Employee Group Insurance Benefits
Dental Plan Snapshot
Benefits are paid at the Traditional and PPO participating provider levels based on the contracting status of your dentist at the time services are rendered.
Please keep in mind that deductibles and benefit payments are based on allowable charges. For details about the dental plan, waiting periods, limitations, and how the plan works, please see the Benefits Summary & Plan Contracts.
| Deductible* | In-Network Contracting Providers |
Out-of-Network Providers |
Benefit Limit* |
Documents | |||
|---|---|---|---|---|---|---|---|
| PPO | Traditional | PPO | Traditional | ||||
| Preventive | none | $25 | 80% | 70% | 70% | $1,000 |  Benefits Summary Plan Contract |
| Diagnostic | 80% | 70% | 70% | ||||
| Other | $25 | 80% | 70% | 70% | |||
| Basic | 80% | 50% | 50% | ||||
| Major | 50% | 50% | 50% | ||||
| Orthodontic** | 50% | 50% | 50% | $1,000 (lifetime) | |||
* Deductibles and Benefit Limits are per benefit period except the Orthodontic Benefit Limit which is a lifetime limit.
** Orthodontic services are for eligible dependent children up to age 19 if the treatment has begun by age 17.
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