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All Dental benefits utilize a PPO provider network regardless of the type of medical plan you have selected. Deductibles and benefit payments are based on allowable charges. Review the Dental Plan Contract posted below for details on waiting periods, exclusions and benefit amounts.
FY24 & FY25 Dental Benefits Summary
The FY25 Dental Benefits Summary will go into effect July 1, 2024
Dental Provisions to Know:
Orthodontic services are for eligible dependent children up to age 19 if the treatment has begun by age 17.
Deductibles and Benefit Limits are per benefit period except the Orthodontic Benefit Limit which is a lifetime limit.
Dental Plan Comparison
Plan Year Benefit: $1,500 maximum per member benefit • Deductible: $50 per member (except listed preventive services) • Pediatric Orthodontia Benefit: $1,000 lifetime maximum
| Type | Covered Service (see contract for full list) | In-Network Contracting Providers – PPO | Out-of-Network Providers |
|---|---|---|---|
| Preventative & Diagnostic | Oral exam & cleanings | 100%, no deductible | 70% after deductible |
| Basic | Fillings, extractions, root canals, etc. | 80% after deductible | 50% after deductible |
| Major | Crowns, bridges, dentures | 50% after deductible | 50% after deductible |
| Orthodontic (Pediatric) | Pediatric benefit only | 50% after deductible | 50% after deductible |
| Other | 80% after deductible | 70% after deductible |