DENTAL PLANS
SUMMARY OF COVERAGE
Plan Highlights
DPPO (In-Network)
OUT-OF-NETWORK
Calendar Year Deductible
$50 per person $150 per family
Calendar Year Maximum Benefit
$1,500 Maximum combined for in and out of network
Diagnostic & Preventive Care Services Oral exams, x-rays, other diagnostic services, routine preventive services
100% (deductible waived)
100% (deductible waived)
Basic Services Filings, simple extractions, endodontics, oral surgery
80%
80%
Major Services Periodontics, dentures, crowns & fixed bridges
50%
50%
Orthodontia Services (to age 19)
50% up to a lifetime maximum of $1,5000
90 th Percentile of Allowed Charges
Dental Plan Reimbursement Level
Based on Contracted Fees
Out-of-Network services are paid based on allowable charges. Member may be responsible for paying the balance of the billed amount above that rate (commonly known as “balance billing”)
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SUPERBLOOM BENEFITS GUIDE
DENTAL PLAN I
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