Dental

Note:

• In-network costs listed
• Rates are lowest with in-network providers
• In- and out-of-network deductibles and out-of-pocket maximum amounts accrue separately

• A Basic PPO (preferred provider organization)
• Covers in- and out-of-network care
• No coverage for major services
• No coverage for orthodontia

• A Basic PPO (preferred provider organization)
• Covers in- and out-of-network care
• Covers major services
• Covers orthodontia for children up to age 19

• A Basic PPO (preferred provider organization)
• Covers major services
• Orthodontia coverage for children and adults

• A DHMO (dental health maintenance organization)
• Covers in-network care only
• Covers major services and orthodontia
• Not available in certain areas

PREVENTIVE CARE

100% covered
No deductible

100% covered
No deductible

100% covered
No deductible

Varies by insurance carrier;
generally 100% covered

MINOR RESTORATIVE CARE

Includes but is not limited to:

• Root canal
• Gum disease
• Oral surgery

You pay 20% (coinsurance) after deductible

You pay 20% (coinsurance) after deductible

You pay 20% (coinsurance) after deductible

Varies by insurance carrier

MAJOR RESTORATIVE CARE

Includes but is not limited to:

• Implants
• Dentures

Not covered

You pay 40% (coinsurance) after deductible

You pay 20% (coinsurance) after deductible

Varies by insurance carrier

ORTHODONTIC CARE¹

Not covered

• You pay 50% (coinsurance)
• No deductible
• Children up to age 19 only

• You pay 50% (coinsurance)
• No deductible
• Coverage for children and adults

Varies by insurance carrier

ANNUAL DEDUCTIBLE

(Employee only/Family)

$100 / $300

$100 / $300

$50 / $150

None

ANNUAL maximum coverage

Per person

$1,000

$1,500

$2,500

None

ORTHODONTIA LIFETIME LIMIT

Excluded from annual out-of-pocket maximum

Not covered

$1,500 per child

$2,000 per person

Varies by insurance carrier