Accidental Dental
50.00% Coinsurance after deductible
Tier 1 in-network
50.00% Coinsurance after deductible
Out-of-network
100.00%
Coverage level is specific to the service rendered; limitations may apply to prosthodontic services.
Exclusions: nan
Basic Dental Care - Adult
20.00% Coinsurance after deductible
Tier 1 in-network
20.00% Coinsurance after deductible
Out-of-network
100.00%
180-day waiting period applies; limitations may apply to endodontic and prosthodontic services.
Exclusions: Limited to members age 19 and over.
Dental Check-Up for Children
No Charge after deductible, No Charge after deductible
Tier 1 in-network
No Charge after deductible, No Charge after deductible
Out-of-network
100.00%
Limit: 2.0 Visit(s) per Year
Limitations may apply to certain types of x-rays.
Exclusions: Benefits are available up to the end of the month in which the member turns 19.
Major Dental Care - Adult
50.00% Coinsurance after deductible
Tier 1 in-network
50.00% Coinsurance after deductible
Out-of-network
100.00%
365-day waiting period applies; limitations may apply to endodontic and periodontal services.
Exclusions: Excludes full or partial dentures, fixed or removable bridges, inlays, onlays, or crowns to restore diseased or accidentally broken teeth. Limited to members age 19 and over.
Orthodontia - Child
50.00% Coinsurance after deductible
Tier 1 in-network
50.00% Coinsurance after deductible
Out-of-network
100.00%
$150 calendar year deductible per member applies.
Exclusions: Benefits are available up to the end of the month in which the member turns 19.
Routine Dental Services (Adult)
No Charge after deductible, No Charge after deductible
Tier 1 in-network
No Charge after deductible, No Charge after deductible
Out-of-network
100.00%
Limit: 2.0 Visit(s) per Year
Limitations may apply to certain types of x-rays.
Exclusions: Limited to members age 19 and over.