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 deductible | Plan pays 50% of MRC* after deductible | Refer to your Patient Charge Schedule for costs and covered services |
| Major care (bridges, crowns, dentures) | Plan pays 50% after deductible | Plan pays 40% of MRC* after deductible | Refer 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 dentist | No age limit | Eligible until age 13 | |
