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Healthy Family - Value Plan
 
Office Visit $10.00
   
CLASS I 100%
Diagnostic and Preventive:
Exams, X-Rays (Periapical and/or Bitewing), Prophylaxis (3x per year up to age 19)
Fluoride Treatment (up to age 19)
100%
   
CLASS II * 50%
Restorative:
Fillings, Routine Extractions, Root Canals, X-Rays (FMX or Panographic)
50%
   
CLASS III * 50%
Prosthetic:
Crowns, Bridges and Dentures (Partials and Complete)
50%
 
CLASS IV * 50%
Specialty Care:
Oral Surgery, Endodontics, Periodontics, Pedodontics
50%
 
* There is a 3-month waiting period for all CLASS II, III and IV benefits
 
ORTHODONTICS
Children (up to age 19) Lifetime Maximum Benefit $1,500.00
Adults (19 and older) Lifetime Maximum Benefit $1,000.00
 
Annual Maximum per Covered Person
Children (up to age 19) Unlimited
Adults (19 and Older) $1,000.00
 
Annual Co-Pay Maximum
One Child $700.00
Multiple Children $1400.00
 
Annual Renewal Date Jan 1st
   
Eligibility
Adults Yes
Children under 19 Yes
 
Availability
Offered on ACA health exchange Yes
Offered direct to public (off exchange) Yes
 
Healthy Family - Max Plan
 
Office Visit $8.00
   
CLASS I 100%
Diagnostic and Preventive:
Exams, X-Rays (Periapical and/or Bitewing), Prophylaxis (3x per year up to age 19)
Fluoride Treatment (up to age 19)
100%
   
CLASS II * 75%
Restorative:
Fillings, Routine Extractions, Root Canals, X-Rays (FMX or Panographic)
75%
   
CLASS III * 50%
Prosthetic:
Crowns, Bridges and Dentures (Partials and Complete)
50%
 
CLASS IV * 50%
Specialty Care:
Oral Surgery, Endodontics, Periodontics, Pedodontics
50%
 
* There is a 3-month waiting period for all CLASS II, III and IV benefits
 
ORTHODONTICS
Children (up to age 19) Lifetime Maximum Benefit $1,800.00
Adults (19 and older) Lifetime Maximum Benefit $1,250.00
 
Annual Maximum per Covered Person
Children (up to age 19) Unlimited
Adults (19 and Older) $1,200.00
 
Annual Co-Pay Maximum
One Child $700.00
Multiple Children $1400.00
 
Annual Renewal Date Jan 1st
   
Eligibility
Adults Yes
Children under 19 Yes
 
Availability
Offered on ACA health exchange Yes
Offered direct to public (off exchange) Yes
 
Healthy Kids - Value Plan
 
Office Visit $10.00
   
CLASS I 100%
Diagnostic and Preventive:
Exams, X-Rays (Periapical and/or Bitewing), Prophylaxis (3x per year up to age 19)
Fluoride Treatment (up to age 19)
100%
   
CLASS II * 50%
Restorative:
Fillings, Routine Extractions, Root Canals, X-Rays (FMX or Panographic)
50%
   
CLASS III * 50%
Prosthetic:
Crowns, Bridges and Dentures (Partials and Complete)
50%
 
CLASS IV * 50%
Specialty Care:
Oral Surgery, Endodontics, Periodontics, Pedodontics
50%
 
* There is a 3-month waiting period for all CLASS II, III and IV benefits
 
ORTHODONTICS
Children (up to age 19) Lifetime Maximum Benefit $1,500.00
 
Annual Maximum per Covered Person
Children (up to age 19) Unlimited
 
Annual Co-Pay Maximum
One Child $700.00
Multiple Children $1400.00
 
Annual Renewal Date Jan 1st
   
Eligibility
Adults No
Children under 19 Yes
 
Availability
Offered on ACA health exchange Yes
Offered direct to public (off exchange) Yes
 
Healthy Kids - Max Plan
 
Office Visit $8.00
   
CLASS I 100%
Diagnostic and Preventive:
Exams, X-Rays (Periapical and/or Bitewing), Prophylaxis (3x per year up to age 19)
Fluoride Treatment (up to age 19)
100%
   
CLASS II * 75%
Restorative:
Fillings, Routine Extractions, Root Canals, X-Rays (FMX or Panographic)
75%
   
CLASS III * 50%
Prosthetic:
Crowns, Bridges and Dentures (Partials and Complete)
50%
 
CLASS IV * 50%
Specialty Care:
Oral Surgery, Endodontics, Periodontics, Pedodontics
50%
 
* There is a 3-month waiting period for all CLASS II, III and IV benefits
 
ORTHODONTICS
Children (up to age 19) Lifetime Maximum Benefit $1,800.00
 
Annual Maximum per Covered Person
Children (up to age 19) Unlimited
 
Annual Co-Pay Maximum
One Child $700.00
Multiple Children $1400.00
 
Annual Renewal Date Jan 1st
   
Eligibility
Adults No
Children under 19 Yes
 
Availability
Offered on ACA health exchange Yes
Offered direct to public (off exchange) Yes
 

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