| Plan year maximum, per
member |
|
|
First year benefit maximum
|
$750 |
|
Second year benefit maximum
|
$1,000 |
|
Third year benefit maximum
|
$1,250 |
| Plan year deductible, per
member |
$50 |
| Service |
Benefit |
| Class 1 (deductible waived*) |
Examinations/x-rays (routine exam
& bitewing x-rays once every six months)
Prophylaxis (cleanings once every
six months)
Fissure sealants
Fluoride
|
|
PPO
Network |
Non-PPO
Network |
| 100%* |
80% |
| Class 2 |
Restorative dentistry (treatment
of tooth decay with amalgam, synthetic porcelain
and plastic materials)
Space maintainers
|
|
80% |
50% |
| Class 3 |
Oral Surgery (surgical extractions
& certain minor surgical procedures)
Endodontic (pulp therapy and root
canal filling)
Periodontics (treatment of tissues
supporting the teeth)
12-month waiting period on major services:
Crowns
Cast restorations
Dentures and bridge work (construction
or repair of fixed bridges, partials and
complete dentures)
|
|
50% |
50% |
| Unique Features |
- PPO Plan
- Deductible waived for Class 1 services rendered
by a participating PPO dentist
- Largest PPO dental network in the state, with
more than 560 participating dentists
- Premier panel dentists paid at non-PPO level
|
|
Plan Updates 
