-
Preventive
100%†
-
Basic
50%†
-
Major
50%†
-
Specialty Care
50%
-
Orthodontic Maximum (Lifetime)
$1,800 Up to age 19, $1,500 Adults 19+ Comprehensive Case Only
-
Primary Care Maximum
$1,250
-
Specialty Care Maximum
$500
-
Office Visit Copay
$20
-
2026 Schedule of Benefits
Coming Soon
-
Provider Directory
-
Preventive
100% †
-
Basic (fillings, space maintainers)
85% †
-
Major (canals, crowns)
80% †
-
Specialty Care
50%
-
Office Visit Copay
$15
-
Orthodontics
up to age 19 $2,000, adults 19+ $1,200,
-
Primary Care Maximum
$3,500
-
Specialty Care Maximum
$1,000
-
2026 Schedule of Benefits
Coming Soon
-
Provider Directory
† PERCENTAGES are APPROXIMATE, see co-payments as listed on the Schedule of Benefits and Fixed Co-Pays.
