The Select Dental Program contains your choice of two managed care dental plans. The Silver Plan is designed for the family seeks preventive care coverage along with a very affordable annual premium. The Gold Plan is for the family that requires maximum coverage levels as well as very low out of pocket costs.
Fight back against today’s high cost of dental care and rising premiums with the Select Dental Program
OFFICE VISIT COPAY
$5.00
$10.00
CLASS I* Preventative and Diagnostic
Exams
100%
100%
Cleanings
100%
50%
X-rays (single, bitewing)
100%
50%
Fluoride (up to age 15)
100%
50%
CLASS II Basic Restorative
Fillings
75%
50%
Extractions (simple)
75%
50%
X-Rays (full mouth)**
75%
50%
Root Canals
75%
50%
CLASS III Prosthetic
Single Crowns***
50%
50%
Bridges
50%
50%
Dentures
50%
50%
CLASS IV Specialty Care****
Endodontics
50%
50%
Periodontics
50%
50%
Oral Surgery
50%
50%
Pedodontics
50%
NCB
CLASS V Orthodontics*****
Lifetime Maximum Children (under 19)
$2,000
$1,500
Lifetime Maximum Adults (subscriber and spouse)
$500
$500
Annual Maximum Usage
$1,500
$1,000
(per family member)
Plan Annual Premiums
Single
$296.40
$230.04
Family of two
$448.56
$313.32
Family of three to five
$604.44
$413.76
Each additional family member
+$66.00
+$27.00
*
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 $2000 per person, depending on the plan you choose and the age of the member