DENTAL PLANS
SUMMARY OF COVERAGE
LOW PLAN
HIGH PLAN
Out-of- Network
Benefits
In-Network
In-Network
Out-of-Network
Individual Deductible Preventive
$50
$50
$50
$50
100%
100%
100%
100%
Basic Major
90% 60% 50%
80% 50% 50%
80% 50%
80% 50%
Orthodontia
$1,500 Per Individual Plus Rollover
Annual Maximum
$5,000
$2,000
Orthodontia Maximum (Lifetime)
$1,000
$2,000
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DENTAL PLAN I
SENDOSO BENEFITS GUIDE
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