Benefit

Choice of Provider

May go to any dentist but Participating Providers won't charge for any balances beyond deductible and coinsurance amount for covered expenses.  Non-participating providers may charge for any balance above usual & customary services.

Annual Deductible
(per calendar year)

$25 per person
$75 per family

Annual Limit
(per calendar year)

$1,500

Preventive/Basic Care
Exams, Cleaning, X-rays, fluoride, fillings, simple extractions, root canal therapy

70% - 100% - Benefits increase 10% each calendar year only if the dentist is seen for covered services.

Prosthetics
Dentures, bridges, crowns, inlays, space retainers

50% after deductible

Orthodontia

50% after deductible

Orthodontia Rider

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