Benefits for 2025 Dental Coverage
SUMMARY OF COVERAGE
*Referrals Required
In Network
Annual Deductible Individual | Family
None
Calendar Year Plan Max
Unlimited
Preventive Care Benefits
$5 Copay
Basic Services
Refer to Copay Schedule
Major Services
Refer to Copay Schedule
Orthodontia (Child / Adult)
$1,104 to $5,425
Employee Cost Per Pay Period (26)
Dental DHMO Plan
Employee
$5.00
Employee/Spouse
$10.00
Employee/Child(ren)
$7.00
Family
$15.00
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2025 Employee Benefit Guide
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