PPO calendar year max
$1,500, $2,000 or $2,500per enrollee
Premier & OON calendar year max
$1,000, $1,500 or $2,000per enrollee
PPO Deductible
$50/$150Per person/per family (excluding P&D)
Premier & OON deductible
$75/$225Per person/per family (excluding P&D)
Percent plan pays
PPO/Premier & Out-of-NetworkOral exams/evaluations
100%2 per calendar year
Cleanings
100%2 per calendar year
Bitewing X-rays
100%2 per calendar year (through age 18); 1 per calendar year (19+)
Full mouth X-rays
100%1 per 5 years
Sealants
100%Once in a 24-month period per tooth (through age 14)
Topical fluoride
100%2 per calendar year (through age 18)
Space maintainers
100%1 per arch per lifetime (through age 13)
Fillings
100%/80%Repeat restorations of same surface payable once in 2 years
Composite/resin restorations
100%/80%Composite resin restorations will be covered on all teeth
Simple extractions
100%/80%1 per lifetime per tooth
Root canal therapy
100%/80%1 per lifetime per tooth
Periodontal maintenance
100%/80%2 per calendar year
Scaling and root planing
100%/80%1 per 2 years per quadrant
Periodontal surgeries
100%/80%1 per three years per quadrant
Oral surgery
100%/80%Frequencies vary by procedure code
Single crowns
60%/50%Replacement 1 in 5 years any other major services on the same tooth
Stainless steel crowns
60%/50%Replacement 1 in 2 years
Crown inlay, only and veneer repairs
60%/50%No frequency limitations
Crown replacement
60%/50%Payable 6 months after insertion then 1 in 12 months
Post and core
60%/50%Replacement 1 in 5 years
Inlays
60%/50%Given alternate benefit of a composite filling
Implants
60%/50%Once every 60 months per tooth for ages 16 and older
Bridges
60%/50%(abutment crowns and pontics) 1 per 5 years
Dentures (complete and partials)
60%/50%1 placement per 5 years
Plan Details
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