Tier 1 in-network
0.00%
Out-of-network
0.00%
Child Coverage Only. Please refer to the Plan Brochure for detailed services covered, not covered, and frequency limitations.
Exclusions: nan
Accidental Dental Adult
20.00% Coinsurance after deductible
Tier 1 in-network
20.00% Coinsurance after deductible
Out-of-network
20.00% Coinsurance after deductible
Adult dental benefits are subject to $1000 per person per year maximum for all covered services. Please refer to the Plan Brochure for detailed services covered, not covered, and frequency limitations.
Exclusions: nan
Basic Dental Care - Adult
20.00% Coinsurance after deductible
Tier 1 in-network
20.00% Coinsurance after deductible
Out-of-network
20.00% Coinsurance after deductible
Adult dental benefits are subject to $1000 per person per year maximum for all covered services. Please refer to the Plan Brochure for detailed services covered, not covered, and frequency limitations.
Exclusions: nan
Dental Check-Up for Children
0.00%
Tier 1 in-network
0.00%
Out-of-network
0.00%
Limit: 1.0 Exam(s) per 6 Months
Dental Check-up is limited to 1 per 6 consecutive month period. Please refer to the Plan Brochure for detailed services covered, not covered, and frequency limitations.
Exclusions: nan
Major Dental Care - Adult
50.00% Coinsurance after deductible
Tier 1 in-network
50.00% Coinsurance after deductible
Out-of-network
50.00% Coinsurance after deductible
Adult dental benefits are subject to $1000 per person per year maximum for all covered services. Routine Dental Services is limited to 1 per 6 consecutive month period. Please refer to the Plan Brochure for detailed services covered, not covered, and frequency limitations.
Exclusions: nan
Orthodontia - Child
50.00% Coinsurance after deductible
Tier 1 in-network
50.00% Coinsurance after deductible
Out-of-network
50.00% Coinsurance after deductible
Medically necessary only. Please refer to the Plan Brochure for detailed services covered, not covered, and frequency limitations.
Exclusions: nan
Routine Dental Services (Adult)
0.00%
Tier 1 in-network
0.00%
Out-of-network
0.00%
Limit: 1.0 Visit(s) per 6 Months
Adult dental benefits are subject to $1000 per person per year maximum for all covered services. Routine Dental Services is limited to 1 per 6 consecutive month period. Please refer to the Plan Brochure for detailed services covered, not covered, and frequency limitations.
Exclusions: nan