Dental Benefits

Deductible (Individual/Family)

$50 / $150

$50 / $150

Calendar Year Benefit Max

$1,000 per covered person

$1,000 per covered person

Preventive Services
Cleaning (prophylaxis) - Once every 6 months

Oral Exams

Fluoride Treatments - Under age 14

Sealants (per tooth)

X-Rays

100%

90%

Basic Services
(Deductible applies)

Anesthesia – Restrictions apply

Fillings – Restrictions apply

Simple Extractions

Surgical Extractions

Perio Surgery

Periodontal Maintenance – Once every 6 months

Repair & Maintenance of Crowns, Bridges, and Dentures
Root Canal

Scaling and Root Planing (per quadrant)

80%

70%

Major Services (Deductible applies)

Bridges and Dentures

Inlays, Onlays, Veneers – Restrictions apply

Single Crowns

50%

40%

Maximum Rollover Amount
Member qualifies by having at least one claim paid
in the prior benefit year, with the total benefits not
exceeding the $500 threshol

$250 - Additional dollars added to a plan’s annual
maximum for future years

$350 - Additional dollars added if only in-network
providers were used during the benefit year

$1,000 – The limit that cannot be exceeded within
the maximum rollover account

$250 - Additional dollars added to a plan’s annual
maximum for future years

$350 - Additional dollars added if only in-network
providers were used during the benefit year

$1,000 – The limit that cannot be exceeded within
the maximum rollover account

Employee

$7.27

Employee + Spouse

$21.74

Employee + Child(ren)

$27.23

Family

$41.71