PPO calendar year max
$1,000, $1,500 or $2,000per enrollee
Premier & OON calendar year max
$1,000, $1,500 or $2,000per enrollee
Deductible
$50/$150Per person/per family (excluding P&D)
Oral 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%1 per lifetime 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
50%Repeat restorations of same surface payable once in 2 years
Composite/resin restorations
50%Composite resin restorations will be covered on all teeth
Simple extractions
50%1 per lifetime per tooth
Root canal therapy
50%1 per lifetime per tooth
Periodontal maintenance
50%2 per calendar year
Scaling and root planing
50%1 per 2 years per quadrant
Periodontal surgeries
50%1 per 3 years per quadrant
Oral surgery
50%Frequencies vary by procedure code
Single crowns
50%Replacement 1 in 5 years any other major services on the same tooth
Stainless steel crowns
50%Replacement 1 in 2 years
Crown inlay, only and veneer repairs
50%No frequency limitations
Crown replacement
50%Payable 6 months after insertion then 1 in 12 months
Post and core
50%Replacement 1 in 5 years
Inlays
50%Given alternate benefit of a composite at the restorative copay
Implants
50%Once every 60 months per tooth for ages 16 and older
Bridges
50%1 per 5 years (abutment crowns and pontics)
Dentures (complete and partials)
50%1 initial placement per 5 years
Plan Details
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