Dental Coverage Continued...
DPPO Low
DPPO High
Plan Highlights
Out of Network
Out of Network
In Network
In Network
Annual Calendar Year Deductible Individual / Family
$50 / $150
$75 / $225
$50 / $150
$75 / $225
Calendar Year Maximum
$1,000 per member
$1,500 per member
Preventive & Diagnostic Services • Oral Examinations (2 per 12 months) • X-rays • Cleanings • Topical Fluoride Treatment (through age 18, one per 12 months) • Sealants (through age 18, one per 60 months) Basic Services • Anesthesia • Amalgam & Composite Fillings • Perio Surgery • Periodontal Maintenance • Repair & Maintenance of Crowns, Bridges, & Dentures • Root Canal • Periodontal Scaling • Root Planning • Oral Surgery - simple extractions
Plan pays 100%; no deductible
Plan reimburses 100% of 90th percentile* fee
Plan pays 100%; no deductible
Plan reimburses 100% of 90th percentile* fee
Plan pays 80%; after deductible
Plan reimburses 80% of 90th percentile* fee after deductible
Plan pays 80%; after deductible
Plan reimburses 80% of 90th percentile* fee after deductible
Major Services • Bridgework • Dentures • Inlays & Onlays • Crowns
Plan pays 30%; after deductible
Plan reimburses 30% of 90th percentile* fee after deductible
Plan pays 50%; after deductible
Plan reimburses 50% of 90th percentile* fee after deductible Children Only
Not Covered
Not Covered
Children Only
Orthodontia
$0
$0
50% up to $1,000 50% up to $1,000
• Lifetime Maximum
(Children up to age 26)
* Since, by definition, many dentists’ usual fees are below the 90th percentile fee, reimbursement is always based on the lesser of the dentist’s billed fee for a given procedure or the 90th percentile fee. This means that 90 percent of dentists’ billed fees will be covered in full relative to the group plan ** The reimbursement for services provided by an out-of-network dentist is capped at the Maximum Allowable Charge (MAC). For example, if you visit an out-of-network dentist who charges $150 for a cleaning (covered at 100%), but the MAC is set at $100, insurance will cover $100 and you will be responsible for the remaining $50 coinsurance level.
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.
Benefits Guide 2024-25 13
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