dental table

 DPPO
In Network
DPPO
Out of Network
DHMO
Deductible per calendar year
Per individual$50$100$0
Family maximum$150$300$0
Preventive care
(exams, cleanings)
Plan pays 100%Plan pays 80% of MRC*Plan pays 100%
Basic care
(fillings, extractions, root canals, and denture repairs)
Plan pays 80% after deductiblePlan pays 50% of MRC* after deductibleRefer to your Patient Charge Schedule for costs and covered services
Major care
(bridges, crowns, dentures)
Plan pays 50% after deductiblePlan pays 40% of MRC* after deductibleRefer to your Patient Charge Schedule for costs and covered services
Benefit maximum per calendar year$1,500 per person** (combined in- and out-of-network coverage)No benefit maximum
Orthodontia
(available for dependent children under age 19)
Plan pays 50% (no deductible required)Refer to your Patient Charge Schedule for costs and covered services
Lifetime maximum orthodontia benefit maximum$1,000 per person (combined in- and out-of-network coverage)No benefit maximum
Coverage for pediatric dentistNo age limitEligible until age 13