Download a PDF of the Plan Summary to the right.
| Premium Option | Basic Option | |
|---|---|---|
| Annual Deductible | $50 Individual $150 Family |
$100 Individual $300 Family |
| Calendar-year Maximum | $2,500 per person | $1,250 per person |
| Diagnostic & Preventive Services Exams, two cleanings per year, x-rays, topical fluoride treatments for children 1x/year to age 15, sealants once every 60 months to age 19 |
Covered at 100% (no deductible) | Covered at 100% (no deductible) |
| Basic Services Extractions, fillings and oral surgery except removal of wisdom teeth, repair or recementing of crowns, and relining of dentures |
Plan pays 80% after deductible | Plan pays 80% after deductible |
| Major Services Inlays, first installation of bridgework, dentures and crowns, implants, removal of impacted teeth |
Plan pays 50% after deductible | Plan pays 50% after deductible |
| Orthodontia | Plan pays 50% up to a lifetime maximum of $1,500 Dependent children and adults. |
Plan pays 50% up to a lifetime maximum of $1,000 Dependent children only up to age 19. |