Select Gold and Silver Benefit Summary

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GOLD

SILVER

OFFICE VISIT COPAY

$5.00

$10.00

CLASS I* Preventative and Diagnostic
Exams
Cleanings
X-rays  (single, bitewing)
Fluoride (up to age 15)


100%
100%
100%
100%

 
100% 
50%
50%
50%

CLASS II Basic Restorative
Fillings
Extractions (simple)
X-Rays (full mouth)**
Root Canals

 
75%
75%
75%
75%

 
50%
50%
50%
50%

CLASS III Prosthetic
Single Crowns***
Bridges
Dentures


50%
50%
50%


50%
50%
50%

CLASS IV Specialty Care****
Endodontics
Periodontics
Oral Surgery
Pedodontics

 
50%
50%
50%
50%

 
50%
50%
50%
NCB

CLASS V Orthodontics*****
Ortho Lifetime Maximum
Children (under 19)
Adults (subscriber and spouse)



$1,500.00
$750



$1,200.00 
$750

 

Annual Maximum Usage
Per family member

 

$1200

 

$800

Plan Annual Premiums
Single
Family of two
Family of three to five
Addition members


$288.96
$437.18
$589.14
+$64.50


$220.46 
$300.18
$396.42
+$25.80


*         Every 6 months at general dental provider
**       Full mouth X-rays are cover once every 36 months
***     Crowns are covered once per tooth every five years.
****    All specialty appointments require referral from primary care dentist
*****  Orthodontic coverage has a lifetime limit of $500 to $1500 per person, depending on the plan you choose and the age of the member