| Annual Maximum Benefits |
In-Network
| $1,000 per member; in-network and out-of-network combined |
Out-Of-Network
| $1,000 per member; in-network and out-of-network combined |
| Annual Deductible |
In-Network
| $50 per member; three-member family maximum |
Out-Of-Network
| $50 per member; three-member family maximum |
Preventive Services
Office visits and cleaning: twice per year
Fluoride and sealant applications
Space maintainer insertion |
In-Network
| Not subject to deductible
No charge |
Out-Of-Network
| Member pays 20% of covered expense, plus 100% of charges in excess of covered expense after deductible |
Diagnostic Services
Oral examinations, consultations and X-rays to determine a particular dental condition. Full mouth X-rays: limit of one set or its equivalent in a three-year period |
In-Network
| Not subject to deductible
No charge |
Out-Of-Network
| Member pays 20% of covered expense, plus 100% of charges in excess of covered expense after deductible |
Minor Restorative Services
Fillings |
In-Network
| Member pays 20% of negotiated fee after deductible |
Out-Of-Network
| Member pays 20% of covered expense, plus 100% of charges in excess of covered expense after deductible |
Major Restorative Services
Oral surgery: tooth extractions
Endodontics: root canal therapy
Periodontics: scaling to cure/prevent gum disease
Prosthodontics: removable (dentures) and fixed (crowns, bridges and inlays)
12 month waiting period for periodontics and prosthodontics |
In-Network
| Member pays 50% of negotiated fee after deductible |
Out-Of-Network
| Member pays 50% of covered expense, plus 100% of charges in excess of covered expense after deductible |
| Orthodontic Services |
In-Network
| Not covered |
Out-Of-Network
| Not covered |
