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
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
$13.85
Employee + children
$17.54
Employee + family
$28.62
Pre-tax
Post-tax
Imputed
Employee + Domestic Partner (DP)
$0.00
$13.85
$6.76
Employee + DP + child(ren)
$17.54
$11.08
$16.48
Employee + DP
+ DP child(ren)
$0.00
$28.62
$34.25
Employee + DP
+ child(ren) + DP child(ren)
$17.54
$11.08
$16.48
*Reimbursement is up to the maximum contracted allowance.
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