Dental Plan Benefits
Annual Deductible $75/person
Annual Benefit Maximum $2,000
Preventive and Diagnostic Services – Plan Pays

  • 2 cleanings in a calendar year
  • Supplemental bitewing X-ray
    (2 per calendar year for children up to 19; 1 per calendar year for adults)
  • For children up to age 16, fluoride treatments twice a year
  • For children up to 19, one sealant application every five years

Preventive and diagnostic services are subject to the annual benefit maximum.

100% deductible waived
Basic Dental Services –
Plan Pays
80% after the deductible
Major Restorative Services –
Plan Pays
50% after the deductible
Orthodontia (children and adults) – Plan Pays 50% after the deductible
Lifetime Orthodontia Benefit Maximum $2,000