• Preventive

    100% †

  • Basic

    80% †

  • Major

    70% †

  • Orthodontics off UCR (up to age 19)

    $1,800.00

  • Orthodontics off UCR (over age 19)

    $1,200.00

  • Primary Care Maximum

    $2,500.00

  • Specialty Care Maximum

    $800.00

  • Total Annual Maximum

    $3,300.00

  • Complete List of Covered Benefits and Fixed Copays

  • Provider Directory

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