DENTAL PLANS
SUMMARY OF COVERAGE
Plan Features
DHMO Plan
DPPO Plan
IN NETWORK COVERAGE
None
$50
Individual Deductible
None
$150
Family Deductible
100%
100%
Preventive Care
80%
80%
Basic Procedures
50%
50%
Major Procedures
None
$1,000
Calendar Year Max
$5
N/A
Office Visit Copay
Not Covered
Not Covered
Orthodontia
OUT OF NETWORK COVERAGE
$50
Individual Deductible
Not Covered
$150
Family Deductible
$1,000
Calendar Year Max
17
PRIVATE PREP BENEFITS GUIDE
DENTAL PLAN I
17
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