Basic Dental Care - Adult
50.00% Coinsurance after deductible
Tier 1 in-network
50.00% Coinsurance after deductible
Out-of-network
70.00% Coinsurance after deductible
nan
Exclusions: nan
Dental Check-Up for Children
No Charge after deductible
Tier 1 in-network
No Charge after deductible
Out-of-network
20.00% Coinsurance after deductible
nan
Exclusions: nan
Major Dental Care - Adult
70.00% Coinsurance after deductible
Tier 1 in-network
70.00% Coinsurance after deductible
Out-of-network
80.00% Coinsurance after deductible
nan
Exclusions: nan
Orthodontia - Child
50.00%
Tier 1 in-network
50.00%
Out-of-network
70.00%
Orthodontic services require prior authorization and are only covered for eligible children with cases of severe orthodontic abnormality caused by genetic deformity (such as cleft lip or cleft palate) or traumatic facial injury resulting in serious health impairment to the beneficiary at the present time.
Exclusions: nan
Routine Dental Services (Adult)
No Charge
Tier 1 in-network
No Charge
Out-of-network
30.00%
nan
Exclusions: nan