The plan covers a wide range of services, including routine checkups, fillings, crowns, and more. Preventive care is fully covered when you see an in-network dentist, and other services are covered based on the type of care and provider you choose.
In-Network
PPO Dentists
In-Network
Premier Dentists
Out-of-Network
Dentists
Annual deductible
Individual: $50;
Family: $150 per family
Annual maximum
$2,000 per individual
Diagnostic & preventive
No charge
No charge
No charge*
Basic services
10% after deductible
20% after deductible
20% after deductible*
Major services
40% after deductible
50% after deductible
50% after deductible*
Orthodontia (adults and children)
50% ($1,500 lifetime max)
50% ($1,500 lifetime max)
50% ($1,500 lifetime max)*
Employee only
$0.00
Employee + spouse
$12.46
Employee + children
$15.69
Employee + family
$25.85
Pre-tax
Post-tax
Imputed
Employee + Domestic Partner (DP)
$0.00
$12.46
$6.14
Employee + DP + child(ren)
$15.69
$10.16
$14.71
Employee + DP
+ DP child(ren)
$0.00
$25.85
$30.89
Employee + DP
+ child(ren) + DP child(ren)
$15.69
$10.16
$14.71
*Reimbursement is up to the maximum contracted allowance.
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