NON-PARTICIPATING PROVIDER
BENEFIT HIGHLIGHTS
PARTICIPATING PROVIDER
Calendar Year Deductible
Individual
$50 per person
Not Applicable to Class I
Family Maximum
$150 per family
Not Applicable to Class I
. Class I
Preventive Care
100%
100%
Class II
Basic Restorative
80% after plan deductible
80% after plan deductible
Class III
Major Restorative
60% after plan deductible
60% after plan deductible
Class IV
Orthodontia
50%
50%
. Class IX
Implants
50% after plan deductible
50% after plan deductible
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