Download and print the Benefit Plan Summary sheet Download and print Member Handbook Download and print Brochure and Application
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GOLD
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SILVER
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OFFICE VISIT COPAY
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$5.00
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$10.00
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CLASS I* Preventative and Diagnostic
Exams
Cleanings
X-rays (single, bitewing)
Fluoride (up to age 15)
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100%
100%
100%
100%
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100%
50%
50%
50%
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CLASS II Basic Restorative
Fillings
Extractions (simple)
X-Rays (full mouth)**
Root Canals
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75%
75%
75%
75%
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50%
50%
50%
50%
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CLASS III Prosthetic
Single Crowns***
Bridges
Dentures
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50%
50%
50%
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50%
50%
50%
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CLASS IV Specialty Care****
Endodontics
Periodontics
Oral Surgery
Pedodontics
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50%
50%
50%
50%
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50%
50%
50%
NCB
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CLASS V Orthodontics*****
Ortho Lifetime Maximum
Children (under 19)
Adults (subscriber and spouse)
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$1,500.00
$750
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$1,200.00
$750
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Annual Maximum Usage
Per family member
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$1200
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$800
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Plan Annual Premiums
Single
Family of two
Family of three to five
Addition members
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$268.80
$406.68
$548.04
+$60.00
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$205.08
$279.24
$368.76
+$24.00
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* 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