|
|
Dental |
|
|
|
In-network only |
Out-of-network |
|
Annual Deductible – Individual |
$50 per person |
$50 per person |
|
Annual Deductible – Family |
$150 per family |
$150 per family |
|
Annual Plan Maximum |
$1,500 |
$1,500 |
|
Waiting Period |
None |
None |
|
Diagnostic |
100% |
100% of Reasonable and Customary |
|
Preventive |
100% |
100% of Reasonable and Customary |
|
Basic |
80% |
80% of Reasonable and Customary |
|
Major Services and Orthodontia |
50% |
50% of Reasonable and Customary |
|
Lifetime Orthodontia Plan Maximum |
$1,000 |
$1,000 |

















