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Benefits & Rates



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PPO/MPA
PPO/MPA
PPO/MPA
Services Covered
Year 1 Plan Pays
Year 2 Plan Pays
Year 3 Plan Pays
Type 1: Diagnostic & Preventive Services

  • Oral exams
  • X-rays
  • Cleanings
  • Fluoride treatments
  • Space maintainers

80%
90%
100%
Type 2: Basic Services

  • Simple extractions, fillings
  • Palliative care
  • Denture repair
  • Sealants
  • General anesthesia

60%
70%
80%
Type 3: Major Services

  • Endodontics
  • Periodontics
  • Complex oral surgery
  • Crowns, Inlays/Onlays, Bridges, Dentures

10%
30%
50%
Waiting Period
None
None
None
Annual Deductible (per person)
$50
$50
$50
Deductible waived on D&P?
Yes
Yes
Yes
Annual Maximum (per person)
$1,000
$1,250
$1,500

*Limitations may apply for some benefits. Please refer to your Evidence of Coverage for a list of benefit limitations and exclusions.