DENTAL PLAN
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Carrier Name
Principal
Name of Plan
Dental PPO
Type of Plan
PPO
Class
In Network Out of Network
Preventive
0%
0%
Deductible then 20% Deductible then 50%
Deductible then 20% Deductible then 50%
Basic Restorative
Major Services
Orthodontia
50%
50%
Plan Details
Deductible applies to Preventive
No
No
Endodontics: Major Periodontics: Basic
Endodontics: Major Periodontics: Basic
Endodontics/Periodontics: Basic or Major
One can of soda is the amount of sugar recommended for three days for a child. Sugary Sodas are a major risk factor for tooth decay*
Orthodontics (Adult/Children)
Children
Children
Waiting Periods Applied
No
No
Deductible Person - Calendar Year
$50
$50
*Source: American Dental Association (ADA)
Family - Calendar Year
$150
$150
Plan Maximums Calendar Year Max
$2,500
$2,500
Ortho Lifetime Max
$1,000
$1,000
The benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases .
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