42
-
Office Visit
$10.00
-
Class I - Preventative
100%†
-
Class II - Basic
70%†
-
Class III - Major
60%†
-
Class IV - Orthodontic
35%†
-
Annual Maximum per Covered Person:
-
Primary Care Maximum
$1500
-
Specialty Care Maximum
$300*
-
Provider Locator
-
2024 Schedule of Benefits
-
Monthly Payment (Single Coverage)
$29.00
-
Office Visit
$10.00
-
Class I – Preventive
100%†
-
Class II – Basic
75%†
-
Class III – Major
50%†
-
Class IV – Orthodontic
35%†
-
Annual Maximum per Covered Person:
-
Primary Care Maximum
$2000
-
Specialty Care Maximum
$500*
-
Provider Locator
-
2023 Schedule of Benefits
-
2024 Schedule of Benefits
† PERCENTAGES are APPROXIMATE, see co-payments as listed on the Schedule of Benefits and Fixed Co-Pays.
* Available after a 6 month waiting period
