DENTAL PLANS
SUMMARY OF COVERAGE
Benefits
In-Network
Out-of-Network
Deductible* (Individual/Family)
$0/$0
$50/$150
Preventive Care
100%
100%*
Basic Procedures
80%
80%*
Major Procedures*
50%
50%*
Calendar Year Max Benefit
$1,500
Orthodontia- Up to Age 19 (Lifetime Maximum)
50% to $1,500 Lifetime Max
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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MOTHER BENEFITS GUIDE
DENTAL PLAN I
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