Benefit

Maximum Paid Per Year

$1,500

Annual Deductible

None

Class I Services
Diagnostic, Preventative

70% - 100% (Increases 10% if dentist is visited once each year)

Class II Services
Encodonic, Oral Surgery, Restorative, Periodic Services

70% - 100% (Increases 10% if dentist is visited once each year)

Class III Services
Gold Fillings, Crowns, Inlays when necessary for restoration

50%

Class IV Services
Dentures, Bridges, Partials, Prosthodontics

50%

Orthodontia

80% to $1,000 lifetime maximum per family member

Orthodontia Rider

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