The High Plan Deductibles and maximums • $0 annual deductible per person for in-network and $25 for out-of-network. The deductible is waived for preventive services. • Annual maximum of $1,500 per person for in-network and $1,500 for out-of-network for you and your dependents. Coinsurance 1 In-network • 100% for preventive services, such as oral exams, bitewing x-rays and cleanings. • 90% for basic services such as palliative (emergency) treatment of pain, simple extractions , minor periodontics and fillings. • 60% for major services such as fixed bridges, complex extractions, root canals, major periodontics, oral surgery, crowns and dentures. Out-of-network • 100% for preventive services, such as oral exams, bitewing x-rays and cleanings. • 80% for basic services such as palliative (emergency) treatment of pain, simple extractions, minor periodontics and fillings. • 50% for major services such as fixed bridges, complex extractions, root canals, major periodontics, oral surgery, crowns and dentures. Child Orthodontia • 50% coinsurance with a lifetime maximum of $1,000 for in-network and 50% coinsurance with a lifetime maximum of $1,000 for out-of-network. Waiting Periods For a complete description of services and waiting periods please review the certificate of insurance. • No waiting period for preventive or basic services. • No waiting period for major services. ________________________________________ OR _ _______________________________________ The Low Plan Deductibles and maximums • $50 annual deductible per person. • Annual maximum of $1,000 per person for you and your dependents. Coinsurance 1 • 80% for preventive services, such as oral exams, bitewing x-rays and cleanings. • 50% for basic services such as palliative (emergency) treatment of pain, simple extractions, minor periodontics and fillings. • 25% for major services such as fixed bridges, complex extractions, root canals, major periodontics, oral surgery, crowns and dentures. Child Orthodontia • We will provide Orthodontia benefits to all enrolled dependent children under age 25 who have cleft lip and/ or palate if the treatment is dentally necessary as a direct result of the condition. 50% coinsurance with a lifetime maximum of $1,000. Waiting Periods For a complete description of services and waiting periods please review the certificate of insurance. • No waiting period for preventive or basic services. • No waiting period for major services.
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1 Percent of Allowable Charge (a charge based on the general level of charges made by other providers in the area for like treatment)
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