Active Employee Benefit Summary
Annual Premium
$554.40
$264.00
Annual Maximum Usage
$1,500
$1,200
CLASS I* Preventive and Diagnostic
X-rays (single)
100%
100%
Fluoride (under 19)
100%
100%
Spacers (under 15)
100%
100%
CLASS II Basic Restorative
Extractions (simple)
100%
75%
X-Rays (full mouth)**
100%
75%
CLASS IV Specialty Care****
CLASS V Orthodontics*****
Lifetime Maximum Children (under 19)
$1,500 max
$1,000 max
Lifetime Maximum Adults (subscriber and spouse)
$1,500 max
$1,000 max
*
Every 6 months at general dental provider
**
Full mouth X-rays are covered once every 36 months
***
Crowns are covered once per tooth every five years
****
All specialty appointments require referral from primary care dentist
*****
Orthodontic coverage has a lifetime limit between $1,000 and $1,500. Limit 1 braces treatment per person