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Preventive
100% †
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Basic
80% †
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Major
80% †
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Specialty Care
50%
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Primary Care Maximum
$3,500
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Specialty Care Maximum
$1,000
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Total Annual Maximum
$4,500
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Office Visit Copay
$10
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Orthodontic Maximum (Lifetime)
$1,800 Up to age 19, $1,200 Adults 19+ Comprehensive Case Only
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2026 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.
