Dental Plan Benefits

Annual Deductible


Annual Benefit Maximum


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